Hospice Functional Areas: Comprehensive Overview of Interdisciplinary Teams

Hospice care is delivered by an interdisciplinary team (IDT) across eight core functional areas, each addressing holistic patient and family needs.

1. Administration

• Leadership, operations, finance, HR, IT, compliance, quality, strategic planning.

2. Nursing

• RN case managers: assessment, symptom management, care planning, coordination.
• LVN/LPN: direct care, medication administration, wound care.
• On-call / triage nursing 24/7.

3. Medical

• Medical Director: overall clinical oversight, policy, certification/recertification.
• Hospice physicians / NPs: home visits, symptom management, complex decisions.
• Collaboration with attending physicians.

4. Social Work

• Psychosocial assessment, counseling, advance care planning.
• Resource linkage: Medicaid, Meals on Wheels, caregiver support, legal aid.
• Crisis intervention, family dynamics, discharge planning (if revocation).

5. Spiritual Care

• Chaplains: spiritual assessment, support, rituals, legacy work, existential distress.
• Respect all faiths/non-faith; non-proselytizing.
• Bereavement support for families.

6. Volunteer Services

• Recruitment, training (12+ hrs), background checks, supervision.
• Roles: companionship, respite, errands, vigil, bereavement calls, admin support.
• Medicare requires volunteers = 5% of patient care hours.

7. Bereavement Services

• 13-month minimum follow-up after death.
• Individual counseling, support groups, workshops, memorial services.
• Risk screening for complicated grief.
• Community outreach.

8. Quality Improvement (QAPI)

• Performance measurement: CAHPS, NHPCO metrics, symptom management outcomes.
• PIPs (Performance Improvement Projects), root cause analysis.
• Regulatory compliance (CoPs), survey readiness.
• Staff education, competency validation.

Integration

IDT meetings (at least every 15 days) coordinate care plans. Each discipline documents in shared record. The patient/family is the center.