Panel Discussion: How To Staff After-Hours

The following transcription has been edited for brevity and clarity.

Smith (IntellaTriage): Many hospice and home health organizations struggle with efficiently and effectively managing calls that come in after-hours and lack the data to help improve their processes. The three most common models are non-clinical answering service, internal nurse team, and external nurse team. Let’s discuss the pros and cons, the impacts, and what to consider for your strategy.

When you think about it, after-hours comprise 75% of the week. Today as we take a deeper dive into understanding the different models available, ask yourself, “Have I been thinking about this from the best angle? Do I have the best model in place for my patients, caregivers, and my nurses?”

Carla Davis, LHC Group (who recently acquired Heart of Hospice): I will speak about the Heart of Hospice model and where we are now in the overall LHC organization. We are taking some aspects of Heart of Hospice, bringing it across the country, and studying which elements we want to do. For example, we had a bifurcated model where calls for patients on service go in one direction and calls for potential patient referrals go differently. You might want a separate structure for patients you’re caring for and those not yet admitted. For the patients on our census, we have:

1. A contract with a non-clinical answering service
2. A centralized internal nurse triage team
3. At the agency level, we have the clinical team on call. The on-call clinical team model varies by the size of the agency. We established this centralized model for about 1700 patients and 16 different locations across five states.

Lisa Schmitz (CommonSpirit Health at Home): We have an internal call structure supported by a non-clinical team. They are not external contractors, but instead, they are our employees (it’s called the Star Center). There is no internal or consolidated nurse triage group, but we use external nurses. These nurses sit at their respective branches, then work the calls after receiving them from the Star Center. It’s one pipeline: referrals, calls, and the patients on our census. It’s a lot coming into one spot.

Barbara Knott (UNC Health): Our after-hours are Monday through Friday and on weekends. We hire an external nurse-triage company to manage our on-call services. They answer the phone as UNC Hospice. Our home health and our home infusion nursing program are attached to this same company as an outsourced service. The company will answer the phone based on where the call is coming from (UNC Home Health/UNC Hospice/UNC Home Infusion Nursing, depending on where it’s coming from). A registered nurse answers the phone and triages and troubleshoots any calls received. We collaborated and created these protocols when we first contracted with this service so that nurses are speaking and functioning the same as if one of our nurses were answering the phone.

Smith: What happens when escalation needs to occur? Who is doing that in each of your models now, and what happens next?

Davis: With the outsource service, the nurse will try to handle any call, but we set up what an escalation would look like in our protocols. For instance, if a patient calls twice, you automatically call the nurse in hospice, home health, or home infusion. We still have an on-call nurse from our agency, but it’s only for answering escalations, not any of the other calls.

When our calls come in, they will press one button for hospice, one for home health, and a non-clinical individual answers the initial call. If it is patient-related, the Star Center team member sends the call to the nurse at the respective branch. At times, there is some struggle with the connection because of the volume of calls we’re answering in the Star Center. Then there’s the wait time for that nurse to return to that patient or family. It can take quite a long time. Our average wait times on the original calls can be from 51 seconds up to 9 minutes depending on the volume, the time of day, after hours, and weekends. We also have staff calling that number occasionally to have something changed in the EMR, etc., so the wait times can be long in 51 seconds – to 3 minutes. Three minutes doesn’t sound like a lot, but when talking to a hospice patient or uncomfortable family member, extend that time in your head because it feels more like 3 hours to them. Three minutes can feel like three years when you’re with a family member or a loved one making a new sound or a sound that you’re not familiar with or knowing their pain has escalated to such an extent.

Davis: We realize, too, that patients/caregivers don’t call until it’s reached a point where they felt like they had to, so there has been a great deal of anxiety long before they picked up the phone. The non-clinical answering service passes on every patient care issue, so it is not as if it’s an employee you know fielding a question. Every patient call goes directly to our centralized triage. We staff the centralized triage according to the day and the call volume we have experienced historically. It may be two or three nurses on call, and their role is to try to handle it, if possible, over the phone or to get something started with the patient’s family while the nurse on the ground is hitting the road and in transit to the home. There are many calls that they can handle, and so the only time the nurse on the ground gets called from triage is if the centralized triage is if it is more appropriate to send the nurse on a visit to see the patient in person. We have standards around what triggers a home visit, so we are consistently handling triage calls and so the triage staff knows when to escalate to the nurse on the ground.

A part of our model that might be unique is that we have psychosocial on call. In most of our locations, we have a manager, salesperson, and aids on call since the nurse doesn’t always need to handle the calls. With the nursing shortage, anything that could be taken care of by a non-nurse is. Maybe even better: if the issue is the daughter’s anxiety, a social work visit would better support that. If the problem is that the patient soiled themselves and the caregiver can’t change them, the aide would better handle that issue. If the person on the ground (usually the nurse) cannot resolve the issue, or for some reason, we can’t contact them, or they refuse to go, etc., then the call is accelerated. Triage knows when to accelerate it, and we have specific timeframes for those situations.

Knott: I want to add to the called the answer time. With the company that we use, 35 seconds is the average time to answer, which has been wonderful. People say they’ve never had anybody answer the phone as fast as they do after-hours. So, people call after hours, and we get staff calling to call out sick, patients calling in to ask, “what time is my nurse coming tomorrow” and the triage nurse handles all of that. None of that gets escalated. You’ll have people call just to call sometimes, and these nurses also take care of that. Our average talk time for the nurse to resolve an issue is less than 3 1/2 minutes. We don’t see those calls, so we’ve been pretty satisfied.

Smith: When you use the answering service, does that company have access to your EMR?

Knott: Yes. During this setup, the triage nurses gained access to the EMR. What happens when there’s turnover at the company? We have even given the triage company the access to request new staff access in our EMR to do that on their own. The system notifies me when someone new is accessing the system, so I log in and approve it. But thankfully, that is entirely managed by the company. Turnover is one of the many reasons that we decided to outsource. When there’s turnover at the agency at the hospice or home health, I’m no longer scrambling for who will cover on-call. Now we spread out on-call. On-call is not my issue. It becomes the triage company’s issue to make sure that we’re covered every day, so the only time I ever know that there’s any turnover is when they access they need to access the EMR for a new employee.

Smith [Question from the audience]: Is there a stipend with an entire team on-call, or is it just described as a routine task on hire?

Davis: I will answer based on the model we use; it depends on the employee’s role. We expect the clinicians and the interdisciplinary team to understand that we indeed hire them to be on-call.

Schmitz: Same with our internal model. If we have an administrator on call for escalated instances, and there’s money attached to that, then, of course, there is on-call pay, plus different incentives if they go over because these are nurses and social workers, aids that are working during the week, too. When our staff is out there after-hours/weekends, they are producing, so they receive productivity bonuses. Because they’re going above and beyond, there’s an associated cost.

Smith: Was there an ultimate tipping point when you determined your organization would no longer handle after-hours triage internally?

Schmitz (newly transitioning to external after-hours triage): We had the traditional model where staff worked during the day and then rotated on-call at night and on weekends. The catalyst for this model transition was our inability to hire nurses because they had to be on call. We repeatedly heard, “I need a work-life balance; I need to be able to go to sleep at night and not worry about answering the phone; about being awake all night.” When you think about the kinds of calls that come in on-call, sometimes it’s just “what time is my nurse coming?” A nurse shouldn’t have to be woken up to answer that question. That was what spurred us to start looking at a different model. About two years ago, we made offers to six hospice nurses in a row, and when we talked about on-call, each of them backed out. So, six nurses in a row would not come and work with us because of on-call. We began looking at an outsourcing option and then talked to our staff nurses, “what would you think if we did this?” There was a resounding: “Oh my God, you mean you think I can sleep at night? Do you mean the only call I get will be a call for hospice specifically? I’ll have to go visit because somebody died or something else happened?” So, there wasn’t much reason not to continue investigating this type of service, and we’ve never looked back.

We also started looking at what we needed to grow. We need to do something different and not the exact model we’ve had for the past 20-plus years. It came to a point during our employee survey. One of the questions was about employee well-being and the two items with outstanding scores (not in a good way):

1. I can enjoy my free time without focusing on work matters  
2. My work leaves me emotionally drained

That emotionally drained item was what we focused heavily on. When we did our town halls and our listening sessions, we heard about nurses on-call and working during the day and then not being able to turn that off. In my region in the company, we’ve lost nurses because of that on-call practice. We just are trying to help work-life balance and personal-professional balance, and that well-being piece is essential to us. If our nurses are emotionally drained and working in hospice, and I’m asking them to go out to that patient, they need to have some energy to take with them. That’s why we started looking at how we can do this differently to support our staff and, in the end, provide better outcomes and experiences for our patients.

Davis: We based our decision to create an internal triage center around the same topics. In addition, it helps me to sleep at night, knowing that we are handling these situations consistently across the agencies, no matter what size of an agency, no matter what resource. We are driving consistent quality and compliance in addressing each of these issues. You may have an agency with the new nurse on-call, and this way, at least I know that we are meeting our standard of quality care.

Common Tradeoffs in After-Hours Strategies

Smith: We hear a great deal about the tradeoffs that organizations are thinking about when strategizing to change their model or stick with it and improve upon it. These include employee satisfaction, cost, growth, and patient experience.

Employee Satisfaction

Schmitz: Well-being and peace of mind are essential. Being a nurse myself and doing on-call myself in the past, I understand our nurses’ feelings. Even if you do not receive that call during the night, it weighs on you, knowing there’s a chance you could. I get it when they say, “I know I’ve only had X amount of calls this week, but not being able to leave work behind is a big part for us.” That’s why we began trying to look at doing something different.

Knott: The nurses are very satisfied; they think this is great. That’s some of what we hear with our clients across the board. We all know the impact of the staffing crisis that we’re all undergoing right now, and it’s another way to improve employee satisfaction and retention rates.

Cost

Smith: The loss of a nurse can be somewhere in the range of $40,000 in attrition costs. Some other hidden costs include recruiting, administrative burdens, and more.

Knott: Right – the turnover piece. We attached like $15,000 per client per staff that left, and we looked at the strategy as if we could reduce our turnover and bring it down by 20%. That was a significant savings of upwards of $915,000 in turnover alone. That doesn’t include recruitment costs, sign-on bonuses, etc. As we looked at a different model, we found savings in the on-call dollars; it can result in significant savings to your bottom line depending on your size. That savings can be put towards better wages or attracting different staff members, and then, of course, the administrative costs.

Davis: Whether you’re doing it centralized internally or contracting it externally, you must end up with an expert at triage. Handling these calls that come in and having various things that go wrong and appropriately resolving them requires a particular skill. You can’t always afford that special skill unless you have a more centralized or external specialist model. So if you’re a small agency, you could not afford to have a full-time on-call triage team. By contracting with companies like [IntellaTriage] or by centralizing it, if you’re fortunate to be large enough that you have enough resources to pull together, you can get people who want to do that job and are very good at doing that specialized job. That’s important because it isn’t the same as case managing. Case managers manage triage positions, but it’s a different job.

Smith: You’re absolutely right. We hire experienced hospice nurses and train them to deliver phone triage, which differs from the bedside. So we’re not teaching our nurses how to be hospice nurses – they already know that. Instead, we train them to perform a different job and be experts at that, and you’re right, and that’s a big piece of the puzzle.

Knott: When we outsourced, we increased our cost, but we took on that cost. Before, when it was the traditional on-call, we had an answering service that we paid maybe $1000 a month, which would put every call through no matter what time of day or night it came through. So when we looked at the increased cost of having a home health or hospice-trained nurse answer every phone call that went through, we did not have to worry about calls that did not come through to our nurses … as Lisa has said: work-life balance. Showing that we care about our employees and their well-being, our ability to hire staff when we first go over to the outsourcing company is a huge deal. We started putting a “modified on-call program” in our ads for nurses, which sparked interest in us. We explained it, and we were able to hire more people.

Our turnover rate in 2018 was about 40% for home health and hospice together, which is outrageous and unsustainable, you know that. Now for 2021, it was down to 15%! I wish I could say it was all because of the talent pool, but it isn’t. We’ve done a lot of work, but the on-call model certainly helped. I’m a believer that you get what you pay for, and we have not at any time regretted the decision. Even our finance people(!) have not ever pushed back when they’ve seen the results that we’ve achieved. These results include not having to worry about on-call, not hiring on-call staff, not looking at turnover, and having people doing more on-call because we’ve had the turnover. The finance team doesn’t even push back anymore, and that’s big.

Smith [Question from the audience]: Did you do a cost analysis of external triage versus internal nursing triage?

Knott: When you talk about a cost-benefit analysis, I don’t just look at pennies to pennies. It’s also the intangibles and benefits to the staff and the organization. So, we did pennies to pennies analysis, but if that were the only analysis, we would have kept everything internal. But no – we do not regret ever going to the outsourced company.

Davis: If you have high turnover, ironically, it increases your calls which increases your cost for on-call, so it is difficult to do a complete analysis because you have to think through all of these variables.

Knott: We can also look at our revenue gains, right? So switching and looking at your models differently, we had nurses dedicated to the weekends or after-hours we have seven on, seven off each branch in each area. We didn’t intend to do anything different, but as the nursing crisis hit us, you hired people for what people were willing to do. So we said to the outsourced company, “OK, you’re willing to do seven on, seven off? Are you willing to do Friday from 5:00 to 8:00 AM on Monday (63 hours)?” So we looked at the nurses doing those specialized schedules and going to a different type of model, which means we’re gaining patient-facing case managers not triaging and being able to serve more and bring on more patients. So there are gains, too, in that setup. So, you want to look at your gains. What will you harvest by switching and looking at different models? You’re attracting other nurses who can now work at the top of their license because you’re doing something else. Another way is that now the nurses we’re currently using for our current model, say the weekend warrior position from Friday 5:00 PM to Monday 8:00 AM. When we move into a different way of supporting after-hours, we have these nurses free.

Possibly we won’t need to fill those roles any longer, right? So now, switching them to patient-facing and utilizing them more than just the triage, they are case-managing, doing starts of care, and serving the community more.

I want to add one more thing related to cost and how we’ve also benefited. Every organization has to have staff meetings, those big team meetings, and one or two people must remain behind, answering the phones if patients call in. Then this interrupts nurses and the meeting because it’s a patient on the phone. We can use the outsourced triage company to work with us during the day and answer all of our calls. We just forward our phones over to the company. They take all the calls and then give us a report at the end of the meeting. That was another cost that we thought was worth it and added flexibility.

Control Over Your After-Hours Triage Care

Smith: When people think about outsourcing triage, there is often a concern for some loss of control or they want to hold onto the process. Can any of you speak to that and how you’ve dealt with that?

Knott: In the beginning, we were worried because we didn’t know these nurses, we have not trained these nurses, so it was purely an ‘I’m going just to fall, and you’re going to catch me kind of moment.’ However, we kept a very close eye during the implementation period and how calls were answered and reported on during the transition. We get great reports on every call about how the triage company managed it. If there was an issue during the implementation where one of the nurses may not have strictly followed the protocol as we set it up, we spoke to our representative, who corrected it, and it wasn’t an issue again. We learned to trust. Giving up control is difficult for anybody, but it was a learned trust that the company gave us, and that’s also not something easy to gain when you outsource. They proved that we could take a breath, and we were able to trust that each call would be handled as though it were one of our nurses on the call.

Schmitz: Well, control. If any of the Commonspirit Health people are listening, they’ll crack up that control is something I struggle with, but the pandemic took power away from us. We had to adapt minute-by-minute, hour-by-hour, day-by-day, and that is why, as we talk about doing a different model, I’m OK. We still control it, but our staff is tired and leaving it in their hands to administer after hours, and on weekends, our team feels less burdened, so I’m OK to start sending it somewhere else. Over the past two years with the pandemic, we learned that we’ve had to give up control, and it worked out. We were OK, and we figured it out as we went, so I’m not worried about control. I’m more worried when I have people saying they are emotionally drained, don’t have work-life balance, are tired, and don’t know when they stop and when they start. I’m worried about that and trying to give them the gift “we got this.” Refresh, renew, recharge, and we’ll see you tomorrow. That’s how I look at control.

Davis: I think that’s the same for us. It was probably a little bit less of an issue because they were Heart of Hospice nurses known in the organization when we centralized, so a little bit less of a problem, but the benefits! You always see people get anxious about losing control. When you centralize your referral-to-admission process, people get nervous about it. But still, I work through those issues, too, because the benefit outweighed the burden.

Growth

Smith: How large are your organizations, and can you help us understand how your model of after-hours triage has played a role in your growth?

Davis: We have all different sizes of agencies that we are supporting, from 35 patients to 235 patients. Again, centralizing triage allows the baby agencies to breathe because the nurses don’t have as much responsibility after-hours, which supports growth. The other concept with either of the two larger triage models that we’re talking about is scalability. It helps to grow each agency and roll in more as we make acquisitions. We have a specific model for how much they can handle but rolling into triage and from the beginning helps support the success of the growth. I knew we were achieving this consistency across all of the agencies.

Knott: With home health, hospice, and infusion together, our census is just a little bit under 1000 patients. When I think about growth in our industry, growth is solely dependent on staff. If we’re able to hire staff, we can grow and accept more referrals. We’ve been able to do that without adding nurses to on-call. In February, our service answered 445 calls, so that’s half just about half of our patients called in during February, which was a short month. The triage company handled the calls; they were taken care of.

Schmitz: Our hospice branches vary from 42 censuses to the largest one being 389, and if you include homecare, our total census is around 12 thousand. In February, we had about 2200 calls between home care and hospice that escalated and needed a nurse.

Smith: Can anyone speak to how their model has improved or detracted from the patient experience?

Knott: I can tell you that in our patient satisfaction, we don’t necessarily ask a question about on-call, but we do have comments that patients always provide. I can tell you that not once has there been a complaint about calling after-hours or trying to reach a nurse on weekends. I think that’s because the nurses answer the phone with UNC Home Health, UNC Hospice, so patients believe they’re speaking to one of our nurses anyway.

Schmitz: Maybe the inconsistency a little bit – we’ll get some feedback about that. So, the nurses who work during the day Monday through Friday, traditional hours, are not those who will cover after-hours weekends. So, there’s just that inconsistency concern that we’ll hear about occasionally and just the timeliness. The initial call can be anywhere from 51 seconds to 9 minutes, and then that’s to speak to our non-clinical person, and then it takes time to get it to a clinical person, so that’s some feedback that we’ve received and have been trying to correct.

Davis: OK, so I’ll just chime in from our experience with the contracted external non-clinical answering service. We do receive complaints because they answer for all kinds of businesses and obviously our care is very special and unique, so that is the problem I’m trying to solve. Once they get to the centralized triage nurses, the patient experience is fabulous. However, there is another thing that I thought I would mention about the patient experience that supports a specialized triage model, either centralized internally or externally. You gain oversight regarding care delivery during the day by the kinds of calls coming at night. If you delve into that and categorize those calls, you can start to solve problems and improve the patient experience. For instance, if it’s the clinical staff not doing something. I’ve just discovered that at one of our locations where we were able to look at the aggregated data and nail down a particular situation. Or maybe it’s your DME partner or your pharmacy partner or whatever.

We have categorized each type of call into buckets to analyze it from a quality improvement perspective, improving the patient experience. You can’t do that as easily if it’s all separate.

If you want to know the health of your agency, in my opinion, look at your after-hour weekend traffic and ask different questions, and that’ll tell you the health of your agency and which areas you need to support.

Smith: Many of our clients use that as a QAPI opportunity. They can see your patient running out of DME on a Friday night or a Saturday morning. The nurse should have accounted for that ahead of time. Our clients are using our reporting to educate and streamline processes, ultimately improving the patient experience.  

What Metrics To Consider When Choosing Your After-Hours Triage Strategy

Speed to Nurse and Speed to Visit

Smith: We’ve heard anywhere from 35 seconds to 9 minutes throughout this conversation. We know that 9 minutes is going to alter the patient experience. As Carla said, this is a specialized patient base that we’re working with. IntellaTriage answers the call in under 60 seconds, and our current average speed-to-nurse is 32 seconds. The sooner you reach a nurse on call; the faster that nurse will be able to triage the situation and decide if it’s time to escalate. That’s a crucial element to factor into your decisions as you work through your after-hours triage. How will you measure your speed to nurse, and how you measure your speed to visit?

First Call Resolution

Has the situation been handled during the first call, or do they have to call back? How often? If you’re monitoring your internal measures and understanding what’s happening, that’s a critical piece of this puzzle. At IntellaTriage, we average around 70%, so great if you are in that range. And if you’re not, it’s something to review.

Employee Satisfaction

The biggest employee dissatisfiers that have come up earlier in this discussion are that you have to be on call all the time and have poor work-life balance because you were on call or you’re not able to turn it off altogether when you leave work. So this is a metric to think about when determining your after-hours strategy. As we all know, the nursing staff crisis has reached disturbing proportions, so we want to work to keep our nurses engaged and happy. The nursing turnover in the industry is between 40 and 45%, and that’s huge. That’s a vast number, especially when we think that the attrition cost for each nurse is $40,000.

CAHPS Scores

The different factors discussed today affect your CAHPS score. Here are the national averages – take some time to see where you measure up and how your after-hours strategy can tip the scales toward improving patient satisfaction.

• Communication with family – 81%
• Getting timely help – 78% 

After-Hours Triage Strategy

Triage Education

Davis: The difference between a bedside nurse to a triage nurse is not quite like an ER nurse, but there is a different thought process. We may have strong case managers and great admission clinicians, but triage? Maybe not. I like that point that the pace is different and especially if it’s in a centralized location. So, now you’re answering, your rate is much quicker. An on-call nurse might be accustomed to answering three calls tonight. With a larger team, you’re answering more calls and trying to understand the experience of the patient and/or their caregiver at that moment. You’re doing it over the phone. And you’re trying to nurse to that, and that’s a difficult thing to do. It takes its own unique training and a special set of skills.

Smith [Question from the audience, a small hospice agency]: Can you recommend a phone service that you found helpful? For example, rolling calls from one internal employee to the next if the first person can’t answer the call has been challenging.

Smith: I believe it was Carla who spoke about this earlier. If you’re small, it makes sense to staff on-call internally because you can keep control over what’s happening. As you grow, it’s a little trickier.

Davis: I think his idea of how you set up the phone structures is not something we’ve talked about today. It is essential, and there’s a lot of technology that can support whichever model you do better. We have a phone system that automatically rolls at certain times and days to the triage team or the agency. It’s also set to cycle through just like [the caller] suggested. That’s important regardless of which model you use.

Smith: Yes, that’s how we roll [the incoming calls], too. We’re not at a small hospice agency, but we do the same thing. We have a small team dedicated to whichever agency we’re working on that evening, but if the call volume is extreme for some reason, there is a secondary team that it rolls to. It hits every person in that team before it goes on to the next team of registered nurses. But the call roll is there to make sure that the call doesn’t go unanswered.

Smith [Question from the audience]: Is there a different staff that ultimately goes out to homes or regular daytime staff when they get called out after the answering service escalates?

Knott: Generally, yes, the after-hours triage does answer it, and then when it’s time to escalate it, there are still on-call nurses, and those are the people who will do the visit.

Schmitz: As everyone said, the model depends on who you can find, how large your agency is, and how geographically spread out you are. Think about what layers you have on-call and how many people you have on-call. It has a lot of very variabilities.

Smith [Question from the audience]: Is there a reason that RNs are preferred for after-hours instead of LVN? Regarding cost, who can perform or pronounce a death just in the way an RN can? Does this speak to the COPS (Conditions of Participation)?

Schmitz: It is a COP. I don’t have the exact copy, but an RN needs to take that first call. LPNs cannot triage; they could be your runner. For instance, the RN could triage and decide, and then the LPN can do what they can do. I think of the LPN as our rare library book, and if they’re going to send out the LPN, they need to check with their administrator on-call, but yes, that’s my understanding.

Knott: I agree. I think it’s also state law, not just federal. LPNs cannot do assessments. We want the triage nurse to assess that patient to understand what’s happening and whether or not to confirm a visit.

Davis: Yes, standard practices are very state-specific, but we have experimented with our LPN teams and some of our agencies, but not the triage function. Triage has to be an RN. But there are opportunities to use the LPN on call, and I think as we are facing this nursing shortage, we’re trying to think about all of these things differently.

Smith [Question from the audience]: Do you know what size it makes sense to do it yourself internally versus externally and outsourcing?

Smith: At IntellaTriage, we have found that outsourcing works best for an agency somewhere in the 65 to 75 average daily census (ADC) or above. It makes sense from a cost perspective and a control perspective at that size. It has to do with the number of calls you’re receiving, and once you surpass that 75 ADC, you’re receiving a lot more after-hours calls, which makes it a lot more challenging to manage.

Schmitz: We have not experienced anything different from a cost experience, but from our length of stay dropping, we see some differences. I’m sure everyone is experiencing that churn: admit-discharge-admit-discharge after our weekend support. I’ve been seeing the wheels come off the bus a little bit around 45-50 and even 60 ADC because it’s a faster pace we see in that length of stay. So cost-wise, I think you’re spot on, but I believe stress-wise, for our staff in the field experiencing that higher churn, it’s probably a lower number. That’s been my experience.