Interdisciplinary team and interdisciplinary plan of care – Ohio Admin. Code 3701-19-11

Each hospice care program must have an interdisciplinary team(s) that provides or supervises the provision of hospice care and services.  The team must do the following:

• Establish policies and procedures governing the provision of care;
• Establish an interdisciplinary plan of care for each patient and family;
• Review the interdisciplinary plan of care at least every fifteen days;
• Encourage and foster active involvement of the patient and family in the development and implementation of the interdisciplinary plan of care; and
• Evaluate the hospice care and services provided and monitor the continuity of care across all settings for the hospice care program’s patients and their families.

The program must designate a registered nurse to coordinate the team’s overall functioning to ensure that:

• There is ongoing assessment of the hospice patient’s and family’s needs;
• All components of the plan of care are addressed by the interdisciplinary team; and
• The plan of care is implemented in accordance with its terms.

The hospice care program must ensure that each patient’s attending physician, if any, periodically reviews the patient’s plan of care.