The Registered Nurse Case Manager (RNCM) is the primary point of contact for all clinical needs of the assigned client and family. The RNCM is responsible for managing the client’s pain and physical symptoms, while also providing support and education. The RNCM ensures quality of life is achieved in line with the client’s desired plan of care. Each client and family have a unique perspective related to end-of-life needs, and the hospice nurse is trained to make a cultural assessment and provide care specific to the individual wishes. The RNCM typically visits each client two to three times a week to ensure medications are appropriate, pain is controlled, and that all other physical symptoms are addressed. Medicare defines hospice as a “visiting service” and therefore the RNCM is NOT able to care for the client 24-hours a day. The RNCM is responsible to ensure the client and/or primary caregiver is educated on how to appropriately disperse medication and provide symptom management. However, a nurse is on-call 24-hours a day, 7 days a week, and is always available to make a visit or provide guidance if there is a change in the client’s condition, a crisis, or unforeseen situation.

The Social Worker is the primary point of contact for all non-clinical needs of the assigned client and family. The role of the Social Worker is vast and differs significantly between each client. The Social Worker is responsible for assisting the client and family in identifying the areas of need, ranging from emotional, financial, legal, logistical, caregiving, legacy projects and end-of-life planning. The Social Worker is trained to assist clients in navigating through insurance coverage/claims/questions, applications for financial assistance, completing Power of Attorney paperwork, determining appropriate caregiving needs, as well as advocating for clients and families and identifying additional local services and resources. The Social Worker is responsible for supporting the entire family system and providing education throughout the dying process. A Social Worker is on call 24-hours a day, 7 days a week.

The role of a Hospice Chaplain is crucial, as many people turn toward spirituality for comfort at the end-of-life. The role of the Hospice Chaplain is NOT to push one specific religion or belief system on the client and family, but rather to provide spiritual support by meeting the client where he/she is in faith and supporting the client and family’s belief system. The expert, and non-judgmental, spiritual care and counseling that a chaplain provides is paramount in helping clients and caregivers, family, and friends find peace. The Hospice Chaplain is also available to assist the client and family in connecting with local clergy or spiritual guides within the community, in conducting funeral services, and in providing on-going bereavement support to the family following a client’s death.

The Hospice Aides collaborate with the RNCM to ensure the personal cares of each client are met and education is provided to the family to ensure proper hygiene. The Hospice Aide is responsible to ensure each client is comfortable by assisting with activities of daily living (ADL) needs (bathing, dressing, eating, transferring, toileting, ambulation). They also provide nail and oral hygiene to the clients and change incontinent products and linens when necessary. It is important to note that the Hospice Aide is NOT available to provide personal cares daily. The Hospice Aide typically visits the client two to three days a week. When the client is no longer able to care for him/herself, it is the responsibility of the Hospice Aide to provide education and guidance to the client’s primary caregiver to ensure personal cares are met as needed.

The Dietary Consultant works collaboratively with the hospice team and client’s family to provide nutrition, hydration, and feeding recommendations on individual needs. The Dietary Consultant has an active role in determining the nutrition and hydration requirements for individuals throughout the life span. Dietary needs at end-of-life are often drastically different than what is perceived as “normal.” The Dietary Consultant is responsible for providing education regarding nutritional needs as a client physically declines.

The Physical (PT), Occupational (OT), and Speech Therapists contribute to the care of the hospice client by assisting the client in maintaining functional abilities for as long as possible. Rehabilitation is NOT the goal of the PT, OT, or Speech Therapist in hospice. The goal of hospice is to allow each client to “age in place”, by being able to continue living in his/her established environment. PT, OT, and Speech Therapy assist the entire hospice team in achieving this goal by assessing the client’s quality of life and providing education on how to maintain safe mobility and functionality.

The Medical Director works with the assigned RNCM to review and make recommendations regarding each client. The Medical Director is responsible for developing a comprehensive medical plan of care for each client, in line with the client’s wishes, and ensuring that every member of the interdisciplinary team, caregivers, and family are knowledgeable about the plan of care. Every client has a right to determine his/her primary caregiver and the interdisciplinary team is happy to work with any doctor identified by the client; however, it is important to note that often a Primary Physician will decline to “follow” a client on hospice services and will refer to the hospice Medical Director. The Hospice Medical Director is specifically trained to care for clients nearing end-of-life and prescribing appropriate medications.

The Hospice Bereavement Program is available to all families for as long as needed, prior to and following a client’s death. The Hospice Bereavement Program is a preventative model of care. The bereavement staff facilitate healthy grieving and thereby aim to prevent the development of grief-related health and mental health problems. Most Hospice Bereavement Programs are not equipped to provide psychotherapeutic intervention and treatment for mental health disorders, and therefore make referrals to appropriate community resources.  Our Bereavement Team understands that grief can arise at any time, so the length of time for bereavement services is unending. Greif comes in many forms and each person experiences different stages of grief at various times; therefore, bereavement services can be initiated at any time, either face-to-face or via telephone.

Hospice Volunteers are essential in providing the level of care and support clients and their loved ones expect from hospice care. The primary goal of a Hospice Volunteer is to provide empathy and companionship to both the client and his/her loved ones during difficult times. The responsibility of the Hospice Volunteer is defined based on the client’s wishes and needs. Self-care is just as important for the primary caregiver as it is for the client. Volunteers are NOT able to provide any “hands-on” care for clients but may provide an “extra set of eyes” to ensure the client’s safety, and to provide the primary caregiver with a respite from caregiving duties. The Hospice Volunteer may also assist with light-housekeeping, legacy projects, dog walking, meal preparation and other duties as appropriate. For those clients who do not have family available, the Hospice Volunteer may also provide additional companionship and social support, as well as provide No One Dies Alone (NODA) services.