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The hospice care approach promotes and provides optimal care with the patient and family being an important part of the process. The patient and family direct all care.
Purpose of the Team Model
The primary purpose of the team approach is to build a caring community for the patient and family. By doing this the team can respond to the needs of the patient and family, 24 hours a day, seven days a week. The entire team is responsible for the physical, emotional, and spiritual needs of both the patient and family members. The patient and family are integral parts of the team and direct the care.
Team Structure
Members of the hospice team include, first and foremost, the patient and family. The role of the hospice team includes direct patient care, indirect patient care, consultative, and supportive care. Each member of the team is crucial in the process of providing consistent, coordinated quality care.
Nurse
The nurse is primarily responsible for the patient's physical condition and comfort. He/she is highly skilled in caring for the physical care of patients and working with the physician. The nurse is also responsible for educating the patient and family on physical care, which includes hands on care by family members, medication administration, equipment, skin care, and nutrition.
Social Worker
The social worker provides emotional support to patients and families, helps with grief and other issues, and supports the patient, family, and significant others. He/she provides assistance for patients and families related to community resources, financial issues, legal issues, advance directives, and funeral arrangements.
Counselor/Chaplain
The counselor or spiritual professional may also be known as the chaplain. Hospice spiritual care is all-inclusive and not specific to any religious faith. Hospice spiritual care is non-judgmental and focuses on healing, forgiveness, and acceptance. Spiritual care is provided through direct counseling with the patient and family by working with the patient's and family's own clergy, or by working with patients who do not have a clergy person and are now in need of spiritual care.
Spiritual support can include prayer, rites, rituals, and assistance in planning and performing funerals and memorial services.
Patient's Primary Physician
The patient's primary physician is also part of the interdisciplinary team. The primary physician is usually responsible for referring the patient to hospice and provides current medical findings, and orders for medications, treatment, and symptom management.
Hospice Medical Director
The hospice medical director is also a physician member of the interdisciplinary team. While the primary physician may have little ongoing interaction with the hospice team, the hospice medical director is responsible for guiding the team with medication orders for pain and symptom control, general treatments, and development of individualized plans of care. The hospice medical director ultimately has the final responsibility of the patient's care while on hospice.
Certified Nursing Assistant (CNA)/Home Health Aide (HHA)
HHA's provide basic physical care to the patient. They provide personal care including bathing, grooming, mouth care, skin care, transfers, and repositioning. HHA's also educate family caregivers in basic physical care. They may be able to take the patient for a walk or wheelchair ride outside, which the primary caregiver may be unable to do without assistance. Visits vary depending on patient and family needs.
Volunteer
Hospice volunteers are special people with the desire to give of their time to work in a variety of roles. The most common role is to work with a single patient and family providing support. Support can be provided through companionship, delivering medications, running errands, driving patients to appointments, taking patients on outings, shopping, hairdressing, preparing a special meal, or visiting patients in nursing homes. Volunteer roles are varied and sometimes specialized. There may be bereavement volunteers who work exclusively with grieving families and friends. For those patients who are alone or with family who require additional support, there are volunteers who will sit at the bedside. Nursing home volunteers provide much needed companionship to hospice patients who reside in nursing facilities.
Consultative Team Members' Roles and Responsibilities
These team members act as consultants to the primary patient care team members and also indirectly or directly provide services to patients and families.
- Physical Therapist
Physical therapists are consulted for equipment and exercise to promote optimal independence. Their goals for hospice patients are to improve mobility so the patient can remain as independent as possible. - Occupational Therapist
The occupational therapist is utilized for equipment and providing options so patients may care for themselves as long as possible. Occupational therapists often work with bed-bound patients or those with limited strength. They explore ways with the patient to continue activities such as brushing their teeth and dressing themselves. The goal is for the patient to find quality of life in independent self-care. - Respiratory Therapist
Some hospice patients have respiratory problems that cause discomfort. Respiratory therapists provide interventions and treatments such as oxygen therapy, breathing exercises, and changes in the environment that promote easier breathing and decreased anxiety. The goal is symptom control for these respiratory problems.
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