One team, one plan of care
The hospice interdisciplinary team: who does what
A hospice interdisciplinary team is the group that plans and gives hospice care together. Medicare requires a doctor, a registered nurse, a social worker and a counselor at its core, with hospice aides, volunteers, therapists and others around them. The team writes one plan of care with the patient, the family and the attending physician, and reviews it at least every 15 days. Here is who does what.
Medically reviewed by Oscar Chien, MD, Medical Director, October 13, 2026
On this page (10 sections)
- What is a hospice interdisciplinary team?
- Which Medicare rule requires each team member?
- Who is on the team and what does each person do?
- How does the team plan care together?
- What is the difference between an interdisciplinary and a multidisciplinary team?
- How often does the team visit?
- Who leads Beta's team?
- How does the team work with facility staff?
- Related guides
- Common questions
What is a hospice interdisciplinary team?
Federal hospice rules (42 CFR 418.56) require each hospice to name an interdisciplinary group. At a minimum it includes a doctor of medicine or osteopathy, a registered nurse, a social worker, and a pastoral or other counselor. The group works with the patient, the family and the patient's own doctor to write an individual plan of care.
A registered nurse on the team is named to coordinate the plan, so that the nurse, aide, social worker and chaplain are working from the same information. The team reviews and updates each plan of care as often as the person's condition requires, and at least every 15 days.
Which Medicare rule requires each team member?
| Team member | Core or other | Medicare rule |
|---|---|---|
| Hospice doctor and medical director | Core | 418.56 (group); 418.64 (physician services) |
| Registered nurse | Core, and plan coordinator | 418.56 (group and coordinator); 418.64 (nursing) |
| Medical social worker | Core | 418.56; 418.64 (medical social services); 418.114 (degree and supervision) |
| Pastoral or other counselor | Core | 418.56; 418.64 (spiritual, dietary and bereavement counseling) |
| Hospice aide | Other | 418.76 (training, competency testing, RN supervision at least every 14 days) |
| Volunteers | Other | 418.78 (trained volunteers; hours equal to at least 5% of paid patient care hours) |
| Physical, occupational and speech therapists | Other, when the plan calls for them | 418.72 |
| Attending physician | Chosen by the patient | 418.56 (the plan of care is made with the attending physician) |
| Every employee and contractor | 418.114 (personnel qualifications) |
Core services must come from hospice employees. The hospice stays responsible for aides, volunteers and therapists arranged in other ways.
Who is on the team and what does each person do?
Hospice doctor and medical director
Certifies eligibility with the person's own doctor, oversees the medical side of the plan of care, and guides the team on symptom control.
The medical director's roleYour own doctor (attending physician)
You can keep the doctor you choose as your attending physician. That doctor works with the hospice doctor on the plan.
RN case manager
A registered nurse who assesses pain and other symptoms, adjusts the plan with the doctor, teaches family caregivers, and coordinates the rest of the team.
Licensed vocational nurse (LVN)
Provides nursing care and symptom checks under the direction of the registered nurse.
On-call nurse
A hospice nurse answers the phone 24 hours a day, 7 days a week, and can visit when needed.
Hospice aide
Helps with bathing, dressing, skin care and other personal care. A registered nurse writes the aide's instructions and checks on the aide's work.
Medical social worker
Helps with emotional strain, family communication, advance directives, community resources and practical planning.
Chaplain or spiritual counselor
Offers spiritual support for any faith or none. Only if the person or family wants it.
Bereavement coordinator
Plans grief support for family before and after a death, for 13 months after a death.
Bereavement supportVolunteers
Trained volunteers offer companionship, short breaks for caregivers and help in the office.
Volunteer with usDietary counselor and therapists
Dietary counseling, and physical, occupational or speech therapy, are arranged when the plan of care calls for them.
How does the team plan care together?
- Step 1
Assessment in the first days
A registered nurse completes an initial assessment within 48 hours of the start of hospice. The team completes the comprehensive assessment within 5 days (42 CFR 418.54).
- Step 2
One plan of care
Written with the patient, the family and the attending physician: the problems, the services and how often, medicines, equipment and the outcomes the team is working toward.
- Step 3
Team review at least every 15 days
The group reviews each plan as often as the person's condition requires, and at least every 15 calendar days, and updates the assessment on the same schedule.
- Step 4
Coordination with the attending physician
The hospice shares the plan and any change in condition with the attending physician and other providers, so that orders, medicines and visits line up.
What is the difference between an interdisciplinary and a multidisciplinary team?
In a multidisciplinary team, each discipline assesses the patient and writes its own plan, and the pieces sit side by side. In an interdisciplinary team, the disciplines share one plan and one set of goals, meet as a group and adjust each other's work. Medicare chose the second model for hospice.
How often does the team visit?
There is no fixed number. Visits are set by the plan of care and change as the person's needs change. Family or hired caregivers provide day-to-day care between visits. See what hospice provides and the four levels of care.
Who leads Beta's team?
| Role | Name and credentials |
|---|---|
| Administrator | Gina Allain, RN |
| Medical director | Oscar Chien, MD, California physician license A54999 |
| Director of patient care services | Gina Allain, RN |
| Chief operating officer | Jack Demirchyan |
| Contact for bereavement questions | Jackie Melkonyan |
| Volunteer program | Ask the main office at (877) 258-7129 to be connected |
We list names only with each person's approval. Clinical credentials are worded as they appear on the person's California license. Languages spoken across the team: English, Spanish, Russian, Armenian and other languages. Ask us to confirm a language match for the clinician assigned to you when care is arranged.
How does the team work with facility staff?
We care for people wherever they call home, including nursing facilities, RCFEs (residential care facilities for the elderly) and board-and-care homes, in coordination with facility staff. The hospice team manages the hospice plan of care. Facility staff keep providing the daily care they already provide. See hospice in assisted living.
Related guides
Culturally competent hospice care and what hospice won't tell you.
Common questions
Who is on a hospice interdisciplinary team?
At a minimum, a hospice doctor, a registered nurse, a social worker and a pastoral or other counselor. Aides, volunteers, a bereavement coordinator, therapists and a dietary counselor join as the plan of care requires.
How often does the hospice team meet?
As often as the person's condition requires, and at least every 15 calendar days under 42 CFR 418.56. Home visits are separate and more frequent.
What is the role of the social worker in hospice?
The medical social worker assesses emotional and practical needs, helps family members talk with each other, assists with advance directives and POLST, finds community resources, and supports the family before and after a death. Under 418.114 the role requires a social work degree or a related degree with MSW supervision.
Do volunteers count as part of the team?
Yes. Medicare requires trained volunteers in patient care or administrative roles, with hours equal to at least 5% of paid patient care hours (42 CFR 418.78). They offer companionship and short breaks for caregivers, not nursing care.
Can we ask for a different nurse or aide?
Yes. Tell the RN case manager or call the office. You have the right to be involved in your plan of care and to voice concerns without fear of reprisal. See patient rights.
About this page
- Written by
- Beta Hospice care team
- Medically reviewed by
- Oscar Chien, MD, Medical Director
- Last reviewed
- October 13, 2026
- Next review
- April 13, 2027
How we write and review this site
Sources
- 42 CFR 418.56: Interdisciplinary group, care planning and coordination of services (opens in a new tab)
- 42 CFR 418.76: Hospice aide and homemaker services (opens in a new tab)
- 42 CFR 418.64: Core services (opens in a new tab)
- 42 CFR 418.52: Patient's rights (opens in a new tab)
- 42 CFR 418.54: Initial and comprehensive assessment of the patient (opens in a new tab)
- 42 CFR 418.78: Volunteers (opens in a new tab)
- 42 CFR 418.114: Personnel qualifications (opens in a new tab)
- Medicare.gov: Hospice care coverage (opens in a new tab)
These sources support the general information on this page. For one personās care and coverage, talk with the hospice team.
You do not have to decide alone.
Call (877) 258-7129 any time, or leave your number and someone from Beta's hospice team will call you. No decision is needed to call. Most families start with a question.
Only a hospice doctor, together with the personās own doctor, can confirm hospice eligibility. A website cannot.
- A nurse answers 24 hours a day, 7 days a week
- You can stop hospice at any time
- You have the right to choose your hospice