A Dozen Ways to Maintain Profitability during Census Fluctuations

March 9, 2018 - 7:36am -- bill.taylor@mul...

A Dozen Ways to Maintain Profitability during Census Fluctuations

  1. Flex Staff
    1. Advertise specifically for flex-part-timers. Harder to find than full-time, but you won’t find them if you don’t look.
    2. Have we asked existing staff if any might want PT/Flex options? We might be surprised.
    3. Ask retiring staff if they’d like 5 to 20 hours a month
  2. Redesign the Volunteer Coordination function toward flexible staff, including for direct care. We’ve got to hit the 5% and these hours are part of our safeguards when census drops.
  3. All new indirect staff is hired with the understanding that we hope and expect to give them 40 hours a week, but if we fall below our relevant range, they will have hours reduced to 32-40 hours until census bounces back.
  4. All raises or increases are granted with written caveats about a fallback to previous amounts if census falls below relevant range.
  5. If PTO is expensed when earned we might revise our PTO policy to allow us the latitude to furlough staff with carried over PTO when census drops
  6. Just ask. Ask who wants an unpaid day off. It frequently works.
  7. Some Hospices might reward with $50 bonuses for staff who volunteer to take a day of “unpaid” leave
  8. If you are hourly and finished with what you need to do today, and you want to leave early an unpaid basis, just clear it with the manager and go. This should always be the case for direct staff, but should be extended to indirect staff as well.
  9. If one team’s census is down and another up, it’s ok to move some pieces around. You might base it on seniority, so the newer staff knows it’s likely.
  10. Indirect Staff
    This strategy may be used because indirect managers react more slowly to census dips than direct managers, and, therefore, are more likely to stray out of the Model.
    1. Each indirect manager has her Model targets—those are the standards and don’t change.
    2. A “cellar” ADC is selected for use as a baseline. Choose the lowest ADC from the last 6 to 12 months.
    3. Using that value and the Model targets, managers will know the actual dollars they have available and will “budget” for that on a day-to-day basis.
      1. If they spend more and stay in standard, that’s fine
      2. If they spend more and go out of standard, they get digs
    4. Should census dip to the “cellar” census, reductions in staffing hours kick in immediately—that day
    5. The cellar value slides with gains in sustainable census and is re-evaluated every quarter
  11. Crisis Care triggers
    1. The sweet spot is where all the direct care staff makes their standard number of visits without “over-visiting” a patient. When census dips, visit staff is incentivized to make too many visits to patients.
    2. Instead, in this system, the clinical leader must recognize the bottom of that sweet spot, and when census falls below that threshold, she immediately
      1. Digs into the EMR looking for patients who would most benefit from Crisis Care—that frequently means pain scores or other distress
      2. Texts all visit staff for help identifying patients who would most benefit from Crisis Care.
    3. A nurse is deployed to that patient
      1. This pulls the location back into the sweet spot
      2. This helps the patient(s) most in need
      3. This bumps revenue
    4. This strategy shouldn’t be employed merely for revenue reasons, nor should it be used without trained, internally-certified Crisis Care nurses.


  1. Preparing for spikes in census
    1. Hire part-timers first—it’s easier to ask for more hours than to ask people to cut back hours
    2. Hire CNAs as receptionists and phone triage positions. They can be trained and ready to deploy when called upon. Larger Hospices can promote RNs and Social Workers to indirect management positions—always ready to visit.
  2. Baker’s Dozen Bonus. All clinical managers should be taught how to manage care and costs when census moves up or down within 10% of the norm. We’ve created a simple Excel-based tool that helps team managers to do that. This tool can be applied to direct care teams as well as indirect departments. Give us a call, we’ll shoot it to you.


Program: People Development & the Model:
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~Patricia Oren, Hinds Hospice