Hospice organizations have not been spared from the staffing shortages that have plagued the healthcare industry. They have had to redeploy workers to cover gaps, offer overtime and bring in costly contingent help and even turn patients away.
In the worst cases, they haven't been able to get a nurse to a dying patient's bedside to comfort them or their family in the final moments.
"Every day is basically a logistical and tactical exercise in making sure we identify our resources and deploy our resources to the bedside," said Dean Forman, chief operating officer of Chapters Health System in Florida, a community-based not-for-profit care delivery system. "Anybody would be lying to you if they said we haven't had an incident or two that we regret."
Like many other healthcare sectors, hospice has long struggled to attract workers, even before the COVID-19 pandemic prompted an exodus of health personnel. Few nurses directly enter palliative or hospice care out of school. Usually, they start in some other area like medical, surgical, oncology or the emergency department and move into hospice after gaining experience with death or seeing how hospice works firsthand, Forman said. And certified nursing assistants are being attracted to higher-paying jobs outside of medicine.
"There was a [registered nurse] shortage before the pandemic, and now it's on steroids," said Carole Fisher, president of the National Partnership for Healthcare and Hospice Innovation.
The Bureau of Labor Statistics projects that employment of registered nurses will grow 9% from 2020 to 2030, among the highest of any profession, and that there will be 194,500 new openings every year. The data isn't broken down into specialties but post-acute care nurses are expected to be in high demand as the U.S. population ages.
With worker shortages, quality of care can suffer, said Caitlin Donovan, senior director of public relations for the National Patient Advocate Foundation.
"When you have low staffing levels, you're getting less one-on-one attention to each patient," Donovan said.
In some cases, hospices like the Grande Ronde Hospital and Clinics in La Grande, Oregon, have had to close their doors for lack of staff. Most organizations have been able to move staff around to cover their patients, but that has left the remaining staff overburdened physically and emotionally, industry members say.
"It's not easy emotionally to work with people and their families all day long who are dealing with the grief of losing someone they love," said Dr. Tara Friedman, regional medical officer at Aspire Health and president of the American Academy of Hospice and Palliative Medicine.
Rebecca Jensen, a registered nurse and the director of inpatient care for LifePath Hospice, which is owned by Chapters Health System, said workers have turned to the on-site licensed clinical social workers and bereavement teams in the buildings to help them handle burnout and the emotional toll of the job.
Jensen, who personally nearly lost her husband to COVID-19, said it has been "heartbreaking" to see her staff battle through the pandemic.
Nurturing a workforce
To help address the staffing problem, Calvary Hospital in New York City recently established a nurse residency program for palliative care using a grant from the Mother Cabrini Health Foundation. Nurses work in inpatient care to start, then move into community settings after six months, said Nancy D'Agostino, vice president for community patient services for Calvary Hospital, where she oversees Calvary@Home, the hospital's home care and hospice service.
"Our hope is that at the end of the year we will have eight new nurses," D'Agostino said.
Grant funding helped establish the curriculum for the program, D'Agostino said. The system intends to continue the program after the first year of nurses complete it.
"We just really are largely challenged because we can't accommodate an increase in referrals unless we have the nurses to take care of them," D'Agostino said.
Calvary has had to turn down patients, especially during the winter's omicron surge when many healthcare workers across the board were out sick, including 40% of Calvary's hospice and home care staff.
"There was a sudden stop," she said.
People weren't getting discharged from hospitals because there wasn't any availability in hospices across the city, she said.
"It really is a domino effect," D'Agostino said.
Flexibility is key
Calvary and other hospice organizations also have offered workers more flexibility in their schedules to help attract and retain workers. As Aspire Health's Friedman sees it, patients need care around the clock, so there is always a shift that will work for someone.
Hospices also have turned to virtual care to handle staffing shortages. While CNAs need to visit patients in person, other members of the clinical team, like nurses or doctors, can do virtual visits, Friedman said. Facilities have offered other services, like grief counseling, online to extend their reach.
Keith Ashmus, who lives in the Cleveland area, has used grief counseling services through hospice since his wife, Marie, passed away last year from Multiple System Atrophy. While COVID-19 cases surged, he was still able to attend individual and group sessions via Zoom.
Organizations have had to be more competitive in their wages to attract nurses and other workers to hospice care, which can be difficult for facilities that run on slim margins, Friedman said.
"Many of our hospice organizations don't have access to a lot of the resources that a major hospital system would have," Friedman said. "Increasing salaries can be pretty daunting for an organization."
Karen Rubel, president and CEO of Nathan Adelson Hospice in Las Vegas, expects things to improve.
"The rates we're trying to compete against, that's not going to last forever, we don't think. That's just really in response to the pandemic and people leaving the workforce," Rubel said. "I think we're going to see some of this taper off that we've been dealing with."
Edo Banach, president and CEO of the National Hospice and Palliative Care Organization, said the hospice organizations need more federal funding through Medicare.
"In order to recruit and retain talent, community-based providers need to be paid more," Banach said.
