Interdisciplinary Care Plan Drafter

SKILL.md

---
name: interdisciplinary-care-plan-drafter
description: >
  Use this skill when a palliative care or hospice interdisciplinary team — including
  attending physicians, APRNs, RNs, social workers, or chaplains — needs to draft a
  CMS Conditions of Participation–compliant Interdisciplinary Care Plan (ICP) for a
  hospice or seriously ill patient. Covers goals-of-care documentation, comfort care
  plan, IDT role assignments, visit frequencies, and Medicare hospice benefit compliance.
  Produces a DRAFT for licensed clinician and IDT co-review before any care delivery or
  billing use.
---

# Interdisciplinary Care Plan Drafter

Converts goals-of-care assessments and clinical data into a structured, CMS CoP–compliant Interdisciplinary Care Plan (ICP) for hospice and palliative care patients. Covers every required element from patient goals and advance directive status through comfort care plan, IDT assignments, and family conference documentation, producing a DRAFT for licensed clinician and IDT review.

---

## Before You Start

This skill produces **DRAFT documentation only**. All content requires review by a licensed attending physician or APRN and sign-off by the full IDT before:
- Any care is delivered based on the plan
- Any content enters the medical record
- Any Medicare or Medicaid hospice benefit billing occurs

**Critical safety rules:**
- Goals-of-care conversations and prognostic discussions must be conducted by qualified clinicians — this skill documents and structures those conversations; it does not conduct them
- Never include statements that constitute a medical order (e.g., "do not resuscitate" as an order) — document patient/family preference and refer to the POLST/MOLST or physician order workflow
- Prognosis statements are labeled **[DRAFT — CLINICAL ASSESSMENT REQUIRED]**; the skill does not generate prognoses

**PII rule:** Collect patient initials and case reference only. Never record full name, date of birth, MRN, address, or insurance number in this conversation.

---

## Flow

### Phase 1 — Patient and Encounter Identification

Ask one question at a time. Collect:
1. Patient initials and case reference number
2. Admission or consultation date
3. Setting: Hospice home care / Hospice inpatient unit / Hospice residential facility / Palliative care consultation (inpatient) / Palliative care consultation (outpatient)
4. For hospice: Hospice diagnosis (principal terminal diagnosis) and ICD-10 code if known
5. For hospice: Prognosis basis — the clinician's stated basis for the terminal prognosis (e.g., "rapid decline in functional status, unresponsive to disease-directed treatment") — label **[DRAFT — CLINICAL ASSESSMENT REQUIRED; ATTENDING PHYSICIAN TO CONFIRM]**
6. Attending physician name and title (or "TBD")
7. IDT composition: list disciplines present (physician, NP/PA, RN/hospice nurse, social worker, chaplain/spiritual care, hospice aide, volunteer coordinator, dietitian — check all that apply)

Flag any missing IDT disciplines required by CMS CoP as **[CMS CoP FLAG — 42 CFR § 418.56 REQUIRES IDT MINIMUM OF: RN, physician/designee, social worker, pastoral/spiritual counselor]**.

---

### Phase 2 — Goals of Care

Collect goals-of-care information as documented by the clinician:

**2a. Patient Decision-Making Capacity**
- Patient has capacity to participate in care decisions: Yes / No / Fluctuating
- If no or fluctuating: Surrogate/DPOA decision-maker identified: [Name — initials + relationship only] / Not yet identified
- Flag: **[SURROGATE IDENTIFICATION FLAG]** if no surrogate identified and patient lacks capacity

**2b. Advance Directive Status**
- Advance directive on file: Yes / No / Patient states none exists
  - Type (if yes): Living will / DPOA for healthcare / Combination / POLST/MOLST
  - Location in medical record: [Confirm]
- POLST/MOLST completed: Yes / No / In process
  - Code status: DNR / Full code / Limited interventions (specify) — document as stated preference; label **[PHYSICIAN ORDER REQUIRED — POLST/MOLST NOT COMPLETED BY THIS SKILL]** if not yet signed

**2c. Goals of Care as Expressed by Patient/Family**
Capture in patient's/family's own words where possible:
- Primary goal(s): (e.g., "remain at home," "be free of pain," "stay alert enough to communicate with family")
- Specific preferences: (e.g., hospitalization preferences, resuscitation, artificial nutrition/hydration, treatments to continue or discontinue)
- Fears or concerns: (e.g., "afraid of being in pain," "worried about being a burden")
- Meaningful activities or priorities: (e.g., specific family events, cultural or religious observances)

Label entire section: **[DRAFT — GOALS OF CARE AS DOCUMENTED BY CLINICIAN; IDT TO REVIEW]**

---

### Phase 3 — Comfort Care Plan by Domain

For each domain, collect the current status and planned interventions. Label all plans **[DRAFT — CLINICIAN TO REVIEW]**.

**3a. Medical / Symptom Management (Attending Physician or APRN)**
- Primary symptom burden: (select all that apply: pain / dyspnea / nausea/vomiting / constipation / agitation/delirium / anxiety / wound care / other)
- For each symptom: current management approach and any medication or treatment changes planned
  - Pain: current regimen, PRN plan, goals (e.g., pain ≤ 3/10), breakthrough protocol — label **[MEDICATION ORDER — PHYSICIAN/APRN TO COMPLETE SEPARATELY]**
  - Dyspnea: current regimen, oxygen status, PRN plan
  - Nausea: current regimen, PRN plan
  - Constipation: bowel regimen
  - Agitation/delirium: current regimen, non-pharmacologic approaches
  - Wound care: wound description, dressing plan, frequency
- Disease-directed treatment status: Discontinued / Continuing for comfort / Modifying — specify

Flag uncontrolled symptoms as **[UNCONTROLLED SYMPTOM — URGENT CLINICAL REVIEW]**.

**3b. Nursing (RN / LPN under RN supervision)**
- Assessment frequency: Visits per week / Continuous care episodes expected
- Nursing care focus areas: (e.g., wound care, catheter care, medication management, family caregiver training, signs-and-symptoms monitoring)
- Caregiver education plan: What will the nurse teach the family/caregiver?
- On-call coverage: 24/7 on-call: Confirmed / Not confirmed — flag if not confirmed

**3c. Social Work**
- Psychosocial assessment status: Completed / In progress / Pending
- Identified social and emotional needs: (e.g., caregiver burden, financial concerns, family conflict, anticipatory grief, isolation)
- Social work intervention plan: (counseling, community resources, bereavement planning, advance care planning support)
- Bereavement risk assessment: Standard / Elevated — if elevated, document plan

**3d. Spiritual / Chaplaincy Care**
- Spiritual needs assessment status: Completed / In progress / Declined by patient/family
- Religious or spiritual affiliation: (if disclosed — optional, document only if relevant to care plan)
- Spiritual care plan: (e.g., regular chaplain visits, connection to community clergy, ritual support, end-of-life spiritual preparation)
- If patient/family declined spiritual care: Document and note re-offer schedule

**3e. Hospice Aide / Personal Care**
- ADL support needs: Bathing / Grooming / Dressing / Oral care / Skin care / Positioning / Transfers / Other
- Aide visit frequency: \_\_ visits per week, \_\_ hours per visit
- Safety considerations for aide visits: (mobility, fall risk, special equipment)

**3f. Volunteer Services** (if applicable)
- Volunteer services accepted: Yes / No / Not yet discussed
- Volunteer role plan: (companionship, respite for caregiver, errands, reading, other)

**3g. Dietitian / Nutritional Support** (if applicable)
- Nutritional status: No concerns / Concerns identified (specify)
- Artificial nutrition and hydration status: Not applicable / Patient/family preference documented (reference Phase 2c)
- Dietitian involvement: Needed / Not needed / Declined

---

### Phase 4 — IDT Role Assignments and Visit Frequency Schedule

Compile a CMS CoP–aligned visit frequency table. All frequencies labeled **[DRAFT — IDT TO APPROVE]**.

| Discipline | Staff (if known) | Planned Visit Frequency | Key Responsibilities |
|------------|-----------------|------------------------|----------------------|
| Attending Physician | | Per plan / PRN / Telehealth | Symptom management, certification |
| RN / Hospice Nurse | | \_\_ visits/week | Assessment, wound care, family teaching |
| Social Worker | | \_\_ visits/month (minimum 1) | Psychosocial support, advance care planning |
| Chaplain / Spiritual Care | | \_\_ visits/month | Spiritual needs, end-of-life support |
| Hospice Aide | | \_\_ visits/week | ADL support per Phase 3e |
| Volunteer | | \_\_ visits/week (if accepted) | Per Phase 3f |
| Dietitian | | PRN / \_\_ (if indicated) | Per Phase 3g |

**CMS CoP minimum:** IDT must meet (in person or by teleconference) at least every 15 calendar days per 42 CFR § 418.56(c). Flag if IDT meeting schedule has not been established as **[CMS CoP FLAG — IDT MEETING SCHEDULE NOT ESTABLISHED]**.

---

### Phase 5 — Family Conference Documentation (If Conducted)

If a family conference was conducted, collect:
- Date and location of conference
- Attendees: IDT members present; family/surrogate present (initials + relationship)
- Key topics discussed (summary — not verbatim)
- Decisions made or documented preferences (reference Phase 2c)
- Any unresolved concerns or questions to follow up
- Next family conference planned: Date or interval

If no conference has been conducted at admission, flag: **[FAMILY CONFERENCE FLAG — CMS CoP REQUIRES FAMILY INVOLVEMENT IN CARE PLANNING; SCHEDULE IF NOT YET HELD]**.

---

### Phase 6 — Open-Items Checklist

Before finalizing the DRAFT, generate a checklist of open items:

- [ ] Attending physician signature on ICP
- [ ] All IDT disciplines have reviewed and co-signed
- [ ] POLST/MOLST completed and in medical record (if not, flag)
- [ ] Advance directive on file and location documented (if not, flag)
- [ ] Surrogate/DPOA identified and documented (if patient lacks capacity)
- [ ] All uncontrolled symptoms flagged in Phase 3a have clinical review plans
- [ ] IDT meeting schedule established (minimum every 15 days)
- [ ] Family conference conducted or scheduled
- [ ] Bereavement plan initiated (if elevated risk)
- [ ] 24/7 on-call coverage confirmed

---

### Phase 7 — DRAFT ICP Assembly

Compile all phases into the following structured document:

```
INTERDISCIPLINARY CARE PLAN — DRAFT
Patient Initials: [From Phase 1] | Case Ref: [Phase 1] | Date: [Today]
Setting: [Phase 1]
Principal Diagnosis: [Phase 1 — ICD-10]
Attending Physician: [Phase 1]
IDT Members Completing This Plan: [Phase 1]

──────────────────────────────────────────
SECTION 1: GOALS OF CARE
[From Phase 2 — patient/family goals, preferences, fears, meaningful activities]
Advance Directive Status: [Phase 2b]
Code Status Preference: [Phase 2b — PHYSICIAN ORDER REQUIRED FOR POLST/MOLST]
DRAFT — FOR CLINICIAN AND IDT REVIEW

──────────────────────────────────────────
SECTION 2: COMFORT CARE PLAN

  2a. Medical / Symptom Management
  [From Phase 3a — symptom burden and management plans]
  [MEDICATION ORDERS — PHYSICIAN/APRN TO COMPLETE SEPARATELY]

  2b. Nursing Care Plan
  [From Phase 3b — visit frequency, focus areas, caregiver education]

  2c. Social Work Plan
  [From Phase 3c — psychosocial needs and intervention plan]

  2d. Spiritual Care Plan
  [From Phase 3d — spiritual needs and chaplaincy plan]

  2e. Hospice Aide / Personal Care Plan
  [From Phase 3e — ADL support and visit schedule]

  2f. Volunteer Services
  [From Phase 3f]

  2g. Nutritional Plan (if applicable)
  [From Phase 3g]

──────────────────────────────────────────
SECTION 3: IDT ROLE ASSIGNMENTS AND VISIT FREQUENCY
[Table from Phase 4]
DRAFT — IDT TO APPROVE AT NEXT IDT MEETING

──────────────────────────────────────────
SECTION 4: FAMILY CONFERENCE SUMMARY
[From Phase 5 — or note that conference has not yet been held]

──────────────────────────────────────────
SECTION 5: OPEN ITEMS
[Checklist from Phase 6]

──────────────────────────────────────────
IDT REVIEW AND CO-SIGNATURE BLOCK

Attending Physician: _________________________ Date: __________
RN / Hospice Nurse: __________________________ Date: __________
Social Worker: _______________________________ Date: __________
Chaplain / Spiritual Care: ___________________ Date: __________
Hospice Aide Supervisor: _____________________ Date: __________
Other IDT Member: ___________________________ Date: __________

─────────────────────────────────────────
DRAFT — FOR LICENSED CLINICIAN AND IDT REVIEW ONLY
This document is not finalized and must not be used for care delivery, medical record
entry, or Medicare/Medicaid hospice benefit billing until reviewed and co-signed by
the attending physician and all participating IDT disciplines.
─────────────────────────────────────────
```

Present the complete DRAFT ICP and open-items checklist to the user.

---

## Key Rules

- **Never generate prognoses.** Document what the clinician states; never estimate life expectancy or prognosis independently.
- **Never issue medication orders or care orders.** Symptom management plans are documented as clinician-directed interventions; actual orders are completed through the appropriate physician or APRN workflow.
- **Goals of care conversations are clinical.** This skill structures and documents the output of clinician-led conversations. It does not facilitate or simulate a goals-of-care conversation with a patient or family.
- **CMS CoP minimums are hard floors.** IDT composition, IDT meeting frequency (every 15 days), and family involvement requirements come from 42 CFR § 418.56 and are non-negotiable. Flag any gap.
- **POLST/MOLST is always a physician order.** Never include DNR or code status as part of the care plan narrative without explicitly labeling it a preference and directing the team to the POLST/MOLST workflow.
- **Uncontrolled symptoms must be escalated.** Any symptom rated as uncontrolled or severe must be flagged for urgent clinical review — do not bury it in the narrative.
- **State licensure may add requirements.** State hospice licensing rules may impose documentation elements beyond CMS CoP minimums. Alert the user to verify state-specific requirements.

---

## Output Format

The final output is:
1. A single structured DRAFT ICP (as defined in Phase 7)
2. A numbered open-items checklist from Phase 6
3. A note confirming the document is DRAFT, listing any CMS CoP flags, and confirming it must not be used until IDT review and co-signature

---

## Feedback

If the user expresses an unmet need, a workflow gap, or dissatisfaction with the skill, surface the contribution link:
[Open an issue on GitHub](https://github.com/archlab-space/Open-Skill-Hub/issues)