Hospice care is a patient — centered care. It is individualized to meet a terminally ill patient’s and his/her family’s specific needs. To do so, hospices develop and oversee with the help of its Interdisciplinary Team and the attending physician what is called a Plan of Care (POC). The POC is basically a road map of the needs and services that must be provided to a patient for whom curative care is no longer an option.
However, over the years, many providers have struggled with individualizing the Plan of Care. In fact, in 2019, the Centers for Medicare and Medicaid Services (CMS), through the regulatory surveys facilitated by the organization, discovered that around 60% of hospices have failed to develop an individualized POC. On top of this, other deficiencies found related to its implementation were hospice staff’s failure to conduct direct — care visits, insufficient visit documentation, incomplete POCs, and inconsistent IDT meetings due to outdated POCs.
If your agency is facing the same concerns which may affect your survey results, here are some tips to help you develop an effective, updated, and complete Plan of Care.
The POC should be developed from the initial and comprehensive assessments you have made wherein problems and needs associated with the patient’s illness are identified. Based on these problems, you should determine the necessary interventions and goals for pain and symptoms management. Make sure that all services included in your POC are linked to the initial and comprehensive assessments and that their scope and frequencies are detailed. Medical supplies, appliances, drugs, and treatments specific to the patient’s needs should be reflected. Outcomes from the POC coordination and implementation should also be measured. Lastly, your IDT should document and record the patient or the patient representative’s level of understanding, involvement, and agreement with the POC.
It is critical that your IDT works closely together to make sure that the patient and his or her family is afforded with comfort and dignity during care delivery. IDTs should, at the minimum, be composed of nurses, physicians, social workers, and pastors or spiritual counselors. Primary caregivers, therapists, aides, and volunteers can also join the IDT in support of the patient’s needs. Your IDT should develop the POC upon hospice election and update it regularly within the care period. To provide a holistic support, there should also be a bereavement POC for the family and primary caregiver for after-patient expiry support.
It is a requirement by CMS that a Registered Nurse (RN) be assigned to act as a coordinator to ensure that quality care is timely provided and coordinated. The RN coordinator could also offer direct nursing care to the patient as well as ease collaboration within the IDT. He or she will oversee the implementation of the POC by making sure that it is individualized and consistently updated. Some of the responsibilities of the RN coordinator are to document and revise patient care goals and objectives, regularly assess the patient’s needs in collaboration with the IDT, facilitate information exchange between the IDT and the patient or patient representative, and oversee that the Plan of Care is successfully implemented.
"Taking these necessary steps will ensure that you not only remain compliant with the hospice Conditions of Participation (COPs) but also preserve the heart of hospice - a patient-centered care."
Data Soft Logic, as your intelligent care partner, is guided by the principle that the Plan of Care (POC) is the living, breathing, and most dynamic document of a hospice agency. As such, we have developed solutions to ensure that any changes to a patient’s information within Hospice Centre are automatically reflected in the Plan of Care. You can be sure that your patients’ POCs are always compliant, updated, complete, and effective. To know more about Hospice Centre and how it can empower your passion for compassion, schedule a demo with us now.
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