Managing Full-Time Need with a PRN Workforce

Any clinical manager has been there. It’s Friday, 4 o’clock, and the phone is ringing. A family caregiver is upset that no one has been out to see their mother.

The visit was clearly scheduled out—what happened? You assure the family member that you will handle the issue and return their call right away. You contact the clinician scheduled to conduct the visit, and they tell you that they are at the beach drinking a frosty beverage. Trying to remain calm, you ask the clinician when they requested to be off, and you get the famous line, “I am PRN. I don’t need to ask for a day off.”

Now, as you scramble to get this visit covered, the realization sets in. Do you have any leverage with this employee? Is there really anything you can do? If an employee is not full time, can you require them to ask for time off? Most importantly, how do you prevent this from happening again?

Home health can seem like dancing with chaos. Your scheduled visits are the sand castle you spend six hours making, only to see get washed away by the next wave. Front-line management is constantly allocating and reallocating resources only to have the next wave come along. In the home health setting, most clinical managers and directors rely on a fair percentage of the staffing matrix being comprised of PRN staff.

The intent of this article is not to describe or discuss the reasons for this staffing model, but to open the dialogue for best practices. Or, more honestly, if best practices aren’t where we are, what is a better practice than we have now? Anecdotally, how do we find, train and retain, and supervise PRN employees that will meet the needs of our patient census?

I believe the easiest way to work through this is to start in the middle: training. Training is the costliest aspect of the employee cycle; you are likely pulling a field manager or a top performer to show this new hire the ropes, so the process needs to be efficient and effective. The onboarding process will tell you so much about the utility of a new PRN employee. Do they have availability for training? Are they receptive to the training you provide? Do they have relevant questions? And there is the tell-tale sign you missed in your HR process—do you have to hold their hand for every single aspect of the onboarding process?

The orientation process will lay the groundwork for this employee. This is where the expectations transition from the generalities of an interview to the reality of what is expected of your staff members. This is where you indoctrinate, where you establish the pecking order, where an employee learns who to call when things go sideways. And, this is where you lay the framework of holding someone accountable for their actions.

The foundation of the orientation process is grounded in the materials that you review with employees. Careful attention to the written material you provide that specifically outlines your expectations will be the cornerstone of counseling employees who do not meet your expectations.

If you have not recently reviewed your written policy for all staff members, set some time aside to study the language. It should be established during the onboarding process that all staff members (PRN or FT) need to notify their supervisor in writing that they will not be available for a scheduled shift within an acceptable time frame. This should be the signed document that you will show to a staff member when they tell you, “No one told me that I needed to ask for a day off.” Have you clearly outlined what is expected of their documentation and defined the time frame where it must be submitted?

After Successful Onboarding, Coverage Area Is Key

Now that you have these employees, how do you keep them? Money. Right, we all know this, but what is the key to money in homecare? It’s proximity—you make your money by seeing as many patients as you can.

If you really want clinicians to buy in, if you really want them to take ownership of a caseload, you need to give them a small radius to see their visits. If I want a PRN clinician to be loyal, if I want them to put my patients ahead of any other agency they may work for—clinicians want volume. With this concept in mind, your staffing matrix can’t include so many clinicians that no one has any volume.

You will get much more loyalty from five staff members averaging 10 visits per week than you will from 10 staff members averaging five. Our agency typically will divide our territory into several small regions. We send every referral within those small regions to the team assigned to that territory. The clinicians know that those cases are coming to them. They do not have to manage cases across the entire 50-mile radius of the agency. They have the opportunity to own their territory.

The verbiage is important—own your territory. Erase that label, “part-time” and emphasize “ownership” instead.

Ownership of territories also creates consistency of care. Not constantly staffing visits with the PRN clinician du jour leads to better patient satisfaction and ultimately better outcomes. The efficiencies of knowing a small area well, be it the traffic patterns, the train schedules, school release times, further allow clinicians to efficiently see patients. This ownership of territories is important when it comes to staffing for vacations. It is far easier to entice a clinician to cover someone else’s region if they know it is for only a short time frame. Conversely, the vacationing employee knows they will have a case load to come back to.