Name of hospice program:

Address:

City

State

Zip

Phone number:

Where are services provided?

• In your home
• In a special inpatient hospice unit
• In a facility (hospital or nursing home) where you are already a patient

What services are provided?

• One or more doctors who can make home, hospital, or nursing home visits
• Spiritual or religious counseling or advisors
• Respiratory, occupational, and physical therapists
• Social workers
• Home health aides
• Shopping and errands
• Meal preparation and nutritional counseling
• Cleaning and household chores
• Respite services if your primary caregiver becomes ill or needs a break
• Prescription medications, and medical supplies and equipment
• Interpreters or other special services related to your culture, ethnicity, or lifestyle

What is the plan of care?

Does the hospice program develop a care plan with you and your family?

Yes / No

The care plan should include specific duties, who will perform them and how often, and the name and phone number of the supervisor. A good program will develop a care plan by providing a health professional (not a clerk or administrative assistant) who will:

• Talk with you and your family in your home (not just over the telephone).
• Talk with your doctor or other health professionals.
• Write down the care plan and give copies to everyone who will be involved in your care.

Who provides care?

• Family members
• Hospice staff
• Your doctor

Licensing and certification

Is the plan:

• Medicare-certified?
• State-licensed? All state health departments certify hospice programs.
• Accredited by one or more professional organizations? These may include:
  • Accreditation Commission for Home Care, Inc.
  • Community Health Accreditation Program.
  • Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
  • National Committee for Quality Assurance (NCQA).

Are the hospice nurses certified by the Hospice Nurses Association?

Yes / No

Are the hospice doctors certified by the American Board of Hospice and Palliative Medicine?

Yes / No

References

Get the names of doctors who refer patients to this program.

Identify families who have used this program. If possible, talk with the families. Ask about their experience and whether they would recommend the program to others.

After your visit

Does this program provide the services you want?

Yes / No

Is this program covered by your insurance?

Yes / No