Hospice interdisciplinary pathway chart in nutshell

Here’s how a pathway works

Hospice Care Plus of Berea, KY, uses an interdisciplinary pathway chart that outlines steps and outcomes for each of five phases of care for hospice patients. With permission from Hospice Care Plus, Hospice Management Advisor reprints a portion of the copyrighted pathway chart below.

Phase I: Preadmission

  • Begins with referral, ends with admit to hospice or referral to other agencies
  • Usually completed by admission nurse
  • Plan of care is initiated (Medicare Std.)
  • Admit criteria validate appropriateness
  • DME, meds and supply needs are identified
  • Can be several contacts/notes

Phase II: Admission

  • Explain hospice philosophy
  • Admission process
  • Assessing initial patient/family needs (all disciplines visit)
  • Meeting basic patient needs
  • Determining priority expected patient outcomes (EPOs); pain, nausea/vomiting
  • Two weeks or less
  • Primary team obtain baseline
  • Storytelling
  • Overlaps with Phase I
  • Initial assessment:
— Nurse: diagnosis, presenting symptoms, medical history, and physical needs
— Social work: family systems, available resources, patient/family coping, and grief and loss history
— Chaplain: spiritual needs & resources and grief issues
— Paint a picture of patient/family

Phase III: Transition

  • Begins with admission completed
  • Decline, with peaks/valleys
  • Ends with rapid decline & death imminent
  • Team focus: symptom management, end-of-life planning, teaching
  • Assess appropriateness and re-evaluate admit criteria throughout this phase

Phase IV: Dying

  • Ends with death
  • Patient may be admitted in this phase
  • Team focus: preparing patient/family for death, comfortable with decline
  • EPOs shift drastically: ex., nutrition
  • Increase in visits and resources
  • Short-stay admissions:

— When prognosis is two weeks or less
— Admitted in phase IV
— Discipline initial assessments are more focused on imminent needs
— One integrated form for all disciplines

  • Hospice Carepath Notes:

— Flow of note: EPO, assessment, comments, managed care & teaching (comments)
— Discipline-specific questions
— Pain assessed with each contact
— Common areas of managed care & teaching
— Prompts thorough, evaluative notes

  • Notes: EPOs across phases:

— Patient/family express grief through storytelling (Phase I)
— Patient/family acknowledge their grief (Phase II)
— Patient/family begin to process their grief (Phase III)
— Patient/family feel grief is validated (Phase IV)

  • Notes: Variances:

— EPOs are not being met
— Variances are expected secondary to changes in patient/family condition and continued decline
— Way to focus where the team needs to re-evaluate the care/approach
— Pain increases: meds changed, frequency changes, increased follow-up
— Anxiety increases: meds changed, social worker/chaplain increase visits and support

  • Notes: Assessment:

— Comprehensive
— What is most important to the patient/family at that time
— Discipline-specific and common areas
— Comments individualize the assessment
— Paint a picture

  • Notes: Managed care and teaching:

— Interventions and actions
— Integrates algorithm and standing orders
— Choices are same on all notes and across all disciplines
— Prompts you for additional care needed and also recognizes care provided

  • Closure Visits:

— Same note used for all disciplines
— Team identified who is appropriate to make closure visit after death
— EPOs focus on families’ ability to process grief
— EPO discipline-specific and common
— Educate on bereavement services

Phase V: Bereavement

  • Begins at death of patient, ends at 13 months
  • Bereavement risk assessment created with input from the team
  • EPOs guide for level of risk and care
  • Three levels of risk: low, medium, or high
  • If unable to discharge, refer to appropriate resources