Plan of Care

Goals of Care

Often when a patient is referred to Palliative Care, they are in need of assistance deciding what next steps are in managing an advanced illness. To help them decide, we discuss what they understand about their illness, what they’d like to improve on, and options for meeting their goals.

Care Providers

Depending on the patient’s plan of care, our nurse practitioner may call in the help and support of additional disciplines, such as:

  • Licensed Clinical Social Worker (LCSW) or Licensed Master Social Worker (LMSW)
  • Chaplain
  • Skilled nursing or CNA provided by home health
  • Physical therapy, occupational therapy, and/or speech therapy provided by home health
  • Infusion services
  • Durable Medical Equipment provided by a DME company typically billed through insurance
  • Pain management centers for long term support

Advance Care Planning

All adults, not just ones facing serious illness, should have advance directives. Over time, these wishes may change depending on diagnosis, quality of life, and spiritual beliefs. Our team is able to help determine what options are best for the patient and family, as well as completing forms and paperwork.

We understand this task seems overwhelming, especially for families. Our goal is to identify what is needed for each individual patient and provide the forms. Some forms may need a physician signature or to be notarized. Additionally, these forms can be updated over time to best fit the needs of the patient.

Forms can include, but not limited to:

  • Living Will
  • State/organization specific forms
  • Body donation

Further guidance can be provided for patients seeking help with setting up a trust or if a patient is a ward of the state.



FAX 763-205-9350

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Call Now 763-205-3600 and receive Top Quality Healthcare for yourself or for your family member