Directions: Use this checklist to help evaluate hospice services to determine which one will work best for you and your family.
General Information |
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No |
Comments |
What services are provided? |
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What kind of support is available to the family and caregiver? |
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What roles do the attending physician and hospice play? |
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What does the hospice volunteer do? |
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How does hospice keep the patient comfortable? |
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How are services provided outside of business hours? |
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How and where does hospice provide short-term inpatient care? |
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With which nursing homes or long-term care facilities does the hospice work? |
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Can this service be brought into a nursing home or other living facility? |
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How long does it typically take the hospice to enroll someone once the request for services is made? |
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How does the physician work with the family and patient? |
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Is the hospice licensed or certified? If so, for what types of services? |
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Are services offered in the home? |
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Is the service insured against liability? |
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Is a written contract provided regarding eligibility, payment and staff training? |
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Is the care plan developed in consultation with your loved one?s physician? |
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Are family members, including myself, included in reviewing and contributing to the care plan? |
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Is the care plan completed in person with a nurse or social worker? |
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Will I have contact with a supervisor? |
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Is there a grievance or complaint process? |
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Are references available for all providers? |
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Types of services offered |
Yes |
No |
Comments |
Individualized service plan |
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Physician supervision |
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Nursing care |
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Overnight home care |
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Assistance with activities of daily living |
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Physical therapy |
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Massage therapy |
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Pain management |
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Ventilator care |
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Emergency care or arranging for hospitalization |
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Meal preparation or delivery |
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Spiritual counseling |
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Respite care (in home or day center) |
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Counseling services (family, individual) |
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Assistance with advance directives |
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24-hour emergency contact |
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Telephone support |
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Housing |
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Patient or family advocacy |
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Medical supplies |
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