MLN Fact Sheet: Creating an effective hospice Plan of Care

MLN Fact Sheet: Creating an effective Hospice Plan of Care
Centers for Medicare & Medicaid Services, Medicare Learning Network (MLN); 5/10/25 
The hospice plan of care (POC) maps out needs and services given to a Medicare patient facing a terminal illness, as well as the patient’s family or caregiver. CMS data shows that some hospice POCs are incomplete or not followed correctly. This fact sheet educates on creating and coordinating successful hospice POCs. The primary goal of hospice care is to meet the holistic needs of an individual and their caregiver and family when curative care is no longer an option. To support this goal:

• The hospice provider develops an individualized POC
• An Interdisciplinary Group (IDG) sets up the POC and it’s overseen by a Registered Nurse (RN) coordinator

Editor's note: "Failing to plan is planning to fail," is a quote often attributed to Ben Franklin. What--if anything--is more important in hospice than the person's Plan of Care? Perhaps, actually using? Perhaps, knowing when, how, and with whom to adjust previous plans to changing needs? Perhaps, implementing each individualized Plan of Care with humanity, integrity, and clinical acumen? My questions are not to diminish the importance of effective Hospice Plans of Care. Rather, to emphasize its core, crucial roles in discerning and providing effective, efficient, coordinated, personalized hospice care. Do you think of the hospice patient's Plan of Care as a noun, "a plan"--or a verb, "to plan"? It's both. This CMS / MLN Fact Sheet is a must-have, must-know, must-use resource. Download it. Share it. Examine its linked reports. Learn. Listen. Improve. Ultimately, whose plan is it? Years from now, who will carry evocative memories of the good, bad, and everything-in-between from the care your hospice is providing, today? (Spoiler alerts: the patient; the caregiver and family.) It matters. Let's learn. Let's plan.