Who Is on Your Hospice Care Team
Every patient who comes to James River receives a dedicated care team assembled around their specific diagnosis, circumstances, and care goals. That team includes professionals trained in medicine, nursing, personal care, social work, spiritual support, and more. Each person has a distinct role, and every role connects to every other.
Depending on your loved one’s needs, services may include:
- Medical Director – Provides medical oversight and physician coordination to manage symptoms, adjust medications, and guide clinical decisions throughout the hospice journey
- Registered Nurses – Offers skilled nursing care for ongoing symptom management, wound care, medication education, and around-the-clock clinical support
- CNAs / Aides – Assigned for personal care and daily comfort assistance, to help your loved one maintain dignity and ease in their day-to-day routines
- Social Worker – Helps to support family communication, help navigate difficult decisions, and connect you with community resources
- Spiritual Care Worker – Present for patients and families seeking comfort, meaning, or guidance, regardless of faith background
- Wound Care Specialist – For patients with complex or chronic wound needs requiring specialized clinical attention
- Volunteers – Offer companionship for patients and meaningful respite for family caregivers
All services are coordinated by a single, dedicated team working together around your loved one’s individualized care plan. You will never have to repeat yourself or wonder who is responsible for what.
How Our Team Works Together for Your Family
Every member of your loved one’s care team communicates regularly, works from the same care plan, and attends interdisciplinary team meetings together. Your family should never have to serve as the messenger between team members. That coordination happens within the team so you can focus on being present.
How that looks in practice:
- When a nurse observes a change in condition, that information reaches the Medical Director the same day
- When a social worker identifies a struggling family caregiver, that observation is shared with the chaplain and nursing team
- When an aide notices a skin change during a personal care visit, the nurse knows before the end of that day
- When something changes at 2:00 in the morning, you call us and a registered nurse answers
- Our team is available 24 hours a day, 7 days a week including nights, weekends, and holidays
- You are never routed to voicemail or an answering service
Serious illness does not follow a schedule. Neither do we.
Care Plan Built Around Your Loved One Specifically
No two patients enter hospice care the same way. No two families need exactly the same kind of support. That is why every care plan at James River begins with listening.
At the start of hospice care, your team conducts a comprehensive assessment that covers your loved one’s current symptoms and medications, their living environment and daily routines, the needs and capabilities of family caregivers, cultural or spiritual considerations that matter to your family, and the personal goals and values that should guide every care decision going forward.
From that foundation, a care plan is built that reflects your loved one as a whole person, not just a diagnosis. As circumstances change, the plan changes with them. No aspect of care is set in stone. Everything adapts because your loved one deserves care that responds to who they actually are, not a standard protocol applied uniformly regardless of the individual.