Hospice Care Agency Evaluation Checklist

Hospice Name: _______________________________________________________ Contact Name: _______________________________________________________ Address: ___________________________________________________________ Telephone: ________________________ Email: _____________________________

Is the hospice licensed by the state? Is the hospice a nonprofit or for-profit organization? Is the hospice Medicare certified? Is the hospice accredited by a state or nationally recognized group such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)? Is the hospice a member of the Oklahoma Hospice and Palliative Care Association (OHPCA), the National Hospice and Palliative Care Organization (NHPCO), or the National Association for Home Care and Hospice (NAHC)? How many years has the hospice been in business? Can the agency provide references? What are the geographic service boundaries? Are you allowed to retain your personal physician? Circle medical equipment that is typically provided to a patient: Electric hospital bed Alternating pressure mattress Bedside commode Other Will the hospice coordinate medication management? Does the hospice require you to identify a family member or friend as a primary caregiver as a condition of admission? What responsibilities are expected of the primary caregiver? What special programs, in addition to routine hospice care, are available? If pets are in the home, will the hospice assist with pet care? Does the agency use volunteers? If so, how are volunteers screened? Are you required to sign a do not resuscitate (DNR) order or an advance directive before being admitted? What costs are covered by Medicare or other insurance? Are you required to designate your chosen funeral, burial or cremation provider before being admitted? How quickly can the hospice start services? Are grief counseling or other support services available to family?

Sources: Oklahoma Hospice and Palliative Care Association (OHPCA), www.okhospice.org and National Hospice and Palliative Care Organization (NHPCO), www.nhpco.org.