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Hospice interdisciplinary care plan



I currently work at a brand new assisted living facility. I am the Director of Nursing. We just admitted a resident that is on hospice (why? she is doing really well). My question is, any tips on doing an Interdisciplinary Care Plan? Is there a specific form I can download? i am set to have a care plan meeting with the hospice nurse this week and don't want to look like a complete idiot. :)

Thanks for your help.


Jensmom7, BSN, RN

Specializes in Hospice. Has 36 years experience.

Ok, just FYI, you can be doing "really well" and qualify for Hospice. It's a common misconception (unfortunately) that you have to have one foot in the grave and the other on a banana peel to be admitted to Hospice.

The Hospice Nurse should have a copy of the Hospice Plan of Care to leave with you. One of the elements of it (IF the patient has a DNR) will be "No hospitalization or ER visits, no labs, tests or meds without first notifying Hospice. Call Hospice at ________ with any change in condition and when patient expires". If the patient has no DNR, then they will have to be sent out per facility policy.

The care plan will focus on symptom management. I know facilities get twitchy about getting tagged if someone loses weight or stays in bed a lot, but remember-Hospice is comfort focused. Most of the time our patients lose weight, no matter how many Magic Cups are shoved at them. They also tend to need more time to recharge their batteries, so they sleep more. I'm finally starting to convince the CNAs at my facility that they won't get in trouble if one of my patients skips a meal or two.

Remember, you aren't doing this in a vacuum. There's a whole Hospice team ready and willing to educate you and your staff. We really mean it when we say "Ask any of us if you have questions. Or call our office." You're the primary caregivers-you get the same emotional support as family members in a home setting get.


Specializes in Hospital medicine; NP precepting; staff education. Has 20 years experience.

When I was a hospice nurse, our care plans were placed directly in the resident's charts, but the facility had their own. I like Jensmom's suggestion, it makes sense.

The interdisciplinary care plan should be focused upon the goals of the patient.

As previously mentioned, hospice will provide a specific and (if they are doing it correctly) reasonably detailed POC. That POC will be focused upon the goals specific to end of life preferences and expectations of the patient, their family, and the health professionals working with them.

The hospice team will be more than happy to help your staff understand how to best serve and support your new resident who likely has fewer than 6 months to live or is expected to experience a significant functional decline in the coming months.

Good luck.

vampiregirl, BSN, RN

Specializes in Hospice. Has 11 years experience.

I've collaborated w/ several facilities on their care plans for hospice patients. One of the items to include on the care plan will probably be a statement about collaboration and communication between your facility and the hospice.

I agree with the above posters. Most of us hospice nurses welcome opportunities to work w/ facilities who are also providing care for our patients. You could even collaborate on a generalized care plan template that could be customized for each patient... that's how the hospice I work for does care planning internally. We have a goal related to symptom management personalized with each patient's goal for care, one addressing pain management, and another that addresses responsibility for knowledge/ interventions. We have a separate goal that addresses collaboration with other facilities and one that defines the aide care plan. Any procedures (wound care, catheter, ostomy etc have their own goal). Theses goals also meet regulatory compliance on the hospice side.

I will say one of the things I love about hospice is that the care plan really is a road map to the care we provide. When I worked LTC, we wrote care plans but they were too cumbersome, difficult to access to really implement as they are intended.