Directions: Use this checklist to help evaluate hospice services to determine which one will work best for you and your family.
| General Information |
Yes |
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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