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New Jersey Palliative Care Services Directory
New Jersey Palliative Care Directory
The New Jersey Palliative Care Directory provides a directory of available services throughout the state.
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1.
Where is your Palliative Care administratively located? (who is your employer?)
(Required.)
Health System
Hospital
Hospice
Long Term Care
Home Health Agency
Outpatient setting
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2.
What is the contact information?
(Required.)
Contact Name
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Company
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Address
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Address 2
City/Town
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State/Province
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ZIP/Postal Code
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Country
Email Address
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Phone Number
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3.
Which of the following services does your program provide?
(Required.)
Symptom management
Emotional support
Spiritual support
Medication management
Goals of care discussions
Advance care planning
Information about disease/prognosis
Caregiver support
Referral to community resources
Care transitions
Other (please specify)
4.
Are your services delivered by an interdisciplinary team?
Yes
No
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5.
Who are the members of the team?
(Required.)
Advanced Practice Nurse
Chaplain
Nurse
Pharmacy
Physician
Physician Assistant
Social Work
Other (please specify)
6.
Do any members of your team have certification in hospice and palliative care?
Yes
No
7.
Does your program provide 24/7 access to your patients?
Yes
No
8.
If yes to above, what is the after hours contact number?
9.
What population does your palliative care program serve? (check all that apply)
Children (perinatal-17 years)
Young adult (18-25 years)
Adults (26 year and older)
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10.
Where do you provide palliative care? (select all that apply)
(Required.)
Patient Home
Long-term care facility
Office/clinic
Hospital
Other (please specify)