Breaking Down Costs, ROIs of Hospice-Death Doula Partnerships

Some hospices that have layered end-of-life doulas (EOLDs) into their workforce are seeing a return on these investments in various forms – including quality outcomes, retention and care continuity.

Among the largest benefits of investing in doula workers is that these professionals can help hospices address unmet needs among terminally ill patients and their families, according to Goodwin Hospice Executive Director Beth Klint. 

The Virginia-based hospice is part of Goodwin Living, a nonprofit senior living and health care organization. Goodwin Hospice formed a collaboration with end-of-life doula provider Present for You LLC roughly three years ago. Since then, the hospice has seen improved quality outcomes and views EOLDs as an “augmented” level of its supportive care and staffing model, Klint said.

“We were recognizing what the needs of people at the end of life were and the gaps between the medical model and non-medical care pieces,” Klint told Hospice News. “We wanted to make sure families felt supported and understood what’s happening, what resources are available to them in their situations. That’s where end-of-life doulas offer something different. So, we developed an arrangement that allowed us to access these professionals whenever we needed it, and that relationship has been able to consistently be utilized to meet more patient needs.”

Costs involved in a hospice-doula partnership

Goodwin Hospice has a service agreement with Present for You that includes “on demand access” to EOLDs when a patient and family need arises, Klint explained. Previously, the hospice relied on volunteer death doulas, which resulted in challenges around timing and availability of these services, she stated.

The doula services are supported through philanthropic donations and offered to patients and families as a complimentary service.

“We basically pay for this service so that we have it available when needed,” Klint said. “Having doulas work with our staff allowed us to identify the needs of people we’re providing care to in an ‘out-of-the-box’ way. Doulas can really be an asset in that they are able to meet with families on their timeline instead of having them rely on volunteers with less availability and flexibility. It’s having a consistent way to be there for patients that legitimizes this reciprocal relationship – it’s providing ways to meet other needs that have improved quality outcomes.”

Having doulas work with our staff allowed us to identify the needs of people we’re providing care to in an ‘out-of-the-box’ way. It’s having a consistent way to be there for patients that legitimizes this reciprocal relationship – it’s providing ways to meet other needs that have improved quality outcomes.

— Beth Klint, CEO, Goodwin Hospice

Some of the upfront costs associated with bringing on EOLDs involve those around fine-tuning the referral structure and how these professionals work with care managers, according to Jane Euler, co-founder and chief doula of Present for You. Aside from these, ongoing costs can vary depending on the services provided and level of expertise.

Through the arrangement, Goodwin Hospice staff, primarily social workers, refer families to Present for You’s death doula services, particularly when caregivers may need more respite or families are in need of greater touch points and communication, Euler stated.

“It’s about helping that family come to terms and understand the declines in end-of-life, as well as resources for respite, funeral services and other pressing questions that hospice staff might have some constraints around when it comes to workforce shortages,” Euler told Hospice News. “We pick up where licensed professionals are limited in time and scope. We provide extra time when other professionals don’t have the resources. We are able to provide multiple additional sets of hands for a cost that is half the cost to hire the least expensive licensed employee.”

Coastal Home Health & Hospice in Maryland is another provider working with death doulas as part of its services. The cost for these professionals averages around $1,000 to $2,000 for services rendered, the hospice provider stated in a recent blog.

Similarly to Goodwin Hospice, Coastal provides death doula services to patients and families at no cost. The hospices’ spiritual care team primarily connects patients with doulas.

“[Doulas] can help you figure out how to meet as many people’s needs and wants as possible, mediate between people’s preferences and help with scheduling,” the organization stated. “We find that the combination of our death doula plus our spiritual care coordinator gives each patient the flexibility to tailor their hospice experience to best fit their final wishes.”

The average cost of bringing an end-of-life doula as a full-time staff member can vary for hospices, with $40,000 – $52,00 in salary annually, according to data from Doula Training.

“The worth of these professionals in hospice is something of a celebrant, they can be part of that bereavement team, they can be working as liaisons in hospitals or other facilities, or they can just be with someone when they’re dying and their families can’t be,” Ashley Johnson, president of the National End-of-Life Doula Alliance (NEDA), told Hospice News. “Their pay can be based on their skill set, their experience in working with aging populations and that even varies state to state. If you’re onboarding doulas, it’s hiring them to wear a lot of different hats on that interdisciplinary team.”

The ROI of Engaging EOLDs

The biggest return on investment for hospices when working with death doulas is the opportunity to improve quality outcomes, according to Klint. Goodwin Hospice has seen the impacts of working with these professionals when it comes to improved Consumer Assessment of Healthcare Providers & Systems (CAHPS) scores, she mentioned.

“The greatest return on investment is the help we can offer with doulas for the families feeling particularly anxious, fearful or really wanting to make sure they’re doing a good job of supporting their ill loved one,” Klint said. “That has had a major impact on the patient and family experiences, and [made] a difference on our CAHPS quality scores. Their importance in terms of quality can really matter when it comes to the evaluation of the last three days of life. That’s where doulas can come in and recognize when someone is declining and touches they might need more of.”

EOLDs can provide a range of services for hospice patients and families, including respite for caregivers, conversations about goals of care and other advance care planning measures, as well as providing more continuous nonmedical care at the bedside, according to Joan Bretthauer, president emeritus at Gateway End-of-Life Coalition based in St. Louis, Missouri. She is also founder of the ACE End-of-Life Doula Services.

Death doula services are not reimbursed by Medicare or other insurance. These services are typically covered by patients and families as an out-of-pocket, private pay expense – which can be a deterrent in terms of access and utilization, Bretthauer indicated.

Hospices can find a number of routes to support EOLD services, including seeking out donations and philanthropic support, grant and scholarship funding, as well as other “creative ways,” Bretthauer said.

Hospices most commonly work with death doulas as part of their volunteer programs, though more providers are recognizing the benefits of expanding the role of these professionals among their interdisciplinary teams, Bretthauer stated.

“What I’ve seen in the last several years is that end-of-life doulas are not going away and are offering a wide variety of different services beyond the regularly-utilized volunteers,” Bretthauer said. “I’ve seen a lot of these workers come from nursing, social worker and physician roles – that’s a great resource to have if you’re a hospice looking to expand your workforce. The biggest advantage of hiring a doula to come in is having that continuity of care and consistent support for the family – that’s something that can be missing when you have staff shortages.”

What I’ve seen in the last several years is that end-of-life doulas are not going away and are offering a wide variety of different services beyond the regularly-utilized volunteers. The biggest advantage of hiring a doula to come in is having that continuity of care and consistent support for the family – that’s something that can be missing when you have staff shortages.

— Joan Bretthauer, president emeritus, Gateway End-of-Life Coalition

A host of paraprofessional, non-traditional and community care workers can be trained as doulas, which can help address not just workforce shortages proliferating in hospice, but also move towards more equitable access, according to Euler.

EOLDs can be trained in a variety of skills that align with end-of-life care, but don’t necessarily require the same levels of licensure and certifications that are included in interdisciplinary hospice roles, she explained.

“You can get someone trained, someone that is representative of the community, and then go into communities to provide this non-medical support,” Euler said. “We can take some of the burden off of burnt out staff and have a better work-life balance. It’s a win-win.”

The end-of-life doula workforce has been evolving in ways that can help hospices both better understand and reach a wider base of patients, according to Johnson.

Death doulas are increasingly coming from a variety of different age demographics, backgrounds, cultures and socioeconomic experiences that can aid in bridging barriers among underserved populations, she stated. Having a representative workforce layered into hospice’s staffing support can go a long way in care delivery and retention, Johnson said.

Adults 36- to 50-years-old represent the largest age demographic of death doulas nationwide, according to a NEDA report shared with Hospice News. More than 50% of death doulas fall into this age group. Individuals 51 and older are the second, the report found.

In terms of race and ethnic backgrounds, the EOLD workforce has become more diverse in recent years, according to Johnson. NEDA data shows that Caucasians make up a large portion of current doula professionals, though Black, Native American, Latino, Asian and multi-racial populations have increasingly entered the field, she stated. 

“Doulas are a resource bank that can work with social workers, chaplains and hospice clinicians, and also bridge gaps in understanding based on their own skill sets, their own experiences in the community,” Johnson told Hospice News. “It’s having a different level of expertise when it comes to end-of-life care and helping families process things and have someone they can confide in. Having a varied group of doulas who understand the differences in patients can open doors to more support in hospice – that support can be transformational for families and staff.”