Mont. Medicaid Hospice Policy Manual, Policy 411

INTERDISCIPLINARY GROUP,

CARE PLANNING AND

COORDINATION OF

SERVICES

The hospice must designate an interdisciplinary group which in

consultation with the member's attending physician, must prepare a

written plan of care for each member. The plan of care must specify

the hospice care and services necessary to meet the member and

family-specific needs identified in the comprehensive assessment

as they relate to the terminal illness and related conditions.

APPROACH TO

SERVICE DELIVERY

The hospice must designate an interdisciplinary group or groups

composed of members who work together to meet the physical,

medical, psychosocial, emotional, and spiritual needs of the

hospice members and families facing terminal illness and

bereavement.

Interdisciplinary group members must provide the care and

services offered by the hospice, and the group, in its entirety, must

supervise the care and services. The hospice must designate a

registered nurse that is a member of the interdisciplinary group to

provide coordination of care and to ensure continuous assessment

of each member's and family's needs and implementation of the

interdisciplinary plan of care. The interdisciplinary group must

include, but is not limited to, members who are qualified and

competent to practice in the following professional roles:

1. A doctor of medicine or osteopathy (who is an

employee or under contract with the hospice);

2. A registered nurse;

3. A social worker; and

4. A pastoral or other counselor.

If the hospice has more than one interdisciplinary group, it must

identify a specifically designated interdisciplinary group to establish

policies governing the day-to-day provision of hospice care and

services.

PLAN OF CARE

All hospice care and services furnished to members and their

families must follow an individualized written plan of care

established by the hospice interdisciplinary group in collaboration

with the attending physician (if any), the member or representative,

and the primary caregiver in accordance with the member's needs.

The hospice must ensure that each member and the primary care

giver(s) receive education and training provided by the hospice as

appropriate to their plan of care.

CONTENT OF THE

PLAN OF CARE

The hospice must develop an individualized written plan of care for

each member. The plan of care must reflect member and family

goals and interventions based on the problems identified in the

initial, comprehensive, and updated comprehensive assessments.

The plan of care must include all services necessary for the

palliation and management of the terminal illness and related

conditions, including the following:

1. Interventions to manage pain and symptoms;

2. A detailed statement of the scope and

frequency of services necessary to meet the

specific member and family needs;

3. Measurable outcomes anticipated from

implementing and coordinating the plan of

care;

4. Drugs and treatment necessary to meet the

needs of the member;

5. Medical supplies and appliances necessary to

meet the needs of the member;

6. The interdisciplinary group's documentation of

the member's or representative's level

understanding, involvement, and agreement

with the plan of care, in accordance with the

hospice's own policies, in the clinical record;

and

7. Services must be consistent with the plan of

care.

REVIEW OF THE

PLAN OF CARE

The hospice interdisciplinary group (in collaboration with the

member's attending physician, if any) must review, revise and

document the individualized plan as frequently as the member's

condition requires, but no less frequently than every fifteen

calendar days. A revised plan of care must include information from

the member's updated comprehensive assessment and must note

the member's progress toward outcomes and goals specified in the

plan of care.

COORDINATION OF

SERVICES

The hospice must develop and maintain a system of

communication and integration, in accordance with the hospice's

own policies and procedures to:

1. Ensure that the interdisciplinary group maintains

responsibility for directing, coordinating, and

supervising the care and services provided;

2. Ensure that the care and services are provided in

accordance with the plan of care;

3. Ensure that the care and services provided are based

on all assessments of the member and family needs;

4. Provide for and ensure the ongoing sharing of

information between all disciplines providing care and

services in all settings, whether the care and services

are provided directly or under arrangement; and

5. Provide for an ongoing sharing of information with

other non-hospice healthcare providers furnishing

services unrelated to the terminal illness and related

conditions.