Hospice Care Team and Coordinated Care Program
Establishes the Agency’s hospice care team (the Medicare interdisciplinary group) with at least a Florida-licensed physician, a nurse, a social worker and a pastoral or other counselor (s. 400.6105(3), F.S.; 42 CFR §418.56(a)); the full-time registered nurse who coordinates each plan of care (s. 400.6105(2), F.S.); the written plan for cooperative planning, decision-making and documentation required by Rule 59A-38.005(2)-(3), F.A.C.; team meetings; the medical director’s part in care conferences; and how the team shares information across disciplines, settings and outside providers (42 CFR §418.56(e)).
- Policy number
- FL-HSP-IDG-01
- Version
- 1.0
- Main rule
- s. 400.6105(3), F.S.
- Library
- Florida hospice · 60 policies
- Category
- Hospice care
- Sections
- 19
In short
- Every patient has a hospice care team (physician, nurse, social worker and counselor) and a named coordinating RN.
- The team reviews each patient at least every 15 days; meetings are held at least every 14 days.
- Attend the meeting or send written input first, then read the decisions within 2 business days.
- Do not wait for a meeting when something urgent changes: call the coordinating nurse and the physician now.
- Share the plan of care and changes with facility staff and the attending physician.
What's inside
19 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (s. 400.6105(2)-(3), F.S.; Rule 59A-38.005(2), F.A.C.; 42 CFR §418.56(a))
- 5. Team Composition
- 6. The Coordinating Nurse
- 7. The Agency’s Plan for Coordinated Care
- 8. Around-the-Clock Access and Continuity
- 9. Team Meetings
- 10. More Than One Team
- 11. Communication and Coordination
- 12. Responsibilities
- 13. Records and Compliance Monitoring
- 14. Staff Training
- 15. References
- 16. Related Policies and Forms
- 17. Approval
- 18. Revision History
An inspector may ask
- Who is on the hospice care team for this patient? Which registered nurse coordinates the care?
- How often does the team meet, and how is attendance recorded?
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