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Minimize Variability to Maximize IDG Meetings

By: J’non Griffin, RN, MHA, HCS-D, HCS-O, HCS-H, HCS-C, COS-C

Posted: June 13, 2025

The plan of care is a dynamic document that directs the services provided by the hospice to meet the goals of the patient and the patient’s family/caregiver. The plan of care requires an understanding of the patient’s and family/caregiver’s goals for hospice care. It is developed based on meeting these needs and is continually assessed and adjusted as needs change.

Care planning occurs with every patient interaction and every staff discussion, and the plan of care is frequently updated as a result. As a living document, it requires a coordinated, collaborative approach, and this is where the interdisciplinary group (IDG) comes in.

The IDG includes at minimum, a hospice physician; a registered nurse (RN); a social worker, mental health counselor, or marriage and family therapist; and a pastoral or spiritual, bereavement, or dietary counselor who participate in the care and services offered by the hospice. Collectively, the IDG supervises all care and services provided.

Per regulatory requirement, the IDG must meet at least every two weeks, or as frequently as the patient’s condition requires, with care planning as the focus of this meeting.

 

DARE to standardize

 

DISCHARGES, LIVE
Patient is no longer terminally ill.
Documentation review:
 Discharge order from the hospice Medical Director.
  Discharge summary completed.
  Referral to other providers.
Discussion:
 Were admissions appropriate for hospice?
 
  
Revocations
  
Documentation review:
 Signed revocation notice for those that elected the Medicare Hospice Benefit.
  Discharge summary completed.
  Referral to other providers.
Discussion:
 Was the patient/family/caregiver not fully onboard with the hospice philosophy?
 
  
Transfers
  
Documentation review:
 Patient request to transfer.
 
 Required and requested medical information for a smooth transition.
 
 Completed transfer summary.
 
  
For Cause
  
Documentation review:
 Identification of the patient or family/caregiver behavior disruptive, abusive, or uncooperative to the point that the hospice’s ability to provide care is impaired.
 
 Patient, family/caregiver notice that discharge was being considered.
 
 Discharge is not due to the patient’s use of hospice services.
 
 Documentation of the problems and efforts made to resolve the problems.
 
 Discharge order from the Medical Director.

ADMISSIONS
Documentation review:
 Brief overview of newly admitted patients immediate clinical, psychosocial, spiritual needs of the patient and family/caregiver.
  Established goals and interventions for the next two weeks.
  Imminence of death/bereavement issues.
  Patient Notification of Hospice Non-Covered Items, Services, and Drugs, if applicable.
  Orders for care and services for interventions associated with goals.
 
  • Core and non-core services.
 
    • Scope and frequency.
 
  •  DME and medical supplies.
 
  • Medication and treatment orders.
 
  • Level of care needs.

RECURRING/RECERTIFICATIONS
Documentation review:
 Clinical information to support continued eligibility.
  Imminence of death, consideration of increase in visits, and update to bereavement.
  Updated problem list:
 
  • New problems identified with updated a goal and intervention.
 
  • Resolved problems removed.
 
  • Documentation of progress toward the outcome of interventions.
  Adjusted visit frequencies and orders based on patient and family/caregiver needs for the next two weeks.
  Patient Notification of Hospice Non-Covered Items, Services, and Drugs, if applicable.
  Updated level of care needs.
  Orders for care, services, medications, and treatments.

EXPIRED/DEATHS
Documentation review: Hand-off from IDG to the bereavement team.
  Updated bereavement needs.

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Read more articles about Hospice Accreditation here.