Patient Referral

The healthcare professionals of a hospice care team work together to ensure that patient needs are satisfied. This section will go into detail on each team member’s role, both for the sake of patients and caregivers, as well as those seeking a career.

The responsibilities of each member of the hospice care services team are:

Physician: The physician is responsible for identifying a patient’s need for end-of-life care, and making a referral. The physician is also responsible for providing hospice information for families and patients, including how hospice works. They are encouraged to remain involved as a member of the patient care team, and to actively participate in the hospice plan of care.

Hospice Medical Director: The hospice medical director provides an oversight of patient care and support to the hospice care team. The hospice medical director attends a team conference to discuss the plan of care by assisting in establishing goals, and participating in decisions regarding patient care.

Registered Nurse Case Manager: The registered nurse case manager coordinates the plan of care with the physician and hospice medical director through initial and ongoing nursing assessments. The nurse visits the patient two or three times a week, or as needed, to ensure all distressing symptoms are effectively managed and that patient and family needs are being met. The RN supervises all care provided by the licensed practical nurse and home health aide, and coordinates care with the other members of the hospice care team to ensure patient and family spiritual and psychosocial needs are met.

Social Worker: As a member of the hospice care team, the social worker provides initial and ongoing psychosocial assessments (mental, emotional, social, and spiritual dimensions of the patient) and establishes a psychosocial plan of care. The social worker normally sees the patient once or twice a month to provide emotional support and ensure patient and family psychosocial needs are being met. The patient/family or any member of the hospice care team can request additional psychosocial visits as needed. The social worker can provide assistance and hospice information to families and patients. This could include helping the patient with a Do Not Resuscitate (DNR) order, assisting with finding community resources, and making arrangements for nursing home placement or transfer to inpatient care facility. The hospice social worker can also provide counseling to the patient or family in times of crisis.

Chaplain: The hospice chaplain provides spiritual support to the patient and family as needed. The chaplain visits once or twice per month or more often if requested. The care provided by the hospice chaplain can address religious issues, however the focus of care is more spiritual, in nature, than religious. Care by the hospice chaplain is non-denominational.

Bereavement Counselor: The bereavement counselor can help the patient deal with the grief associated with declining health and guide the family through bereavement before and after the loss of a loved one. The bereavement counselor can provide bereavement services to the family up to a year, or longer, after a loved one passes.

Home Health Aide: The home health aide assists the patient and family with personal care needs and light housekeeping. They also inform family members how hospice works, and teach the correct and safe method for providing personal care to the patient. The home health aide supplements the care provided by the nurse case manager.

Hospice Volunteer: The hospice volunteer provides companionship and support to the patient and family. All hospice volunteers are required to attend volunteer training at the hospice. The volunteers of Crossroads assist with general services and offer companionship for the patient.

How can the hospice care team help?

The hospice team works together to ensure all the patient’s needs are met. We partner with the patient’s primary care and specialist physicians to address their physical needs, keeping the physician in the loop about how their patient is progressing. We work hand-in-hand with families, meeting them and their loved one where they are to provide additional care designed to keep their loved one comfortable. Working together to care for the whole patient allows the hospice team to address your loved one’s unique challenges and needs.

Additional resources about the hospice team in general

Additional resources about hospice team member roles

Resources for prospective employees