Hospice Providers: Staffing is Our Top 2020 Challenge

Concerns about staffing outweigh worries about growing competition in the hospice space as well as emerging payment models that stand to transform aspects of the industry such as the Medicare Advantage hospice carve-in and the Primary Care First initiatives.

Hospice News in collaboration with Dallas-based tech company Homecare Homebase surveyed more than 300 industry professionals, including owners, executive leaders, managers and staff about the movement they expect to see in the hospice space during 2020.

More than 26% of respondents indicated that staffing would be the greatest challenge hospice providers would face during 2020, compared to 18% who cited increased competition and another 18% who said new payment models were their biggest concern.


“While nursing is one of the fastest growing occupations in the nation, hospice organizations continue to experience nursing shortages. Hospice is considered a specialty nursing practice. As such, many providers require previous hospice experience, narrowing the pool of applicants. In fact, some state hospice regulations require up to two years of full-time nursing practice to be employed as a hospice nurse,” Catherine Dehlin, director of hospice and palliative services for the consulting firm Fazzi Associates, told Hospice News. “Additionally, the number of hospice patients is increasing year over year, creating a never-ending need for more hospice nurses. With the aging of our population, the increase in number of hospice patients will not be ending anytime soon. Couple that with the aging of the hospice nurse, and it’s easy to see why organizations are struggling to recruit and retain nurses.”

Hospices are already struggling to fill their ranks.The United States has 13.35 hospice and palliative care specialists for every 100,000 adults 65 and older, according to an April 2018 study. The research estimated that by 2040 the patient population will need 10,640 to 24,000 specialists; supply is expected to range between 8,100 and 19,000.

Hospice and palliative care providers also experience shortages in non-physician disciplines, including chaplains, nurses, and social workers. As far back as 2008, the U.S. Centers for Medicare & Medicaid Service (CMS) began allowing hospice providers to use contracted nursing staff because not enough nurses were available to fill permanent positions.


The aging baby boomer population is both a challenge and an opportunity for hospice. Hospice utilization is rising; a record 50% of Medicare decedents received hospice care during 2018, according to the National Hospice and Palliative Care Organization (NHPCO). However, many hospice staff members are also approaching retirement, with nearly half of the total nursing workforce expected to retire within the next decade.

Hospices face unique recruitment challenges, particularly because medical, nursing, and social work students receive very little exposure to hospice or palliative care during their training. A 2018 study concluded that most students in clinical disciplines do not feel prepared to provide family care at the end of life.

“Another contributing factor for hospice nursing shortage lies in the physical and emotionally toll that a dedicated hospice nurse experiences. In addition to the obvious strain of caring for dying patients, due to overwhelming regulations, hospice nurses must be tech savvy, organized, and efficient while displaying compassion and empathy,” Dehlin told Hospice News. “This is a skill that’s difficult to teach and many organizations do not have the time or resources to devote to that level of training.”

Staff burnout is also a significant factor when it comes to staff recruitment or retention. A 2019 study found that more than 62% of hospice and palliative care clinicians have suffered from burnout, causing some to leave the field. As hospices contend with widespread staff shortages across all disciplines, staff burnout threatens to increase turnover and cause some staff to leave the industry altogether.

Factors leading to burnout included emotional exhaustion, working longer hours, being younger than 50-years-old, and working weekends. Staff working in smaller organizations were at higher risk, according to the study.

Some hospice providers are taking steps to bolster recruitment and retention, as well as combat the effects of burnout.

Hospice and home health care franchiser Interim Healthcare recently received the Optimas “Silver” Award for recruiting. The awards recognize human resources successes in solving business challenges.

Melbourne, Fla.-based Hospice of Health First, a component of the integrated health care delivery network Health First, last year began implementing wellness programs to help reduce the risk of burnout and support staff retention.

Hospices are also seeking ways to build up and accelerate opportunities for clinicians to get the specialized training they need to thrive in the hospice workforce.

Susan Lysaght Hurley, director of research at Massachusetts-based hospice provider Care Dimensions, is working to build a national training model based on that organization’s current nurse residency program in a project financed through the Cambia Health Foundation’s Sojourns Scholar Leadership Program.

The staffing issue has not escaped the notice of policymakers who have pursued legislation designed to expand the hospice and palliative care workforce. The U.S. House of Representatives in October approved the Palliative Care and Hospice Education and Training Act (PCHETA) and is under consideration by the Senate. Even if Congress passes the bill, separate legislation would be needed to fund it.

“This has been taken back to CMS for technical assistance. There are real needs out there in terms of the workforce for providing better information and better education on hospice and palliative care, and we’re still hopeful that this legislation will pass,” said NHPCO President and CEO Edo Banach. “After it passes, it still needs to be funded. So the authority is one thing, but the funding is actually the more important piece.”

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