This year has brought both tumultuous challenges and evolving opportunities for hospices that will steer hospice leadership during 2024.
Hospice News spoke with a group of industry leaders about the most impactful forces that will shape the space in the coming year. Some themes from last year have carried over as far as their biggest concerns, but some have adapted their plans to address them.
A few of 2023’s largest hurdles include intensifying regulatory oversight as well as prolific workforce shortages amid rising demand. This has created a need for innovative strategies around recruitment and retention.
CEOs and other hospice executives also noted emerging themes. Among them is an evolving conversation around potential changes to the Medicare Hospice Benefit, an increasing focus on equitable access and service diversification to engage patients further upstream.
Hospices also have their eyes on a shifting payment landscape as value-based models become more prevalent. A few examples include the Guiding an Improved Dementia Experience (GUIDE) Model, Accountable Care Organization Realizing Equity, Access and Community Health (ACO REACH) and the hospice component of the Medicare Advantage Value-Based Insurance Design (VBID) demonstration, which the U.S. Centers for Medicare & Medicaid Services (CMS) has extended through 2030. Impacts from the the Medicare Care Choices Model (MCCM) demonstration have also come under hospices’ radar.
Research released earlier this year has also impacted the discussion around length of stay and associated costs. Hospice care reduces Medicare expenditures by about $3.5 billion for patients in their last year of life, a 3.1% reduction, according to a joint report released in March by the National Hospice and Palliative Care Organization (NHPCO), the National Association for Home Care & Hospice (NAHC) and NORC at the University of Chicago.
Meanwhile, staffing pressures have eased for some hospices coming out of the pandemic, but have worsened for others competing for sparse resources.
Recruitment and retention strategies have been in the spotlight for hospice leaders as they invest in expanded employee benefits, offered bonuses and higher wages and focused on organizational culture with sustainability in mind. Hospices have also increasingly focused on ways that technology can improve efficiency to reduce the burden on employees.
Regulatory oversight intensifying
We are at risk of having the bad actors in our industry taint those of us who are doing the work in an ethical, patient-first way. It’ll be even more difficult to confront challenges related to protecting the hospice benefit, surviving continuous audit activity and maintaining outstanding quality if we are first having to repair the image of the hospice industry. Our regulators must come up with ways to more effectively weed out the fraudsters.
— Lynne Sexten, CEO, Agrace Hospice & Supportive Care
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[Three words to sum up 2024 would be]: Protect the benefit. Someone recently told me, ‘Hospice in [the state they live in] is cutthroat.’ If you stop a moment and consider that statement, we need to acknowledge that the benefit must be protected, so that we can care for people during what are ultimately the more important moments of their life. Hospice shouldn’t be a ‘boom-and-bust’ business. When it is, we set our clinicians up for failure, and in turn, fail our patients when they are at their most vulnerable.
— Brent Korte, CEO, Frontpoint Health
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We will continue to be held accountable for quality, and that’s just the nature of working with a federal payer for the most part. But this is a big point of contention in hospice around ways to ensure that quality and integrity are maintained from a regulatory perspective. It can be burdensome at times for providers. When Medicare represents nearly all of your revenue, it can be a tremendous cost to have billers focus on complying with evolving requirements.
– Heath Bartness, CEO and founder, St. Croix Hospice
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[It’s having] innovation, awareness and -nimbleness in an ever-changing regulatory environment without distraction from our core focus of serving patients will be important in 2024. The drive for quality care improvements and innovation on how that care is delivered can’t stop.
We expect to devote tremendous time and resources in 2024 to continuing quality improvements. Continued improvements in how we delivered care, with particular focus on expediency and presence, was an area of tremendous gains this year.
— Matt Winer, COO, Agape Care Group
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Rethinking the Medicare Hospice Benefit
What’s been highlighted by research pieces among various stakeholders is the overall value of the hospice benefit and illustrating misunderstandings and misconceptions created around the time.
The benefit being restricted to six months for the initial prognostication has remained consistent for 30+ years, even though the types of individuals and their complexities have changed and impacted access to the hospice benefit. An eight- or nine-month stay is not somehow indicative of an issue.
Research has allowed us to provide insight that elevates how the total cost of care of savings is actually greater in that longer window that it may have been perceived to be. Earlier access is a universal concern.
– Nick Westfall, president and CEO, VITAS Healthcare
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People still believe that hospice is the final few days of life. President Jimmy Carter’s hospice journey since February is now in nine months, and that has really built notoriety and allowed a brighter light to shine around longevity and its benefits. That’s helping hospice gain esteem as we come into an election year in 2024.
There are vital components of hospice to discuss around the meaningful service it can be for patients, families, caregivers and the community as a whole with meeting psychosocial, physical and spiritual needs. It can’t be done in this silo of six months.
– Bartness
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For a lot of people, the six-month or less prognosis requirement can be a deterrent. Extending that to a year will build a bigger window for patients and families to grasp all the end-of-life pieces and make those harder decisions.
Many of those with terminal illnesses are having longer journeys and changing the benefit to a year or opening up more doors to concurrent care in the benefit could go a long way to building awareness, access and trust among patients and referral sources.
Six months can be a hard pill to swallow and with most patients being referred too late, extending the benefit could allow higher quality and reduce overall costs of managing patients longer with less intensive care.
– Altonia Garrett, COO, Blue Ridge Hospice
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The ability to serve critically ill patients earlier on their end-of-life journey via a concurrent model of care. Our patients transitioning through our palliative care program and subsequent hospice care delivery often have our highest satisfaction and best quality outcomes. Evolving a comprehensive hospice benefit that allows providers to meet patients where they are on their journey with appropriate levels of care through ebbs and flows in acuity could transform things.
— Winer
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If I could change anything about the hospice benefit, [make] palliative care a fifth level of care and expand the eligibility of the hospice benefit to include those who are outside the six-month prognosis window. I think the published outcomes of the Medicare Care Choices Model demonstration project speaks volumes to the kind of cost reducing, quality of life improving impact this would have.
— Sexten
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Creating more equitable access
Over the last several years, there’s been a battle cry around health equity and addressing social determinants of health. It’s developing action plans that assess and ask about real ways to improve things. Looking back at the past year, there were some additional frameworks that CMS built with health equity and some really beneficial things took place.
There are real opportunities to push partnerships in communities, hospitals, and with Accountable Care Organizations for hospices. It’s being resilient, adaptive, mindful and meaningful as we grow to meet ever-evolving needs and ensuring more equitable access to care in hospice at a time when people need us the most – especially those in underserved communities.
– Keith Everett, CEO, Hospice of Acadiana
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As we look at 2024, the three words that come to mind are differentiate, focus and serve — these will be key and critical to success.
Never wavering on your North Star of being patient and family-focused and meeting community needs will leave hospices well-positioned to provide quality care. It’s having that focus as a strong underpinning for all team members to serve those underserved communities. It’s elevating that in your internal culture and not losing momentum – that loss of momentum could be a hurdle and friction point.
– Westfall
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Hospices have opportunities to continue to focus on high quality care and excellence. This includes creating specialized programs and being intentional in how they are reaching out to all communities. Palliative care programs can be a bridge to hospice for people of color to help them think about their prognosis and things that will impact them later on.
These services can be easier to wrap your head around than the last six months of life prognosis for hospice. It’s a way for these diverse populations to build trust with serious illness and end-of-life care providers.
– Garrett
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[It’s about] organically growing, starting operations in underserved areas, and finding high quality companies to add to the Agape family. [It’s] finding ways to engage with and create awareness and serve the 50% of the United States decedents that don’t currently utilize the gift of hospice for a variety of reasons.
— Winer
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Value-based transformation
A large challenge in hospice has been how to improve care for growing amounts of dementia patients. What models like GUIDE can help payers understand is more education around what it looks like for people with this diagnosis at the end of life and being more intentional about offering the most care we can. It’s also all these other diseases that can be difficult to prognostic with the end of life, with cardiac issues being a big one that is a revolving door of keeping people in and out of hospitals that exacerbate readmission and reimbursement issues.
– Garrett
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It’s having value creation and recognition for the hospice benefit within health care. We continue to invest in enhancements to our care model that keep patients in a home setting with high-touch, effective and meaningful care. This improves patient and family satisfaction and reduces the overall cost burden to the system.
— Winer
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[It’s] preparing for a different business mindset while doubling down on patient focus and preserving end-of-life care. [It’s also] preparing for VBID and the ‘metrification of hospice.’
— Korte
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What’s really important for hospices to embrace right now is that the uncertainty is not going away. The train has left the station and we don’t have a clear vision of what changes will be in regulatory or reimbursement environments.
The VBID demonstration project ending in 2030 now is really going to leave hospices in a critical planning period right now of figuring out what is next, and their goals and objectives in solidifying a foundation that will last through these pivotal points. It’s important to show your worth in data around overall outcomes with these value-based models, and that’s a huge opportunity for hospices to educate payers on why their services are important.
– Everett
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A lot of larger health care and hospital systems are contemplating figuring out their hospice needs by forming deeper relationships with these providers in other settings, like primary care providers and rural health care clinics. Getting ahead of continued unneeded emergency visits and hospitalizations at the end of life by ensuring more access to caregivers in the home is what hospices do as a tremendous resource. We need more of a true lever to develop those relationships and overcome payment challenges.
– Bartness
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Rebuilding the workforce
[Summing up 2023 in three words]: recruitment, retention, flexibility. Coming off of the pandemic and ‘great resignation,’ means developing sustainable approaches to meeting the evolving needs of the workforce is an absolute must.
— Sexten
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Workforce shortages are playing a key role in how hospices are being resilient transitioning into next year. Some of our most skilled and experienced workers are in terrible shortage as they move into retirement and this will be even more difficult with effects from COVID. It’s having new technologies that can help our people take care of patients.
– Everett
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A common theme tossed around by providers has been a laser focus on the importance of every single one of our team members and elevating our existing teams. It’s utilizing that important resource to help tell the story that attracts new team members as building blocks for your overall bedside capacity as demand for hospice continues to increase. Without a good core foundation that’s rooted in your team members, you aren’t going to come out of the pandemic stronger than when you entered it.
– Westfall
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It has been really hard for hospices in different markets to find good, qualified staff who want to work in this space, so doing well with recruitment is one of the biggest challenges. That’s going to be more of an issue to meet increases in demand in the next several years, particularly with clinical staff. It’s also [having] a focus on staff inclusivity, belonging and wellness [in your] organizational culture. Outside, it is the right thing to do, and internally this helps to attract and retain top talent.
– Garrett
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The backbone of a quality provider of in-home health care services will remain [its] employees. Attention to attracting, training, supporting and listening to their feedback will continue in 2024. Technology investments that support quality improvements and create value around care coordination, high-impact visits in the last week of life, hospital readmission avoidance and staff retention are big areas of focus.
— Winer
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For 2024, it’s about great teams excelling and having a vision that we have to recruit amazing people to carry out meaningful experiences in hospice. It’s not just educating clinicians, it’s ensuring we’re placing paths of success for every clinician, every interdisciplinary team member to build our workforce up.
Retaining these team members means recognizing them in a meaningful way beyond just the paycheck. We’ve helped our people pay for their nursing degrees, tuition reimbursement programs and we’ve set up ways to have different roles built through community education, even in areas of accounting and among direct care workers. There are many creative ways to expand your existing roles and bring on new skill sets.
– Bartness
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Companies featured in this article:
Agape Care Group, Agrace Hospice & Supportive Care, Blue Ridge Hospice, Frontpoint Health, Hospice of Acadiana, St. Croix Hospice, VITAS Healthcare
