A Team Approach to Care

Adapted from articles published by the NHPCO  

Hospice uses a highly qualified, specially trained team of professionals and volunteers working together to meet the physiological, emotional, social and spiritual needs of persons facing the end of life and bereavement.

The team consists of your provider and a medical director, registered nurse, social worker, chaplain, care aide and a volunteer.


  • Serves as a key member of your Hospice care team.
  • Provides medical direction to the Hospice care team in the development, provision, and revision of your plan of care.
  • Provides physical and emotional support to you and your family during the terminal phase of this illness.
  • Participates with your Hospice care team in the management of pain and other symptoms with a goal of comfort care.
  • Coordinates with other physicians regarding your care plan.

May I keep my regular doctor?

Your regular doctor may continue as your primary care physician. Your physician will continue to provide medical direction to the Hospice care team with regard to your medications, treatments, changes in your care plan and any other questions or concerns you, your family or the Hospice care team may have that affects your care. The hospice nurse is primarily responsible for keeping your doctor informed and up-to-date on how you are doing. Occasionally, the medical director assumes care for you if you do not have a physician or your regular doctor can no longer follow your care needs. Occasionally, the medical director assists your regular physician by consultation about your plan of care.


  • Assesses your medical needs and coordinates with your physician and other team members to achieve physical, emotional and spiritual comfort.
  • Provides education to you and your caregivers concerning the needs of seriously ill individuals.
  • Assesses current needs for medication and equipment and anticipates future needs.
  • Provides 24-hour consultation and/or home visits, for problems, questions, concerns or needs.
  • Recognizes this new experience by listening to you, teaching you, helping you to clarify your choices, and by providing a sense of normalcy to this experience.

Does the nurse talk about this life-limiting illness?

The nurse provides the opportunity to talk about the impact of this illness on you and those who love and care for you. It’s up to you to decide if or when you are ready to share those thoughts. Hospice values the experience of preparing for one’s own death in ways that are important to you and your family.

When does the nurse visit?

Nurse visits depend on your needs. The frequency and length of those visits change with your needs. Your primary nurse works Monday through Friday. On-call staff are available 24 hours a day for your evening and week-end needs. When you call the office after hours, you will be connected to an answering service. The answering service will have a hospice nurse call you back within 10 minutes. Your hospice nurse will explain this in more detail at the time you begin to receive hospice care.


People often mistakenly identify the social worker as an agent of a government or state agency. In actuality, the social worker is a trained counselor who will help you prioritize what is important to you. The social worker supports you and your family emotionally and can facilitate individual or family conferences to provide support to all who are affected by your illness. The social worker:

  • Educates and makes referrals to resources to meet needs such as caregiving, homemaking, respite, food and shelter, legal assistance, and funeral arrangements.
  • Works on such things as life reviews (recalling memories of your life) or leaving a legacy of audio or video tapes, written messages or photos. These activities help to accentuate the joys and landmarks of your life.
  • Helps you examine relationships you may want to strengthen. Supports you and your family, including children, through the anticipatory grief process and helps to prepare your survivors for the grief they will experience later.

When does a social worker visit?

Visits vary patient to patient. The social worker will visit on a schedule that will attempt to meet your needs and the needs of your family.





The chaplain is an integral member of your Hospice care team and is available to companion you and your family during this challenging time by supporting you emotionally and spiritually. You may ask the chaplain to help with life changes, decision making, relationships, life values and matters of faith, troubling feelings or whatever is most important to you. The chaplain can be a partner in prayer or simply a good listener during difficult times.

While all chaplains have an advanced theological education, they also receive specialized training in hospice care and the unique spiritual issues that can arise with serious illness, loss and grief.

What about my family and friends?

The chaplain is there to support your life, that means supporting the people you care about and those who care about you. This is a new experience for all of you.

What if I’m not religious?

The chaplain’s first concern is that this time of your life be as satisfying and as rich as possible. Religion may or may not be a part of that. Belief in a higher power may not even be a part of that. Only you can say what makes your life good. The chaplain follows your lead and is there to support whatever gives your life meaning.

What if I have my own church?

The chaplain will be happy to assist your minister or spiritual leader, if you wish, or just provide a little extra support. Sometimes a person will be far away from their place of worship when they begin hospice service. In such cases, the chaplain can sometimes arrange to bring the sacraments, rituals or prayer services of your tradition directly to your home.

When does the chaplain visit?

The chaplain visits every patient and/or family shortly after admission to develop, with their help, an appropriate plan of care. This will be your opportunity to ask any questions about their services and decide what level of participation the chaplain will have in the days ahead.

After the first visit the chaplain will ask if you would like more visits. The frequency of visits will depend on your needs and will be set up according to your plan of care.

Will the chaplain help with funeral or memorial services?

The chaplain will be glad to help you or your family make plans for these important events. Chaplains may or may not be able to officiate, depending on their schedule.


Providing assistance with personal care is the primary responsibility of the aide. The aide visits depending on your needs. The aide may provide personal care and assist with activities of daily living. The aide may help with shampooing, shaving and other general grooming as well as changing bed linens to make you feel clean and refreshed. The aide can also train other family members who care for you.

How long will the aide stay in my home?

The aide’s visit usually lasts an hour. If you need more care in the home, ask to speak with your social worker. Your social worker can assist you in obtaining extra caregiving in the home.

What supplies will the aide need?

A clean washcloth and several towels, soap for bathing and any other toiletries you normally use would be helpful to have ready. These items might include shampoo, toothbrush, toothpaste, lotion, and a comb or brush.

How are aide services initiated?

Your hospice nurse will arrange for aide services to begin. A staff member will call you to set up a visiting schedule. The aide will provide your hospice nurse with any changes related to your comfort that he or she observes.


A volunteer provides emotional and spiritual support to you and your family depending on your needs. Volunteers go through extensive training to understand the needs and experiences of the terminally ill and their families. Volunteers may:

  • Stay with you so that your caregivers may leave the home for short periods, rest, or to accomplish other tasks.
  • Provide companionship to both you and your caregivers in homes and care facilities.

To learn more about how to care for caregivers, click on this link to A Message to Caregivers.


How many hours can a volunteer help?

A volunteer will usually help from one to four hours a week. When a volunteer is assigned, the time and schedule will be mutually worked out between you, your family and the volunteer.

How do I get a volunteer?

Make a request for a volunteer to your hospice nurse or social worker. You and your family are unique, and the way in which you deal with this stage of life will also be unique


Source: NHPCO article, Hospice 101- A special kind of care


Call Chaplaincy Health Care today at (509) 783-7416 to ask questions, get answers, learn more or to begin Hospice care services.


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