Interdisciplinary Team Plan of Care

Hospice Program of Care – Interdisciplinary Team Plan of Care
The hospice interdisciplinary team collaborates continuously with the patient’s attending physician to develop and maintain a patient-directed, individualized plan of care. The plan is based on interdisciplinary team assessments which recognize the patient and family’s physiological, social, religious, and cultural variables and values.

Plans will include a minimum of:
• Patient and family problems and needs
• Realistic and achievable goals and objectives
• Frequency and mix of services and levels of care to be provided
• Agreed upon outcomes
• Prescribed and required medical equipment and supplies
• Patient and family understanding, agreement, and involvement with the plan of care

Other aspects that may influence the development, review, and revision are:
• The use of advance directives
• Ensuring the care plan is followed in all care settings
• Regularly scheduled interdisciplinary team conferences
• Documenting team findings and conclusions
• Providing for revision or review at a minimum of every 14 days after admission for home care and every 7 days for acute inpatient.

A written plan for bereavement intervention will be initiated and developed prior to providing bereavement care. The plan is based on an assessment of the needs of the bereaved family and recognizes their social, religious, and cultural variables and values. At a minimum, the bereavement plan documents:
• An assessment of risk factors
• Goals
• The scope, type and frequency of follow-up services
• The family’s acceptance of bereavement services