Q: What are the necessary components to the plan of care for residents receiving hospice services?
A: To establish and maintain continuity of care, the facility and hospice must collaborate in the development of the resident’s plan of care and includes the following:
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- The coordinated plan of care must identify the provider responsible for performing each or any specific services/functions that have been agreed upon
- The plan of care may be divided into two portions, one maintained by the nursing home and the other maintained by the hospice, and both must be aware of the location and content of the coordinated plan of care (which includes the nursing home portion and the hospice portion)
- The plan of care must be current and internally consistent to ensure that the needs of the resident for both hospice care and nursing home care are met at all times
- Based on the shared communication between the hospice and the nursing home, the coordinated plan(s) of care should reflect the identification of:
- Diagnoses
- A common problem list
- Palliative interventions
- Palliative goals/objectives
- Responsible discipline(s)
- Responsible provider(s); and Resident/designated representative choices regarding care and goals
Written By:
Liz Wheeler, BSN, RN, CHPN, IPCO, QCP, CDP
Clinical Consultant
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