What Is an Interdisciplinary Team?
A group of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patient and family. A hospice interdisciplinary team can include a community physician, the hospice medical director, registered nurses, licensed vocational nurses, medical social workers, spiritual care providers, bereavement coordinators, home health aides, and trained volunteers.
Community/attending physician: These physicians act as the patient’s attending physician and are not Snowline staff members. They are an integral partner in supporting the care of the patient. The physician and the patient care team work collaboratively to ensure the highest quality of care and comfort for the patient. If an individual does not have a community/attending physician, the hospice medical director can act as the attending physician at the request of the patient or designee.
Snowline’s medical director and physicians work closely with the attending physician to ensure comfort and quality of life for the patient. This includes, but is not limited to, care plan oversight, collaboration with the community physician, home visits, and oversight and guidance on symptom management. It is important to note that not all patients receiving hospice services will have a visit from the Snowline physician. The interdisciplinary team provides frequent reports to the Snowline physician who supports care plan oversight and makes recommendations when indicated.
Role of the Nurse
Registered Nurses make routine home visits to provide medical services to patients. This includes supporting with pain management, addressing other symptoms that cause discomfort, providing instruction on how to care for the patient and maintain safety. Registered nurses assign additional home visits to Licensed Vocational Nurses (LVNs) when needed. Nursing services are available 24 hours a day, 7 days a week. Any time you have questions or concerns please call for support.
Every hospice patient is assigned a Registered Nurse (RN) Case Manager. The hospice RN Case Manager will perform routine assessments, identify the patient and families’ goals, and in partnership with the patient and family establish a patient-centered, individualized plan of care.
The hospice RN Case Manager provides education and training on the patient’s disease progression and personal care needs. The nurse will identify if there are any specific durable medical equipment needs to support the patient’s care and safety. The nursing assessment will identify physical symptoms that may need medical interventions. The interventions could be medications, treatments, and/or non-pharmacologic interventions. For any interventions that are ordered the nurse will provide education and training on anything the patient, family, or caregivers need to do to support.
A critical function of the hospice RN Case Manager is performing routine comprehensive assessment and reporting those to the interdisciplinary team. Clinical assessment is an important part of determining a person’s continued hospice eligibility. Medicare defines specific guidelines on hospice eligibility by diagnosis and part of the role of the interdisciplinary team is determining if the patient continues to meet eligibility. If it is determined that the patient is no longer eligible then the interdisciplinary team supports with discharge planning.
Role of the Medical Social Worker
Medical Social Workers evaluate needs and advocate for the rights of the patient. This often includes emotional support and counseling for both the patient and family, support for advance care planning, establishing, and defining goals of care. Psycho-social and emotional support is a critical piece of what medical social workers can do to support, this can be for the patient, family, or paid caregivers. Additionally, the medical social worker can provide appropriate community resources that may be beneficial.
Hospice social workers are a critical part of the hospice interdisciplinary team providing emotional support to the patient, family, and any who will be impacted by the death of the patient. Your hospice social worker will complete an assessment that identifies your goals, needs, and strengths. Once the assessment is performed the social worker will partner with you to establish an individualized plan of care.
The hospice social worker can support the patient and family with coping skills and nonpharmacologic interventions to address symptoms. The hospice social worker can help you understand the role of hospice and the philosophy of care and how that relates to your established goals.
The hospice social worker can support with completing or updating advance directives, exploring goals to complete or update a POLST (physician orders for lift sustaining treatment), and connecting patients and families with community resources that can support the goals established in the plan of care.
Hospice supports education and training to support the patient and family understanding of the disease process and what to expect. Proactive education helps prevent crises and prepares for the changes that may be seen in a person with a life-limiting disease. Hospice social workers are strong patient advocates and will support the patient and family in achieving realistic goals through their advocacy.
As stated previously, the hospice social worker is a critical part of the interdisciplinary team. They attend interdisciplinary team meetings and support the rest of the team in understanding the patient and family history, goals, and needs.
Role of the Spiritual Care Provider
Spiritual Care Providers offer spiritual and emotional guidance to support the patient and family in accordance with, or independent of, the family’s religious beliefs. Telephone calls and home visits may include spiritual care and counseling, support for a broad base of beliefs and practices, coordination with personal clergy, and assistance in planning and officiating a funeral or memorial service if needed.
Spirituality can give meaning to life. It refers to the universal human need for love, hope, value, and dignity and may or may not involve religious beliefs and practices. Spirituality involves how we make sense of the world, including how we connect to ourselves, each other, and our universe.
Snowline respects all spiritual traditions. Together with patients and families, Snowline spiritual care providers create a spiritual-care plan to address concerns and beliefs. If faith community involvement is desired and not already provided, the spiritual care provider can plan and coordinate care with your faith community.
Fear, anxiety, despair, and even physical pain diminish when one feels heard and accepted in the process of coming to terms or coping with life- limiting illness. Each spiritual care provider creates a safe environment where exploring concerns and expressing feelings can be shared without judgment. For those who prefer not to verbalize their thoughts or feelings, a caring presence can facilitate moments of prayer and meditation.
Spiritual care provides can provide non-judgmental listening, spiritual counseling, discovery of hope and meaning, exploring beliefs of an afterlife, reconciling life choices, examining loving relationships, family support, fellowship and spiritual conversation, prayer and meditation, religious rituals, and assistance with funeral or memorial services. Visits from a spiritual care team member support the patient as a whole-person, your entire being- physical, emotional, spiritual- is worthy of feeling at peace.
Spiritual care is not limited to the patient. Spiritual care is available for the patient’s family, as desired. All persons have spiritual concerns when facing death. The hospice spiritual care provider may, through engagement, help hospice patients explore their belief stance, personalize it and use it creatively to cope with living and dying.
Focusing on spiritual health may not cure an illness but may help you and your family feel better, prevent illness, and increase your ability to cope. Snowline spiritual care visits can help you express emotions, reframe your perspective, and leave you feeling inspired to try new coping skills.
Snowline provides congregations with information about hospice care, including:
- Eligibility criteria
- The role of the interdisciplinary team
- What spiritual care providers do to support hospice patients and their families.
- How chaplains compliment your clergy
- Comfort care vs. curative care
- Length of stay
- Do Not Resuscitate orders, also referred to as DNR
- Durable Power of Attorney for Healthcare, also referred to as DPAHCs
- Advance Directives
- How hospice supports individuals and families with life-limiting illnesses.
- Religious views and medical treatment
- Grief and bereavement support
- Hospice reimbursement
This is not an all-inclusive list, if you have a topic that you are interested in learning more about please contact Snowline.
A Snowline Spiritual Care visit reminds you and your care team that you are a whole person and that your entire being – physical, spiritual, emotional and psychological – is worthy of being healthy and well.
Focusing on spiritual health may not cure an illness but may help you and your family feel better, prevent illness and increase your ability to cope. Snowline Spiritual Care visits can help you express emotions, reframe your perspective and leave you feeling inspired to try new coping skills.
Snowline Spiritual Care providers are trained to assist and care for people of many faith traditions. They do not replace lay or ordained ministers of a person’s faith tradition but are available to coordinate and complement spiritual care that is provided by one’s own faith community if that is the desire. Snowline Spiritual Care providers can lend a non-judgmental ear no matter the choice or circumstances. The spiritual care providers also directly communicate the patient’s concerns with the Snowline interdisciplinary team.
Snowline recommends a relationship with a spiritual care provider to deal with any spiritual or existential needs or concerns. Typically, visits occur two times per month. The frequency of visits is up to the patients, their families, and caregivers. Of course, the patient may decline to have visits, or stop them at any time.
Snowline cares for people of all faiths, including those who do not subscribe to any particular religion or faith system. Snowline’s care is holistic, meaning it encompasses each individual’s medical, social, psychological and spiritual well-being. Snowline Spiritual Care policy includes spiritual awareness and support for patients, their caregivers, the Snowline staff, and volunteers.
During an initial visit, the Snowline Spiritual Care provider will gather information for a spiritual assessment. Based on that initial visit, a spiritual care plan will be developed within the patient’s overall care plan. The spiritual plan will guide the interventions for succeeding visits. The interventions will be what the patient and/or family desire from the visits. See Snowline Spiritual Care Contributes to Quality of Life.
Snowline Spiritual Care is an essential element of the interdisciplinary care plan. As people approach life’s end, they often reflect on their lives and try to sort out its meaning and purpose. This spiritual reflection can aid a person’s overall well-being. Snowline was founded on the belief that, even when a cure is no longer possible, there is still an opportunity for quality of life, comfort, dignity, and hope. Snowline Spiritual Care can offer those opportunities.
Snowline Spiritual Care providers want to partner with the clergy of our patients. Contact with the clergy can be initiated by the patient or family or the Snowline Spiritual Care provider. Snowline Spiritual Care providers will not contact a clergy person without the patient’s permission or power of attorney.
Yes. Snowline Spiritual Care providers can provide funeral or memorial services sensitive to the patient’s and family’s beliefs and wishes.
One’s spirituality is based on whatever gives personal meaning. The Snowline Spiritual Care provider helps and supports people hoping to find or strengthen those things that provide meaning. Snowline Spiritual Care providers are typically referred to by their first names. A more formal address certainly may be used if that is more comfortable.
Not exactly. The clergy are trained in pastoral care but are not necessarily trained to meet the spiritual needs of other faith traditions. Snowline Spiritual Care providers are trained to talk to people of many faith backgrounds and those with no faith community connection. Snowline Spiritual Care providers have post-graduate professional degrees at accredited seminaries. Our per diem chaplains have at least a graduate degree.
No. Snowline Spiritual Care providers provide spiritual care for your present situation and will not try to connect you with a place of worship unless you request that we do so.
While that is certainly an option, a Snowline Spiritual Care provider will be better able to meet a patient’s spiritual needs if they know the patient beforehand. This is done through regular visits. Also, regular visits can address some issues before they reach a crisis stage.