Specific Interdisciplinary Care Plan

When a loved one enters hospice care, a specific interdisciplinary care plan is created to provide tailored treatment for the member.
Passionate Heart Hospice will utilize a case management system to guide an interdisciplinary group to provide comprehensive, coordinated hospice care to patients and family/caregivers. It is the responsibility of the Clinical Supervisor/Nursing Supervisor to assign a Case Manager who is a Registered Nurse (RN). The Case Manager will be responsible for coordination of services with the interdisciplinary group from referral to discharge.

The type and scope of services provided by the interdisciplinary group will be based upon the comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals, and interventions. The exact combination of services and the level of care will be unique to each patient and family/caregiver, and it will change as the needs of the patient and family/caregiver evolve over the course of their involvement with hospice.

The interdisciplinary group will maintain responsibility for the provision and coordination of care, regardless of the setting where care is provided to its patients.