The essential function of the interdisciplinary team, IDT, is to work together as a cohesive unit to meet the physical, emotional, spiritual, and psychosocial needs of the patient and family. The expectation is all members work as equal partners in addressing the patient’s and family’s identified needs associated with the terminal illness and related conditions.
The IDT also has regulatory requirements that must be met in order for Medicare-certified hospice providers to participate in the Medicare program.
The federal regulations that pertain to the provision of hospice services are known as the Medicare Conditions of Participation, commonly referred to as the CoPs. So often the members of the IDT do not have a solid understanding of the CoPs and the impact their documentation or lack of documentation has on an agency’s ability to bill Medicare for services provided.
The delivery of hospice care is based on the comprehensive assessment and the individualized plan of care, both of which require the involvement of the IDT.
The comprehensive assessment is intended to assess the patient and family from a holistic point of view, not just from a medical perspective. The purpose is to “identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process” from which the IDT is to develop an individualized plan of care to address the identified needs.
Hospice providers are allowed to choose their own methods in which to complete the comprehensive assessment. Regardless of the process, all IDT members are expected to contribute. Often when a patient refuses a discipline, the documentation fails to support the continued input of the refused discipline. Regardless of the patient’s acceptance of the various members of the IDT, all members are expected to act as a resource to the other disciplines that are providing care to assist them in meeting any psychosocial, emotional, and spiritual needs of the patient and family.
Once the comprehensive assessment has been completed, an individualized plan of care must be developed that specifically addresses “the hospice care and services necessary to meet the patient- and family-specific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions.” There should be a direct link between the needs identified and the services ordered. Oftentimes a need is clearly identified, but the documentation does not demonstrate how that need was addressed. This tends to occur when a discipline is refused at admission and a team member documents an unresolved issue but does not document the follow-up to address that issue.
The plan of care must also be based on the identified “patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments.” Documentation should clearly demonstrate the IDT is working toward the achievement of the patient- and family-identified goals. In circumstances where goals are not met, or new needs arise, documentation must reflect a revision to the plan of care in an attempt to address unresolved goals or newly identified problems.
In order to accomplish these vital functions of the IDT, documentation of the coordination of services is crucial. The expectation is “the hospice must develop and maintain a system of communication and integration, in accordance with the hospice’s own policies and procedures, to ensure that the interdisciplinary group maintains responsibility for directing, coordinating, and supervising the care and services provided.”
We have all heard, “if it’s not documented, it’s not done.” This remains true, as without documentation to show that all members of the IDT participated in the completion of the comprehensive assessment, the development of the plan of care, and the coordination of care, hospice providers risk being cited deficiencies during a survey. More importantly, they lack evidence that the best possible care was provided to the patient and family during the most difficult time of their lives.