Name of hospice palliative care program:

Address:

City

Province or Territory

Zip

Phone number:

Where are services provided?

• In your home
• In a special inpatient hospice palliative care unit
• In a facility (hospital or nursing home) where you are already a patient

What services are provided?

• One or more doctors who can make home, hospital, or nursing home visits
• Spiritual or religious counselling or advisors
• Respiratory, occupational, and physiotherapists
• Social workers
• Home health aides
• Shopping and errands
• Meal preparation and nutritional counselling
• Cleaning and household chores
• Respite services if your primary caregiver becomes ill or needs a break
• Prescription medications, and medical supplies and equipment
• Interpreters or other special services related to your culture, ethnicity, or lifestyle

What is the plan of care?

Does the hospice palliative care program develop a care plan with you and your family?

Yes / No

The care plan should include specific duties, who will perform them and how often, and the name and phone number of the supervisor. A good program will develop a care plan by providing a health professional (not a clerk or administrative assistant) who will:

• Talk with you and your family in your home (not just over the telephone).
• Talk with your doctor or other health professionals.
• Write down the care plan and give copies to everyone who will be involved in your care.

Who provides care?

• Family members
• Hospice palliative care staff
• Your doctor

References

Get the names of doctors who refer patients to this program.

Identify families who have used this program. If possible, talk with the families. Ask about their experience and whether they would recommend the program to others.

After your visit

Does this program provide the services you want?

Yes / No

Is this program covered by your insurance?

Yes / No