RG – Interdisciplinary Team (IDT) and Care Planning
The hospice interdisciplinary includes physicians, nurses, hospice aides, social workers, counselors, chaplains, therapists, and trained volunteers. The Medicare Hospice regulations use the term “interdisciplinary group” in the regulatory text, but the term “interdisciplinary team” can be substituted. All staff should be knowledgeable and compliant with the Federal hospice regulations, specific state hospice licensure regulations, and accreditation standards as applicable.
A plan of care must be established and periodically reviewed by the attending physician, if any, the medical director, and the interdisciplinary team of the hospice program; must be established before hospice care is provided; and services provided must be consistent with the plan of care.
NHPCO Member Resources and Compliance Guides
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- NHPCO Care Planning Primer (September 2023)
- Interdisciplinary Team Competency Grid (2023)
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Regulations
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- Hospice Care Code of Federal Regulations 42CFR 418
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Subpart C §418.56
Subpart F §418.200 Covered Services
Subregulatory Guidance
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- Medicare Benefit Policy Manual Chapter 9-Coverage of Hospice Services Medicare Benefit Policy Manual (cms.gov)
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40 - Benefit Coverage
40.1.9 - Other Items and Services
40.2.4 - Special Modalities
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- State Operations Manual SOM - Exhibit (cms.gov)
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2080C - Hospice Core Services
2080C.1 - Waiver of Certain Staffing Requirements
2080D - Hospice Required Services
2080D.1 - Hospice Interdisciplinary Group (IDG)
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- Medicare Claims Processing Manual Chapter 11 - Processing Hospice Claims Medicare Claims Processing Manual (cms.gov)
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40 - Benefit Coverage
Other Resources
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Alerts/Newsbriefs/Newsline
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The hospice medical director, physician employees, and contracted physician(s) of the hospice, in conjunction with the patient’s attending physician, if any, are responsible for the palliation and management of the terminal illness and conditions related to the terminal illness.
A hospice may designate only one physician to serve as medical director.
NHPCO Member Resources and Compliance Guides
Regulations
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- Hospice Care Code of Federal Regulations 42CFR 418
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Subpart B §418.22, §418.25
Subpart C §418.62, §418.64
Subpart D §418.102, §418.114
Subregulatory Guidance
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- Medicare Benefit Policy Manual Chapter 9-Coverage of Hospice Services Medicare Benefit Policy Manual (cms.gov)
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40.3 - Contracting With Physicians
40.4 - Core Services
Other Resources
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Alerts/Newsbriefs/Newsline
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Education
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The hospice must provide nursing care and services by, or under, the supervision of a registered nurse. Nursing services must ensure the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and updated assessments.
A Registered Nurse (RN) is a core member of IDG and updates the plan of care as a part of the IDG. A RN writes the patient care instructions for the Hospice Aide and provides supervision of a Hospice Aide. A RN must complete the initial assessment. A Licensed Practical Nurse (LPN)/Licensed Vocational Nurse (LVN) cannot fulfill any of the duties as noted above. In general LPNs/LVNs can observe, record, and report but may vary by state licensing regulations. The LPN/LVN patient care is overseen by a RN.
NHPCO Member Resources and Compliance Guides
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- Medicare CoP Tip Sheet: Nursing (June 2022)
- MyNHPCO Nurse
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Regulations
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- Hospice Care Code of Federal Regulations 42CFR 418
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Subpart C §418. 62 §418.64, §418.66
Subpart D §418.114
Subregulatory Guidance
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- Medicare Benefit Policy Manual Chapter 9-Coverage of Hospice Services Medicare Benefit Policy Manual (cms.gov)
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40.4 - Core Services
40.4.1 - Contracting for Core Services
40.4.2.1 - Waiver for Certain Core Nursing Services
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- State Operations Manual SOM - Exhibit (cms.gov)
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2080C - Contracting for Highly Specialized Services
2080C.3 - Hospice Nursing Shortage Provision
Other Resources
Cross Reference
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Medical social services must be provided by a qualified social worker, under the direction of a physician. Social work services must be based on the patient’s psychosocial assessment and the patient’s and family’s needs and acceptance of these services.
For specific personnel qualifications for social workers and supervisory requirements, refer to 418.114 CoP Personnel Qualifications Conditions of Participation Compliance Guide Social worker supervision. The only detail that is provided by CMS about supervision is in the interpretive guidelines at §418.114(b)(3): “Each hospice must employ or contract with at least one MSW to serve in the supervisor role as an active advisor, consulting with the BSW on assessing the needs of patients and families, developing and updating the social work portion of the plan of care, and delivering care to patients and families. This supervision may occur in person, over the telephone, through electronic communication, or any combination thereof. The hospice must allow time for this supervision to happen on a regular basis and provide documentation as to the nature and scope of supervision. The hospice must also ensure that non-social work trained bachelor’s prepared employees filling the role of social worker are supervised by a MSW who graduated from a school of social work accredited by the CSWE and who has at least one year of experience in a health care setting.”
NHPCO Member Resources and Compliance Guides
Regulations
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- Hospice Care Code of Federal Regulations 42CFR 418
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Subpart C §418. 62 §418.64
Subpart D §418.114
Subregulatory Guidance
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- Medicare Benefit Policy Manual Chapter 9-Coverage of Hospice Services Medicare Benefit Policy Manual (cms.gov)
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40.4 - Core Services
40.4.1 - Contracting for Core Services
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- State Operations Manual SOM - Exhibit (cms.gov)
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2080C - Core Services
Other Resources
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Alerts/Newsbriefs/Newsline
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Beginning January 1, 2024, marriage and family therapists and mental health counselors may serve on the hospice IDT. The inclusion of marriage and family therapists and mental health counselors on the hospice IDT was authorized as a part of the Consolidated Appropriations Act, 2023 (CAA 2023).
The calendar year (CY) 2024 Physician Fee Schedule final rule implemented provisions of the CAA 2023 to enable hospices to include one social worker, one marriage and family therapist, or one mental health counselor on the hospice IDT. Hospices must have at least one of these practitioners serving on the IDT, but are not required to have all three.
Marriage and family therapists and mental health counselors provide counseling services, a core service. How a hospice provides supervision over a marriage and family therapist or mental health counselor is up to the hospice to determine.
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- For specific personnel qualifications for marriage and family therapists, refer to 42 CFR 410.53.
- For specific personnel qualifications for mental health counselors, refer to 42 CFR 410.54.
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NHPCO Member Resources and Compliance Guides
Nothing applicable at this time.
Regulations
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- 42 CFR 418.56(a), Condition of participation: Interdisciplinary group, care planning, and coordination of services
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Subregulatory Guidance
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- CMS Change Request 13437 (December 6, 2023)
- CMS Hospice Open Door Forum Questions and Answers Document (November 29, 2023)
- Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs) Provider Enrollment Frequently Asked Questions (FAQs) (March 2024)
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Other Resources
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Marketplace
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Counseling services must be available to the patient and family to assist in minimizing stress and problems that arise for the terminal illness, related conditions and the dying process. Counseling services must include bereavement, spiritual, and dietary.
Bereavement. A hospice must have an organized program for the provision of bereavement services furnished under the supervision of a qualified professional with experience or education in grief or loss counseling.
Spiritual Caregiver. A hospice must provide spiritual counseling to meet patient/ family needs in accordance with the patient’s and family’s acceptance of this service, and in a manner consistent with patient and family beliefs and desires.
Dietary Counseling. Must be performed by qualified individuals which included dietitians as well as nurses and others who are able to address and assure the dietary needs of the patient are met.
NHPCO Member Resources and Compliance Guides
Regulations
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- Hospice Care Code of Federal Regulations 42CFR 418
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Subpart C §418.62 §418.64
Subregulatory Guidance
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- Medicare Benefit Policy Manual Chapter 9-Coverage of Hospice Services Medicare Benefit Policy Manual (cms.gov)
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40.4 - Core Services
40.4.1 - Contracting for Core Services
40.2.3 - Bereavement Counseling
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- State Operations Manual SOM - Exhibit (cms.gov)
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2080C - Hospice care Services
Other Resources
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Alerts/Newsbriefs/Newsline
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Education
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Marketplace
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- Guidelines for Bereavement Care in Hospice
Topics covered include Assessment, Community Bereavement Services, Complicated Grief, Documentation, Plan of Care, Policies, Quality Assessment/Performance Improvement, Scope of Services, Self-Care, Supervision, and Volunteers.
- Guidelines for Bereavement Care in Hospice
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All hospice aide services must be provided by individuals who meet the personnel requirements specified in the Medicare Hospice Regulations at 418.76. Hospice aides must also be supervised by an RN every 14 days.
NHPCO Member Resources and Compliance Guides
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- Medicare CoP Tip Sheet: Hospice Aide (June 2022)
- My NHPCO CNA
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Regulations
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- Hospice Care Code of Federal Regulations 42CFR 418
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Subpart C §418.70, §418.76,
Subregulatory Guidance
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- Medicare Benefit Policy Manual Chapter 9-Coverage of Hospice Services Medicare Benefit Policy Manual (cms.gov)
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40.1.7 Hospice Aide and Homemaker Services
Other Resources
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Nurse Practitioners must be employed by the hospice in order to perform hospice care roles. NPs are nurses and therefore a core service. NPs can complete face-to-face visits. A patient may chose a hospice NP to serve as a patient’s attending physician however, they may NOT:
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- Certify terminal illness
- Replace the hospice physician in the IDT
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NPs may write orders for care per the allowance in their state’s Advanced Nurse Act.
NHPCO Member Resources and Compliance Guides
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- Medicare CoP Tip Sheet: Nursing (June 2022)
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Regulations
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- Hospice Care Code of Federal Regulations 42CFR 418
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Subpart C §418.64, §418.66
Subpart D §418.114
Subregulatory Guidance
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- Medicare Benefit Policy Manual Chapter 9-Coverage of Hospice Services Medicare Benefit Policy Manual (cms.gov)
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40.4 - Core Services
40.4.1 - Contracting for Core Services
40.4.2.1 - Waiver for Certain Core Nursing Services
Other Resources
Cross Reference
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Alerts/Newsbriefs/Newsline
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Education
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The Medicare Patient Access to Hospice Act, effective Jan. 1, 2019. It allows PAs to serve as the attending physician to hospice patients and to provide hospice care within their scope of practice. While they are authorized to serve as a patient’s chosen attending physician, they may NOT:
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- Certify terminal illness
- Complete the face-to-face visit
- Replace the hospice physician in the IDT
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NHPCO Member Resources and Compliance Guides
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- Medicare CoP Tip Sheet: Pharmacist (June 2022)
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Regulations
Medicare Patient Access to Hospice Act Text - S.2214 - 115th Congress (2017-2018): Medicare Patient Access to Hospice Act of 2017 | Congress.gov | Library of Congress
This bill amends title XVIII (Medicare) of the Social Security Act to allow physician assistants to provide hospice care under Medicare.
Subregulatory Guidance
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- Medicare Benefit Policy Manual Chapter 9-Coverage of Hospice Services Medicare Benefit Policy Manual (cms.gov)
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40.4 - Core Services
Other Resources
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Cross Reference
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Alerts/Newsbriefs/Newsline
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Education
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Marketplace
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NHPCO Member Resources and Compliance Guides
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- Medicare CoP Tip Sheet: Pharmacist (June 2022)
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Regulations
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- Hospice Care Code of Federal Regulations 42CFR 418
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Subpart C §418.70, §418.72, §418.74
Subregulatory Guidance
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- Medicare Benefit Policy Manual Chapter 9-Coverage of Hospice Services Medicare Benefit Policy Manual (cms.gov)
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40.1.8 - Physical Therapy, Occupational Therapy, and SpeechLanguage Pathology
Other Resources
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Cross Reference
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Alerts/Newsbriefs/Newsline
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Education
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