The Interdisciplinary Group, the Care Planning Process, and Coordination of Services in Hospice

The Interdisciplinary Group, the Care Planning Process, and Coordination of Services in Hospice 

Federal regulations pertaining to hospice agencies have specific guidelines regarding the interdisciplinary group, the plan of care, and care coordination. To maintain compliance with these regulations, hospice team members need to understand these regulations and how they are applied to everyday practice. After reviewing the required elements of care coordination, you will consider how to apply them in patient scenarios.


Hours: 1.25


Certificates provided by accrediting body (7 Match)

California Board of Registered Nursing

1.25 HOURS

Provider approved by the California Board of Registered Nursing, CEP# 13791

Nurses will receive 1.25 contact hours for participating in this course.

District of Columbia Board of Nursing


DC-RN -- District of Columbia Board of Nursing Approved Continuing Education program (CE Provider #50-290).

Nurses will receive 1.20 contact hours for participating in this course.

Florida Board of Nursing


Florida Board of Nursing CE Provider #: 50-290

Nurses will receive 1.00 contact hours for participating in this course.

American Nurses Credentialing Center

1.25 HOURS

Relias, LLC is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Nurses will receive 1.25 contact hours for participating in this course.

Georgia Board of Nursing

1.25 HOURS

Georgia Board of Nursing CE Provider #: 50-290

Nurses will receive 1.25 contact hours for participating in this course.

South Carolina Board of Nursing

1.25 HOURS

This program was approved by the South Carolina Board of Nursing Approved Continuing Education Program (CE provider #50-290) CE Broker Course # 20-[Custom_Code]

West Virginia Board of Registered Nursing

1.25 HOURS

Course Details

Hours: 1.25
Type: Online Course
Content Expiration Date: 7/31/2021
Learning Objectives:
Discuss the application and impact of federal regulations on the interdisciplinary group process in hospice.
Explain criteria required in the plan of care to maintain compliance with federal regulations.
Illustrate effective care coordination as outlined by federal regulations.
Apply the required elements of care planning and care coordination to hospice practice.

Section 1: Introduction

About This Course

Learning Objectives

Section 2: The Hospice Interdisciplinary Group

An Interdisciplinary Approach

Who is the Attending Physician?

The Interdisciplinary Group: Structure and Function

Interdisciplinary Group Documentation



Section 3: Plan of Care Criteria

Plans of Care Effect Surveys and Payment

Plan of Care Must Be Comprehensive

Plan of Care Should be Evolving

Content of the Plan of Care

Interventions for Pain and Symptoms

Visit Frequency

Measurable Outcomes

Medications and Treatments: Timely Response

Durable Medical Equipment and Supplies

Document Understanding of the Plan of Care



Section 4: Coordination of Services

Registered Nurse Role as the Coordinator of Care

Communicating a Change in Condition to the Interdisciplinary Group

Interdisciplinary Group for Policies and Procedures

Communication: The Interdisciplinary Group and the Attending Physician

Educating Caregivers

Coordinating Unrelated Services



Section 5: Applying the Process: Case Studies

Mrs. Brady

Mrs. Brady, Part 2

Mrs. Harris



Section 6: Conclusion


Course Contributors



Instructor: Lauren Templeton, D.O.

Dr. Lauren Templeton, a Physician Consultant with Weatherbee Resources since 2017, has over 10 years of physician experience with 8 years specializing in hospice and palliative medicine.  Dr. Templeton began her career in internal medicine, but soon thereafter was drawn to end-of-life care due to its overall philosophy and her passion for ensuring a dignified death for her patients. 
Dr. Templeton currently works in hospice as the medical director for a medium size not-for-profit hospice based in Texas. In this role, she assists with compliance, quality improvement and documentation review. She continues to participate in clinical care managing hospice patients in both the home care and inpatient setting. 

Dr. Templeton also serves as associate medical director for the Palliative Care Department at a local medical center, as well as, serving on the ethics committee for the same facility. 

Dr. Templeton's mission is to help support hospices by educating on the role of the hospice medical director from a regulatory and clinical perspective. She continues a robust educational program within her own hospice program and is a speaker with the Texas New Mexico Hospice Organization. Dr. Templeton is an advocate of the hospice benefit and speaks to groups such as the Alzheimer's Association about hospice care. 

As a Physician Consultant with Weatherbee, Dr. Templeton assists hospice providers and physicians with:

  • Orientation for new medical directors and team physicians.
  • Education, coaching, and mentoring for hospice physicians.
  • Consulting on complex issues (e.g., making appropriate coverage determinations; ethical issues; challenging pain and symptom management cases; admission, recertification, and level of care eligibility; etc.).
  • Auditing physician and other clinical record documentation (e.g., thoroughness and appropriateness with regard to hospice eligibility; compliance with regulatory requirements; appropriateness with regard to coverage determinations; etc.).
  • Re-tooling the interdisciplinary group meeting and related processes.
  • Preparing physicians for Administrative Law Judge (ALJ) hearings.
  • Providing expert witness testimony in ALJ hearings and other legal matters involving patient eligibility.

Dr. Templeton graduated from Pennsylvania State University with a Bachelor of Arts and received her doctor of osteopathy from Ohio University College of Osteopathic Medicine in 2009. She completed a residency in Internal Medicine and is board certified with the American College of Osteopathic Internists. She completed a fellowship in Hospice and Palliative Medicine at Texas Tech University and became board certified in hospice and palliative medicine in 2013. Dr. Templeton became Hospice Medical Director Certified (HMDC) in 2018.

Disclosure: Lauren Templeton, D.O. has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Instructor: Colleen O'Keefe, RN, CHPN

Colleen O'Keefe RN, CHPN, is the Senior Project Specialist for Weatherbee Resources. She is certified in Hospice and Palliative Care and is also a Hospice and Palliative Nurses Association (HPNA) Approved Educator. Colleen has served as an RN Case Manager, Supervisor for a Continuous Home Care team, Clinical Educator, and Compliance Officer. Her clinical, regulatory, and leadership expertise allows her to deliver uncompromising consulting services.

As a Senior Consultant & Project Specialist with Weatherbee Resources, Colleen conducts clinical record audits for hospice organizations facing Additional Development Requests, writes independent expert cover letters to support technical and clinical eligibility for hospice care, and provides assistance and guidance throughout the appeals process. Colleen conducts comprehensive baseline assessment audits and mock surveys to assess regulatory compliance and identify potential risk exposures, and devises action plans to address problem areas. She also conducts education for hospice organizations across the country. Colleen also has experience and expertise in conducting investigations for hospices facing payment-related scrutiny by governmental agencies.

Colleen is a registered nurse and holds a bachelor's degree from Northwestern University.

Disclosure: Colleen O'Keefe, RN, CHPN has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Expert Reviewer: Lynn Stange, RN, BSN, MA, CHC

Lynn Stange first joined the Weatherbee team as an Associate Consultant in 2006, and was promoted to Director of Consulting in 2007. Lynn re-joined Weatherbee in 2017 as the Chief Compliance & Consulting Integrity Officer and in February 2018, Lynn was promoted to President. In July 2018 Lynn, along with Carrie Cooley, Principal/CEO, purchased Weatherbee Resources, Inc. and Lynn assumed the title of Principal/President of Weatherbee Resources.

In her new role, Lynn is responsible for strategic growth initiatives in the areas of compliance, quality, and education. Lynn works with consulting clients in the areas of Quality Assurance Performance Improvement (QAPI), mock surveys and compliance audits, Joint Commission accreditation, State Licensure preparation, plans of correction, pursuit of the Malcolm Baldrige National Quality Award, hospice acquisitions/sales, and program development. Lynn will also oversee all aspects of Weatherbee's Hospice Compliance Network (HCN) and Weatherbee's product line. Lynn's breadth of experience with a variety of regulations and standards allows her to connect with clients quickly to aid them in identifying their most critical needs thereby assuring excellent outcomes. 

Lynn is a nationally recognized speaker in both the hospice and compliance arenas, having spoken at both the National Hospice and Palliative Care Organization (NHPCO) annual Management and Leadership Conference and at the annual Health Care Compliance Association (HCCA) national conference. Lynn is a member of the NHPCO Regulatory Committee since 2014. As a member of Weatherbee's Speaker's Bureau, Lynn teaches on a variety of regulatory, compliance, and leadership-related topics and is a permanent faculty member of Weatherbee's renowned Hospice Regulatory Boot Camp.

Lynn has been a registered nurse for 30 years with a Bachelor's degree in nursing from Carroll College in Helena, Montana and a Master's degree in Organizational Management from the University of Phoenix, Las Vegas. Lynn has been a State surveyor in both Montana and Nevada, and earned her Certification in Healthcare Compliance (CHC) in 2014.

Disclosure: Lynn Stange, RN, BSN, MA, CHC has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Staff Writer: Susan Heinzerling, RN, CHPN
Susan Heinzerling began her nursing career as a Med/Surg nurse. Renal patients in acute care, with multiple chronic conditions and repeated hospitalizations inspired her practice of hospice nursing where she began as Hospice Admissions Nurse and later became a Hospice RN Case Manager. Susan has practiced hospice nursing in both a large, urban area and in a rural setting. Susan earned a B.S. in Biology and B.S. in Nursing from the University of North Carolina at Chapel Hill and a Master's degree in Physiology from North Carolina State University. She became a Ph.D. Candidate in Immunology at the University of South Alabama. Her research experiences in the biomedical sciences led to an interest in evidence-based practices. Disclosure: Susan Heinzerling, RN, CHPN has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Target Audience:
The target audience for this course is: Beginner level Social Workers; Entry level Professional Counselors; Nurses; in the following settings: Hospice.
Relias will be transparent in disclosing if any commercial support, sponsorship or co-providership is present prior to the learner completing the course.
Course Delivery Method and Format
Asynchronous/Online Distance Learning; please see certificate details for specifics on delivery format.
Relias has a grievance policy in place to facilitate reports of dissatisfaction. Relias will make every effort to resolve each grievance in a mutually satisfactory manner. In order to report a complaint or grievance please contact Relias.
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All courses offered by Relias, LLC are developed from a foundation of diversity, inclusiveness, and a multicultural perspective. Knowledge, values and awareness related to cultural competency are infused throughout the course content.
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All characteristics and organizations referenced in the following training are fictional. Any resemblance to any actual organizations or persons living or dead, is purely coincidental.
To earn continuing education credit for this course you must achieve a passing score of 80% on the post-test and complete the course evaluation.
If you require special accommodations to complete this module, please contact Relias Customer Support here.