Interdisciplinary Team, Care Coordinator, Withdrawal from Hospice

Interdisciplinary Team: Basic Hospice services may include visits from Physicians, Medical Residents, Medical Interns, Registered Nurses, Social Workers, Chaplain, Volunteers, Home Health Aides or Certified Nursing Assistants. As a teaching institution, Hospice offers clinical internships for students in all professions of the interdisciplinary team. Students and Interns may be included in home visits by Hospice professionals. Other professionals may be called on from time to time to assist in the care of the patient. Need for these services will be reviewed by the Hospice team as the needs change. The patient will be consulted regarding changes.

Care Coordinator: During a patient's participation with Hospice, it is usually the Care Coordinator (a family member, a close friend, or someone hired to provide this assistance) who is responsible for seeing that the physical needs of the patient are safely met on a day-to-day basis. Sometimes the Care Coordinator role is shared among several individuals. The Care Coordinator assures the patient's safety and well-being in the home, at all times. The Care Coordinator also conveys appropriate information about changes in the patient's condition to members of the Hospice team. This communication helps the Hospice Team anticipate the changing need for services (such as additional help in the home, supplies or medications).

Withdrawal: The patient may withdraw from Hospice at any time. Additionally, Hospice may discharge a patient based on the following criteria: patient no longer requires Hospice services as they desire curative care not consistent with Hospice philosophy; patient/family/caregiver are not in agreement with Hospice plan of care and elect to discontinue services; patient is no longer terminal (six months or less), or the medical director and/or attending physician determine the patient is not Hospice appropriate; patient chooses another Hospice program; patient leaves service area of Hospice of the Charles County; family or care coordinator not providing or arranging appropriate caregiving assistance.