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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 holistic hospice care for the patient and the family.
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THE HOSPICE INITIAL AND COMPREHENSIVE ASSESSMENT
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The initial and comprehensive assessments are the drivers for all care and care planning. There is a direct link between the needs identified in the patient assessment, the POC developed by the hospice team, and coordination of that care. These two processes are linked in a continuous cycle, one driving the other. Figure 3.1 provides an overview of the process for hospice care planning.
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The hospice regulations allow for the IDG to complete an initial assessment per the patient’s admission scenario and needs. An initial assessment must be completed by a registered nurse (RN) within 48 hours from the effective date of the patient’s hospice election. The purpose of this initial assessment is to identify the patient’s/family’s immediate care needs in the location where the patient will receive hospice care. 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. Examples of this situation could be when a patient is discharged from the hospital 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 they are 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 patient’s imminent death. When this happens, the patient is discharged due to death. Your hospice will have a policy and procedure to manage this scenario. Contact your supervisor should this occur.
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The regulatory requirements for the initial and comprehensive assessment are contained in the Medicare hospice Conditions ...