This article describes a participatory action research project addressing the problem of African American access to and use of hospice. Qualitative interviews conducted with six African American pastors resulted in the identification of major themes used for development of a scale to measure barriers to hospice. A subsequent quantitative study documenting these barriers was conducted with 127 African American and European Americans. Results of both studies, which were used to further social action efforts in the community, indicated the cultural barriers of differences in values regarding medical care and differences in spiritual beliefs between African Americans and European Americans. Results also indicated institutional barriers, including lack of knowledge of services, economic factors, lack of trust by African Americans in the health care system, and lack of diversity among health care staff. Implications for social work practice and policy are discussed.

Despite the holistic approach inherent in the hospice philosophy, social work may be viewed in hospices as ancillary or secondary to medicine. Social work, in turn, may have a lack of training and sensitivity about other professions' expertise and values and as a result be unprepared to collaborate across the cultural boundary that exists between professions. Barriers to full use of all disciplines on the interdisciplinary team include lack of knowledge of the expertise of other professions, role blurring, conflicts arising from differences among professions in values and theoretical base, negative team norms, client stereotyping, and administrative issues. This article outlines the barriers and proposes solutions to address them.

In a struggle to balance fiscal realities with hospice philosophy, some hospices have attempted to cut costs by reducing social work involvement. This cross-sectional survey of 66 hospices found, however, increased social work involvement was significantly associated with lower hospice costs. Additional benefits included better team functioning, more issues addressed by the social worker on the team, reduced medical services, and fewer visits by other team members, along with increased client satisfaction and lower severity of case. The authors concluded that higher salaries should be paid to a sufficient number of highly educated and experienced social workers. These social workers should be dedicated solely to the hospice social worker position, should participate in intake interviews, and should be supervised by a social worker.

The importance of interdisciplinary care for patients and families facing the end of life is examined. Descriptions of varying forms of team functioning are provided with an emphasis on the characteristics of high-functioning interdisciplinary teams. The value of empowering the patient and family to direct the care they receive from their team is emphasized. Interdisciplinary team interventions in end-of-life care focus on the biopsychosocial and spiritual dimensions of human experience and facilitate growth and development in the last phase of life. Despite its great promise for improving patient care, the interdisciplinary model is notwith the exception of hospice care-widely implemented in today's health care system. The contributions of interdisciplinary teams to end-of-life care can be enhanced through the development of interdisciplinary team training programs, the creation of payment structures that support the interdisciplinary team model, and continuing research assessing the dynamics of team functioning and the benefits that interdisciplinary team care provides to patients and families near the end of life.Interdisciplinary team care is in general not well represented in either the health care system or in the published literature that studies this system. However, interdisciplinary team care is a key ingredient in health care for patients with chronic or life-threatening illness because these patients present a range of problems that affect all dimensions of human experience and that require the expertise of many professional disciplines. How these disciplines work together 340

Despite many efforts to increase access to end-of-life care, culturally diverse groups are still not being served. Interviews of 22 hospice and palliative care program directors in one southeastern state indicated that directors overestimated how well programs are doing in meeting the needs of diverse groups but were very interested in implementing cultural diversity training for their staff Those who were more concerned about such issues had recruited more diverse volunteers into their programs. The presence of diverse staff or volunteers predicted a more diverse patient population. A number of efforts were underway to develop cultural competence and provide culturally competent care. Several directors reported no efforts in this direction, however Directors described programmatic barriers and resources needed. The authors concluded that directors should provide leadership in their agencies in welcoming diversity. Implications for further research and work within the larger end-of-life care field are discussed.