Hospice physician and medical director
The hospice medical director oversees the clinical program and certifies that patients meet eligibility. The medical director or a hospice physician reviews the care plan, advises on complex symptom management, and is available for consultation when a nurse needs help.
Your own physician can usually remain involved as the attending physician. Some physicians prefer not to follow patients on hospice, in which case the hospice physician takes on that role. Either arrangement is normal; ask which one applies to you.
Registered nurse case manager
The nurse is the person you will speak with most. They assess the patient, build and update the care plan, manage medications, teach family members what to watch for, and decide when a visit needs to happen sooner.
The nurse is also the person who arranges equipment, calls the physician, and requests a change in level of care when symptoms escalate. If you are unsure who to call, call the nurse.
Home health aide
The aide provides personal care: bathing, grooming, skin care, and help with positioning and dressing. Aide visits are typically a few times a week and are intended to supplement family caregiving, not replace it.
Aides do not manage medications or make clinical decisions. If you notice a change in the patient’s condition during an aide visit, tell the nurse.
Chaplain and spiritual support
Chaplains offer spiritual and existential support in line with the patient’s and family’s own beliefs, including for people who are not religious. They do not proselytize, and their visits are optional.
They are often the people who sit with a family during the hardest conversations, and who help with rituals around death when a family wants them.
Volunteers and bereavement counselors
Trained hospice volunteers provide companionship, practical help, and short breaks for caregivers. The scope of a volunteer program varies considerably between agencies. Ask what is actually available rather than assuming.
Bereavement counselors support the family after the death, typically through phone contact, mailings, support groups, or individual counseling. Medicare requires hospices to offer bereavement support for up to a year after death.
How our team works
Hospice of Grace provides care through this interdisciplinary model, with the team based in Arcadia and traveling to patients from there. Ask during intake which disciplines will be involved in a particular case, and who to call when something changes.
Ask who will be responsible for what (the nurse, the aide, the social worker, the chaplain) and how quickly each can be reached. That answer is more useful than a page of portraits, and it tells you what the first week will actually feel like.
Common questions
Will we see the same nurse each visit?
Usually a primary nurse manages the case, with coverage from others when that nurse is off. Continuity varies, so ask how the agency handles scheduling and after-hours coverage.
Can we refuse the chaplain or social worker?
Yes. Both are offered, not imposed. You can decline any service and change your mind later.
Who do we call at night?
The on-call hospice nurse. Keep that number where every caregiver can find it. Call 911 instead if there is a fall, an injury, or an emergency unrelated to the terminal illness.
Does the hospice team replace our family doctor?
Not necessarily. The hospice physician and your own physician coordinate. Some physicians remain the attending; others hand off to the hospice medical director.
Medical social worker
The social worker helps with the parts of dying that are not medical: family disagreement, caregiver exhaustion, financial strain, placement decisions, advance care planning, and connecting people to community resources.
This is often the most underused part of hospice. If your family is arguing about care, if you cannot sleep, or if you do not know how to pay for something, ask to see the social worker.