The IDT or Interdisciplinary Team
The IDT team is composed of individuals who are employees of the hospice and will provide substantially all core services. The services will include at least:
■ Physician who is a Doctor of Medicine or Osteopathy - Together with the team , will create a care plan
that manages pain and control symptoms associated with the patient's terminal illness or disease
■ Registered Nurse - Assess the needs and manage the pain and symptoms of the patients. The nurse will
educate family or caregivers in how to assist or care their loved ones.
■ Social Worker- Look after the emotional needs, helping patients with feelings of fear and anxiety or communication
issues with family, insurance benefits and other difficulties.
■ Pastor or Chaplain or Counsellor- Provide emotional and spiritual support, guide family through tough decisions
concerning end of life issues, provide understanding to relieve strained relationship between loved ones, strengthen
faith of patient or family.
■ Bereavement Coordinator - Help through the different phases of the end of life process, prepare for the situations of
end of life and provide counselling and support for up to 13 months
■ Volunteer Coordinator - Prepare the volunteer care plan for volunteer to support the need of the family or patient
Additional members may include the physical therapy, occupational therapy, speech therapy, dietitian , pharmacist, and home health aide. A Bliss Care will designate a registered nurse to coordinate the implementation of the plan of care for the patient. The nurse will develop a hospice aide plan of care for the hospice aide to follow which is specific to the needs of the patient.
The IDT responsibilities will include but not limited to:
■ Participation in the establishment of the plan of care with the patient/family and attending physician.
■ Provision and supervision of hospice care and continuity of services
■ Periodic reviews and updates of the plan of care for each patient receiving hospice care , and for each family receiving
bereavement service and establishment of policies governing the day to day provision of hospice care and services
Other services include coordination of ■ Durable medical equipment ; ■ Medications related to the terminal illness for
comfort and symptom management and ■ Respite/inpatient care to support family /caregiver.