The Attending Physician makes the referral to Hospice as this is usually the patient's Primary Care Provider. The Doctor is encouraged to continue and follow the patients care while on Hospice, but at the very least is expected to be updated as the patient's condition changes. With continued involvement from the Attending Physician there is a better continuity of care for the patient.
Hospice Medical Director
The Hospice Medical Director provides oversight over the Hospice team for all of the patients. The Doctor does this by participating in Interdisciplinary Group (IDG) meetings and acting as a resource for the Nurse, Social Worker and Chaplain. The Hospice Medical Director usually follows with the Attending Physician on the care plan, but has the capability to become the Attending Physician should the patient's Primary Care Provider not want to follow.
Registered Nurse Case Manager
The RN Case Manager creates and manages the patient's care plan with guidance from the Attending Physician and/or the Hospice Medical Director. The RN Case Manager makes patient visits as little as once every two weeks to as much as three times a week or more, if the need occurs. The RN Case Manager supervises the Licensed Practical Nurse (LPN) and the Hospice Aide (CNA) that make visits to patients.
The Social Worker completes an initial psycho social assessment with the patient and/or their families to establish a care plan. The Social Worker than makes one to two visits per month with the patient to update the care plan. The patient and/or families may request additional visits in a month if there are additional needs that need to be met. This individual typically provides resources on Counseling, Do Not Resuscitate (DNR), assisting with financial and community resources and placement (permanent or for Inpatient Respite/General Inpatient (GIP)).
The Chaplain completes an initial spiritual assessment with the patient and/or their families to establish a care plan. The Chaplain then makes one to three visits a per month with the patient to update the care plan. If the patient and/or family do not have a spiritual provider within the community then he or she will assume that role. If the patient and/or family have an existing spiritual provider within the community, then the Chaplain can help establish a home visit from that spiritual provider. Care provided by the Chaplain is non-denominational and is accepting of all faiths and beliefs. The Chaplain can represent the Hospice as an officiant over the funeral.
The Hospice Aide (CNA) follows the care plan established by the RN Case Manager during the initial visit. The CNA will bathe and provide personal care to the patient, while also providing light housekeeping for the patient and/or family. The CNA is highly skilled in showing family members and/or caregivers the correct methods of positioning and providing other personal care. The visits from the CNA range from one time a week up to three or more times per week.
Hospice Volunteer - A volunteer is provided when the RN Case Manager determines that there is a lack of company or companionship with the patient, and the patient and/or family request additional company or companionship. A Volunteer for any need can be provided and the needs usually range from reading, knitting, completing puzzles to watching a movie or general conversation. The Volunteer is hands off and is not allowed to provide any physical care to the patient.
The Bereavement Counselor role is usually carried out by the Social Worker or Chaplain. An initial Bereavement Assessment is completed with the patient and/or family upon admission to Hospice. The Bereavement Counselor keeps contact with the Hospice Team, patient and/or family throughout the patients time to help counsel any of the changes that are occurring. This individual completes a second Bereavement Assessment upon discharge from services to determine any changes from the first Assessment. The Counselor will continue contact with friends, family and even the facility (if the patient lived in one) for a period of up to 13 months through phone calls and mailings. If further professional support beyond what the Bereavement Counselor can provide, a referral is made to a higher professional.