Culture, Compensation, Education Are Keys to Hospice Chaplain Turnover

The hospice chaplain shortage is reaching a tipping point. As they work to recruit and retain their chaplain labor force, hospices are contending with a barrage of issues that also can impact patient access.

Hospice chaplains are being asked to do more with less time and resources available, which can adversely affect the quality of spiritual care, according to Saul Ebema, president of Illinois-based Hospice Chaplaincy.

“The major leading cause for turnover is high caseloads leading to a lot of burnout and compassion fatigue,” Ebema told Hospice News in an email. “When someone is overwhelmed, it is impossible for them to provide quality care.”

A shrinking labor pool

On average, the tenures of more than a third of hospice chaplains in the United States lasted only one to two years between 2010 and 2019, according to research from Zippia. Only 13% stayed in the field for 11 years or more during that decade.

More than 7,768 chaplains were employed by hospices nationwide in 2019, according to the Zippia report. As the general population ages and a large contingent of chaplains themselves approach retirement, their numbers may be insufficient to meet demand.

The average age of hospice chaplains nationwide hovered around 51 years old in 2019, Zippia researchers found, with nearly 80% 40 or older. Without a new wave of spiritual care professionals, demand for care will outstip supply of professionals to provide it.

On top of retirement and burnout, another leading cause of chaplain turnover is a lack of competitive compensation, Zippia researchers found.

While spiritual care falls under the bereavement assessment as part of the four core hospice services, reimbursement streams for chaplain staff are extremely shallow, according to George Handzo, director of health services research and quality at the HealthCare Chaplaincy Network.

“Hospice reimbursement [has] not kept up with inflation, so hospices are eternally tightening their belts and increasing the workloads,” Handzo told Hospice News. “I think there’s growing awareness of the value that chaplains bring, but at the same time, mergers, health care consolidations and other deals are disruptive in the space and putting economic pressure there.”

With widespread shortages ongoing, more hospices are losing employees to competitors with deeper pockets who can offer higher salaries and wages.

If this trend continues, financial pressures to recruit and retain staff will likely worsen rather than improve for smaller providers with smaller profit margins, according to Reverend Margo Richardson, hospice chaplain at Minneapolis-based Allina Health.

She told Hospice News that pay rates for chaplains are “woefully inadequate.”

The price of ineffective workload management

While the ability to offer higher compensation is crucial to attracting staff, keeping them also involves things like managing caseloads so chaplains and clinicians are not overloaded, according to Ebema.

But determining appropriate workloads is difficult when demand for services outstrips supply — and when hospices have no claims data or standardized measures for evaluating quality.

Hospices currently have no means of reporting chaplain visits on Medicare claims. Calls from industry stakeholders have grown louder for the U.S. Centers for Medicare & Medicaid Services (CMS) to institute quality measures and allow providers to include chaplain visits on claims.

Some hospices have found their own ways of measuring chaplain productivity, with mixed results.

A former employer of Richardson’s implemented a point system in which staff were required to submit a daily productivity report to supervisors. Point requirements spread across interdisciplinary teams, including chaplains, who were required to meet specific daily thresholds, according to Richardson.

If an interdisciplinary team member from one discipline didn’t have enough points, they would be asked to help out on another team, she continued. This left employees burdened with more documentation responsibilities that often took time away from patient care and left chaplains in particular spread too thin, said Richardson.

These added responsibilities extended her work day by several hours and left her with little time away to recover, she stated.

“The most harmful thing was that our management began meeting with us every morning to share our expected productivity points for the day,” Richardson told Hospice News. “Chaplains had to schedule in software their visits at least a day ahead so reports could be generated and checked. I never understood how the ‘formula’ establishing this goal worked, but point requirements were established for each discipline, and I heard the formula was tied to financial goals.”

The value of supportive workplace culture

A workplace culture in which employees feel supported is a key element of the chaplain retention balancing act, according to Alisha Rule, director of family support services at New York-based Helios Care. The hospice and palliative care provider offers services across three counties in its home state and employs two full-time chaplains. Each has worked with the hospice for roughly a decade, Rule stated.

“One of the biggest factors in this is our emphasis on work/life balance, self-care and true teamwork collaboration,” Rule told Hospice News in an email. “Additionally, our chaplains cover for each other. No one should ever feel like they cannot take time off or have to ‘choose’ between home and work. We foster teamwork by celebrating personal and professional successes, cheering each other on, [and] routine check-ins. This is heavy work, so we ensure that we’re helping each other to maintain self-care.”

Limited opportunities for training

Another contributing factor is that — like physicians, social workers, and nurses — chaplains have few pathways for receiving hospice and palliative care education and training.

Most hospices do not have financial support systems in place for chaplains to continue their education and retain board certification, according to Richardson. These costs typically fall on the employees themselves. This may create an incentive for them to seek new employment that can offer higher pay, tuition reimbursement or who supplement education expenses, she added.

Hospices that provide supportive training and education pathways for chaplain staff stand to retain them against competitors, according to Handzo. Though the cost to invest in these efforts may be higher in the short-term, retention may be a worthwhile long-term return on investment, he added.

“Training up people you already have, that’s possible,” he told Hospice News. “It’s possible to have chaplains do their required clinical training, and even academic training in place at their current job. You may have to pay a little more, but that’s a worthwhile value added for hospices, because they’ll get more value from trained and certified people in general than you will from untrained people.”