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Hospice care is individualized by the interdisciplinary group (IDG) for each patient and the patient’s family. Needs are assessed through an initial and comprehensive assessment process, and the IDG develops a plan of care (POC) to meet those needs. The assessment and care planning processes are continuous and overlapping and depend on the IDG’s planning and coordination of care skills. This part discusses the comprehensive assessment and the POC as it relates to planning, management, and coordination of care for the hospice patient and the family.


The initial and comprehensive assessments are the drivers for all care and care planning. The following information will help to delineate the difference and the important data needed for these requirements.

Initial Assessment

To deliver the right care to the patient and family, there must first be an assessment by the hospice IDG. An RN has 48 hours from the effective date of the hospice election to complete an initial assessment of the patient’s needs. The regulatory requirements for the initial and comprehensive assessment are contained in the Medicare hospice Conditions of Participation (CoPs) at §418.54 Condition of Participation: Initial and Comprehensive Assessment of the Patient. The purpose of this initial assessment is to collect the information necessary to treat the patient’s/family’s immediate care needs in the location where the patient will receive hospice care. The regulations specify that the RN must be the first to begin the assessment process for the IDG (Centers for Medicare and Medicaid Services [CMS], 2008).

An initial RN assessment works well when there is a short window of time to determine the pressing needs of the patient. Generally, an initial assessment takes place in a shorter time than a comprehensive assessment, and the RN communicates and coordinates with the patient’s attending physician and hospice physician about the patient’s priority needs and interventions for symptom management (CMS, 2008). Examples of this situation could be when a patient is discharged from the hospice late in the day and is too tired for a long admission visit. The RN would assess and meet the patient’s immediate needs and plan to return the next day to complete a more in-depth nursing assessment of the patient’s/family’s needs and to begin developing the POC. Another example of the initial assessment being appropriate is a patient who is referred to hospice care when he or she is imminently dying. In this situation, the RN is assessing the patient’s urgent needs to provide care that enhances comfort and maintains dignity. Depending on the patient’s status, the rest of the IDG may not be able to complete a comprehensive assessment before the patient dies. If that happens, the IDG members who were not able to complete their assessment would document in the clinical record that they could not complete it because of the ...

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