Also Known As:
Plan of care, individualized care plan, interdisciplinary care plan. See also: Plan of Care.
Type:
Written, regulated care guide
Primary Purpose:
To document exactly what care the patient receives, visits, medications, equipment, services, and goals, so the team and family are aligned every day.
When It Applies:
Built at admission and updated every 14 days, or sooner if the patient’s condition changes.
Who Is Involved:
The patient (when able), the family, the hospice nurse, the medical director, an aide, a social worker, a chaplain, and any other team member involved.
Where It Occurs:
Written by the team, kept in the home (and in the agency’s records), and accessible to the family at any time.
Duration:
Active for the entire hospice stay. Reviewed at minimum every 14 days at the IDG/IDT meeting.
Coverage:
Required and covered under the Medicare Hospice Benefit.
Key Focus:
Symptom management, medication schedule, visit frequency, equipment and supply needs, spiritual and emotional care, family training, and end-of-life goals.
Common Misunderstanding:
The care plan is not set in stone. It’s a living document and families can request changes, more aide visits, different medications, a chaplain or social worker added, at any time.
What a Hospice Care Plan Actually Includes
A care plan is the written, personalized roadmap for your loved one’s hospice care. It covers everything the team has agreed to do, and how often, to keep the patient comfortable, safe, and supported.
A typical Lifted care plan includes:
- The patient’s primary diagnosis and key symptoms to monitor
- Medication list with dosing, timing, and as-needed instructions
- Nurse visit frequency (how often the RN comes)
- Aide visit frequency (bathing, grooming, ADL support)
- Social worker, chaplain, and volunteer involvement
- Equipment in the home, bed, oxygen, commode, suction
- Goals of care, written in the family’s own words when possible
- What to do in a crisis and the 24/7 phone number to call
Who Builds the Care Plan
The care plan is drafted by the admitting nurse during the first visit and reviewed by the full interdisciplinary team within 48 hours. It is then revisited every 14 days at the team’s IDG meeting, or sooner if anything changes, to make sure the plan still matches what your loved one needs today.
The family is part of the plan, not a recipient of it. If a visit time isn’t working, you say so. If you want a chaplain added, you ask. If symptoms shift, the plan shifts.
How the Care Plan Protects Quality
A clear, current care plan is one of the most powerful tools in hospice. It prevents medication errors, ensures visits don’t get skipped, and gives every new team member instant context about your loved one. At Lifted, our CHAP accreditation requires rigorous standards for care planning, and we hold the bar above that.
Ask any prospective hospice how often the plan is reviewed and what happens when a family requests a change. The answers matter. See our guide on choosing a hospice.