Hospice News explores the issues garnering growing attention in end-of-life care delivery in seven of this year’s “hidden gem” stories. Topics span trends related to program integrity, workforce development, health equity, service diversification and the keys to hospices’ growth strategies.

Hospice Investors to Watch

Hospice merger and acquisition (M&A) activity has seen a cooling period compared to previous record-breaking years in the market. Stakeholders are projecting a more frothy market in 2025, with renewed signs of life among a diverse range of investors and available hospice assets.

Among the most significant dealmakers in the hospice space this year was Optum, subsidiary of the insurance and health care giant UnitedHealth Group (NYSE: UNH). The company initiated two of the largest hospice and home health transactions in recent memory. Optum completed its $5.4 billion acquisition of LHC Group in 2023. This year, it made moves to acquire Amedisys for an estimated $3.3 billion, swooping in after Option Care Health (Nasdaq: OPCH) agreed to buy the company..

The U.S. Department of Justice has sued to block the deal, citing workforce, labor and payer concerns.

Meanwhile, Addus HomeCare Corporation (Nasdaq: ADUS) and Gentiva also completed one of the largest deals of the year. Addus earlier this month closed a $350 million acquisition of Gentiva’s personal care business. Though Addus has focused on growing its personal care and home health services, hospice remains a pillar of its strategy. The company seeks to co-locate its three services in the markets it serves.

VITAS Healthcare, a subsidiary of Chemed Corp. (NYSE: CHE), returned to the M&A market after a several-year hiatus. The company completed its $84 million acquisition of Covenant Health and Community Services in April. VITAS has indicated in earnings calls that it will be on the hunt for additional deals in 2025.

Anatomy of Hospice Grief Camps for Children

Many hospices offer summer grief camps for bereaved children and adolescents, which come with a host of operational and logistical considerations. Hospices have taken varied approaches to shaping their youth grief programs, but common threads exist.

Providers have increasingly honed their focus on designing developmentally-appropriate bereavement counseling and integrating therapeutic elements into memory- and trust-building activities. Grief camp programs have included pet, art and music therapies alongside group activities such as martial arts, yoga, meditation, hiking and ziplining, among others. These activities are aimed at helping children to process anxiety, stress, depression and trauma experiences associated with a loss.

Hospice leaders have indicated that training bereavement staff and volunteers is crucial to assess and address a child’s emotional reactions. Having a multitude of personal and professional backgrounds has helped some hospices develop a wide variety of supportive grief services that meet a range of unique bereavement needs for different losses.

While the summer programs are often brief in length, the experiences children gain can be significant in their ability to process grief emotions as they reach adulthood. Many hospices extend bereavement support by providing access to additional resources such as ongoing individual and group grief therapy.

EOL Doulas’ Growing Value Proposition

Interest in end-of-life doula collaborations has grown among hospice and home health providers in recent years. More organizations are seeing improved patient and family support as a large return on investment from these partnerships.

About 6% of hospice providers indicated plans to diversify their services to include end-of-life doulas in the Hospice News 2024 Outlook Survey. A significant driver of this interest is a doula’s ability to help patients access and understand their health care options as their illnesses progress.

Doulas can help foster collaborative, goal-concordant care as well as improve quality, according to some hospices. These professionals are able to provide additional bedside services and better understand the challenges that patients and caregivers are facing. Hospices have indicated that doulas have served as valuable resources when it comes to addressing patients’ emotional, spiritual and nonmedical needs.

Hospices have also pointed to doulas’ potential to help reduce disparities. Doulas often come from a variety of professional backgrounds and have diverse cultural and spiritual backgrounds, which can strengthen their ability to communicate with patients on their goals of care at the end of life.

Patient, Staff Satisfaction Biggest ROIs of Trauma-Informed Hospice Care

Investing in trauma-informed training can come with improved hospice patient and staff satisfaction.

Hospices have focused on expanding awareness and education to better equip staff in both recognizing and responding to a wide range of trauma experiences. Trauma-informed education has helped hospices to provide improved goal-concordant care while also aligning with staff’s professional goals and personal values in meaningful work.

A host of operational and financial considerations involved in trauma-informed training such as including evidence-based educational initiatives and ensuring that educators are well-versed in equipping staff with helpful resources, tools and information.

Hospices that have invested in trauma-informed training have seen improved retention and organizational reputation. Other hospices have reported benefits such as increased staff and patient satisfaction, as well as strengthened supportive organizational cultures.

While recognition around trauma issues has grown, the needle has much farther to go to address the systemic challenges.

Studies have found that more than half of individuals across the country have experienced at least one traumatic event in their lifetime. These experiences can have profound impacts on a person’s ability to navigate their daily life and relationships with others. Instances of violence, abuse and trauma can result in higher levels of pain and increased risk of depression, fatigue and loneliness at the end of life, research has found.

‘Let Patients Lead the Way’: Hospice Veterans’ Advice for New Nurses

Hospice nurses share the benefits of their experience with new recruits to the space as providers nationwide work to improve recruitment and retention.

The opportunity to provide person-centered care is key to attracting and keeping new hospice clinicians, but can be easier said than done, according to industry veterans. Hospice nurses with decades of experience have stated that training clinicians to provide goal concordant care involves an empathetic and unbiased approach.

Nurses often encounter situations in which they don’t agree with a patients’ choices, or they are caring for people with diverse family dynamics and lifestyles. The ability to provide quality end-of-life care comes with education and coaching on how to manage individuals’ expectations and needs alongside clinicians’ own experiences.

In addition to learning the keys to active listening, hospice clinicians also need a strong sense of humor to balance the daily stresses of providing end-of-life care, according to seasoned nurses in the field.

Hospices Have Long Road Ahead on Improving Health Equity

Hospices have employed a wide range of strategies to reduce proliferating health disparities, but some providers say the industry has much more room for improvement.

End-of-life care models have evolved in an effort to improve equity and inclusion among underserved patient populations across different belief systems and various racial, ethnic and cultural backgrounds. Yet, hospice providers often lack an understanding about the nuanced barriers preventing greater access, awareness and utilization of their services, according to some providers and industry stakeholders.

Many health equity initiatives have historically focused on uncovering the racial disparities and related systemic issues such as a history of discrimination, fear and mistrust in the health care space alongside socioeconomic, geographic and educational factors. Research has increasingly found that minority groups often report less satisfaction and a lack of pain and symptom management, resulting in overall poorer quality of care.

Armed with this understanding, hospices have increasingly sought to strengthen community partnerships across their service regions, improve staff training and hire more diverse staff, as well as implement significant changes to their organizational culture. But unknowns remain as far as the barriers among LGBTQ+ communities, people with disabilities, individuals with limited English proficiency, rural area populations, and patients adversely affected by persistent poverty or inequality.

Efforts to move the needle toward improvement came earlier this year when the U.S. Centers for Medicare & Medicaid Services (CMS) fueled a total of $1.4 million in grants that support health equity research.

Health equity issues also received heightened attention in evolving payment initiatives such the Accountable Care Organization Realizing Equity, Access and Community Health (ACO REACH) model. The demonstration became effective in January and requires participating providers to develop a health equity plan designed to identify and reduce disparities among underserved patient populations.

Hospices stand to lose out on a vast and growing underserved senior population, with some providers increasingly concerned that misunderstandings about patients’ cultural perceptions, values and goals could create significant barriers for several years to come.

How Fraudulent Evade Regulators

Fraudulent operators have eluded the consequences of their unethical or illegal practices by employing unscrupulous tactics, including moving patients around between different provider numbers.

Multiple sources have reported mounting program integrity concerns to Hospice News about the patterns of fraud and abuse in the space, even as regulators increasingly crack down on the sector. Numerous media and government reports have surfaced since 2021 related to unethical and illegal activity occurring among hundreds of newly licensed hospices, particularly in four hotbed states of California, Arizona, Nevada and Texas.

Though law enforcement and regulatory agencies have increased oversight in the industry, bad actors have continued to find loopholes and evade scrutiny.

Sources cited that fraudulent actors often maintain multiple provider numbers, which enables the perpetrators to move patients between the various hospices they own. Another common practice cited was transferring patients who have reached the payment cap to avoid recoupment.

Hospices have grown increasingly concerned about the various costs of fraud on future payment, access and sustainability. Fraudulent operators have misspent millions of Medicare dollars in recent years, though the actual amounts are difficult to narrow down. Regulators have sought ways to identify patterns of fraud hidden in operators’ billing claims, quality scores and audit results.