The Inter-Disciplinary Group (IDG) is composed of individuals who provide the complete spectrum of care to the patient and his/her loved ones. The team members are a community of care providers with the patient and family at its center. Horizon team members contribute expertise in managing physical, emotional, and spiritual symptoms – but the patient and family are the experts when it comes to determining how their care is planned. Each patient’s IDG members include the patient’s primary care physician, the Horizon Medical Director, the patient’s Hospice Nurse, Certified Nurse’s Assistant, Social Worker, and Chaplain, and sometimes a volunteer. With the patient’s and family’s goals, and our knowledge, we will collaboratively develop a Plan of Care that is individualized and carried out by hospice professionals and volunteers. IDG members are in constant contact with one another regarding each patient and family.
Every two weeks, the IDG and the Medical Director will meet to review and update each patient’s Plan of Care. The patient and family’s participation in the Plan of Care helps us meet their needs, thus achieving comfort, dignity, and quality of life. Hospice services are provided in the place the patient calls home on a scheduled basis or as needed 24 hours a day.
All hospice care is provided under the guidance of the patient’s primary doctor and Horizon Hospice’s Medical Director. The medical director oversees physician services within our organization. He/She will act as a medical resource to IDG (Inter-Disciplinary Group) members and is available to supplement primary physician services. He/She is present at IDG meetings, routinely directing and approving the Plan of Care. If the IDG identifies the need for physical, occupational, or speech therapy, these services are recorded in the Plan of Care and ordered by a physician.
Each Horizon nurse is a licensed and skilled professional with expertise in end-of-life care. He/She is there to minimize any distressing symptoms and serve as a teacher and supporter. The nurse maintains ongoing communication with the patient, his/her family, caregivers, and other members of the IDG. Each patient’s primary nurse is notified of any contact that patient has with other nurses (for example, during on-call hours).
Nursing responsibilities include:
- Completing initial assessments to determine hospice needs
- Evaluating and re-evaluating patient and family/caregiver needs
- Administering medications and treatments as prescribed by the physician
- Counseling the patient and family in meeting the nursing and related needs
- Providing healthcare instructions to patients and family
- Working in cooperation with the family/caregiver and hospice Interdisciplinary Group to meet the emotional needs of the patient and family/caregiver
CERTIFIED NURSE’S ASSISTANT (CNA) SERVICES
Our CNAs have training and expertise in end-of-life caregiving and provide personal care in a manner that meets each patient’s specific needs. CNAs assist patients with activities of daily living such as bathing, shaving, shampooing, and changing bed linens. They also provide support and teach a patient’s other caregivers about Hospice and safety. The CNA often becomes a source of emotional support to the patient and family.
CNA responsibilities include:
- Providing patients and families with positive communication techniques
- Planning and preparing nutritious meals, including shopping, as assigned
- Providing proper care and observation of patient’s skin to prevent the breakdown of tissue
- Assessing and reporting on patient’s condition and significant changes
SOCIAL WORKER SERVICES
Horizon Social Workers are skilled professionals who have training and expertise in end-of-life planning, as well as, individual and family counseling. They connect patients and families with helpful community resources. A patient or family member may rely on his/her social worker as a companion or confidante. The social worker is there to support, validate and advocate for the emotional well-being of the patient and family.
A Social Worker’s responsibilities include:
- Assessing the psychosocial status of patients and families/caregivers related to the patient’s terminal illness and environment – communicates these findings to team members
- Carrying out social evaluations, including family dynamics, caregiver abilities, communication patterns
- Counseling patient and family/caregivers as needed in relationship to stress, and other identified coping difficulties
- Educating patients and families on, and assists in, preparation of advanced directives
- Serving as a liaison between patients and families/caregivers and community agencies
SPIRITUAL CARE SERVICES
Horizon recognizes and respects all faith traditions. All our chaplains have an interfaith perspective and are there to support the spiritual and religious beliefs of the patient and family. Soon after a patient and family’s admission to Horizon, a chaplain will meet with them to discuss and assess their spiritual needs. Horizon recognizes dying as not only a physical event but also an emotional and spiritual journey that requires special attention. Spiritual care may be provided by one of our hospice chaplains, or we can coordinate with other community clergies.
Chaplin responsibilities include:
- Performing spiritual assessment of patients and families
- Serving as a liaison and support to community chaplains and spiritual counselors
- Providing consultation, education, and support to the interdisciplinary group on spiritual care
- Providing for funeral or memorial services for patients as requested
Volunteers are valued members of the Horizon team. All volunteers receive extensive training and are supervised and supported by the Volunteer Coordinator. Horizon volunteers can provide support, companionship, and respite for caregivers and other practical non-medical services. Our volunteers also provide therapies to complement hospice treatment, which may include massage, pet therapy, and other healing arts.
Horizon is committed to providing support to loved ones for a minimum of 13 months after a death. Contact is maintained by the staff members and volunteers who practice through our bereavement program. We are here to support people through their healing journey and help honor those who have lived fully and died well.
Bereavement Coordinator responsibilities include:
- Coordinating the assessment and delivery of grief counseling
- Planning for Bereavement Program development
- Providing bereavement support to hospice personnel coping with work-related grief
- Providing bereavement information and referral services to callers from the community