Also Known As:
Interdisciplinary team, IDT, IDG, care coordination team, hospice care team
Type:
Federally required interdisciplinary care group
Primary Purpose:
To deliver comprehensive medical, emotional, spiritual, and practical care to the patient and family, coordinated as one.
When It Applies:
From admission through end-of-life and into bereavement.
Who Is Involved:
Hospice physician, RN case manager, hospice aides, social worker, chaplain, bereavement coordinator, volunteers, and any clinical specialists called in as needed.
Where It Occurs:
In the patient’s home or care setting, with a biweekly team meeting at the agency to review the plan of care.
Duration:
Throughout the hospice stay and for at least 13 months after the death (bereavement portion).
Coverage:
Required and fully covered under the Medicare Hospice Benefit.
Key Focus:
Coordinated, whole-person care, physical, emotional, spiritual, social, across every team member.
Common Misunderstanding:
The hospice team is not just the nurse. The federal benefit requires a full interdisciplinary group, and the difference between a strong hospice and a weak one is often how that group actually functions together.
Every Role on the Team
A Lifted hospice team includes:
- Hospice Physician / Medical Director, oversees the plan of care, certifies eligibility, and consults on complex symptoms
- RN Case Manager, the family’s primary clinical contact, visits regularly, available 24/7
- Hospice Aide (CNA), handles bathing, grooming, and daily personal care
- Social Worker, supports family decisions, paperwork, and resources
- Chaplain, interfaith spiritual care, available to every family
- Bereavement Coordinator, supports the family for at least 13 months after the death
- Trained Volunteers, companionship, reading, music, errands, family respite
- Specialists, wound-care nurses, music therapists, pet-therapy teams, and others as needed
How the Team Works Together
Every two weeks, the full team meets to review each patient’s plan of care, what’s working, what’s changed, and what needs to adjust. This meeting is the Interdisciplinary Group (IDG) meeting and it is required under Medicare rules.
Between meetings, the team communicates daily, through documented visit notes, phone calls, and direct messaging. A change the aide notices at a bath becomes a medication adjustment by the nurse before the family even calls. That is how strong hospice teams operate.
What Sets a Great Hospice Team Apart
The Medicare rules describe the floor, every team must include these roles, must meet every 14 days, must document the plan of care. CHAP accreditation adds rigor on top of that. But the actual difference between hospice teams is human: how often they visit, how warmly they show up, how fast they respond, and how clearly they communicate.
If you’re weighing options, ask about each team member individually, who they are, how often they visit, what the patient and family will actually experience. See our guide on choosing a hospice.