Also Known As:
Care plan, individualized plan of care, IPOC. See also: Care Plan.
Type:
Required written care guide
Primary Purpose:
To document the patient’s complete care plan, diagnosis, goals, medications, visit schedule, equipment, and team members, in one place, accessible to everyone involved.
When It Applies:
Built at admission, updated continuously, formally reviewed every 14 days at the IDG meeting.
Who Is Involved:
Every member of the hospice team, the patient (when able), and the family.
Where It Occurs:
Kept in the home and in the agency’s records; accessible to the family at any time.
Duration:
Active for the entire hospice stay.
Coverage:
Required and covered under the Medicare Hospice Benefit.
Key Focus:
Goals of care, symptom management, visit frequency, medication regimen, equipment and supplies, and family education.
Common Misunderstanding:
The plan of care is not a static document. It updates as the patient changes, sometimes weekly, sometimes daily during a decline.
What a Plan of Care Documents
The hospice plan of care is the central, written, regulated document that tracks every element of your loved one’s care:
- The patient’s diagnosis and significant symptoms
- Specific goals of care (in the family’s own words when possible)
- Medication list with doses, timing, and as-needed instructions
- Visit schedule, nurse, aide, social worker, chaplain
- Equipment in the home
- Supplies being delivered
- Family education topics covered and still to cover
- Crisis plan, what to do, who to call
How the Plan Stays Current
The plan is reviewed at the team’s IDG meeting every 14 days. But it also changes between meetings, every time the nurse adjusts a medication, every time the aide reports a new pressure area, every time the family asks for a different visit time.
Lifted’s expectation is that the plan in the home matches the care actually being delivered. If something on paper isn’t happening, or something is happening that isn’t on paper, the plan gets corrected.
Your Family’s Voice in the Plan
The plan is a working document, not a directive handed down. If the visit schedule isn’t working, the plan changes. If you want a chaplain added, the plan changes. If your loved one wants more music and less talking, the plan changes.
Speak with your RN case manager at any visit, or contact our team to request updates.