This article is sponsored by Homecare Homebase. This article is based on a Hospice News discussion with Susan Ponder-Stansel, CEO of Alivia Care, Scott Levy, Chief Government Affairs Officer for the National Alliance for Care at Home and Dr. Derrel Walker, CMO of The Pennant Group. This discussion took place on April 10th, 2025 during the Hospice ELEVATE conference. The transcript below has been edited for length and clarity.

Hospice News: Can each of you give us a brief introduction to your organizations?

Dr. Derrel Walker: The Pennant Group is, well we call ourselves a leadership company that does health care. So we’re focused on leadership development, and we provide home health, hospice, mobile primary care, palliative care, and home care services across 14 states. We do a lot of different things, all focused on changing the lives of our patients.

Scott Levy: Good morning, everyone. I’m with the National Alliance for Care at Home. I’m sure a few of you have heard about the recent merger of two long-standing, well-established national trade associations that have represented home-based care for many years. Last summer, the boards of HPCO and NAHC came together—Bill and I have joked over the years about how to pronounce “NAHC”; it seems to depend on where you are, maybe north or south of the Mason-Dixon Line.

Anyway, the National Alliance for Care at Home was officially formed last summer, and I started in January as the Chief Government Affairs Officer. It feels like I started two days ago, or maybe two years ago—it depends on the moment!

We are the leading voice for home-based care advocacy in Washington, D.C. That includes home health, hospice, private duty home care, Medicaid home- and community-based services, and palliative care. Our mission is to ensure that the voice of the home-based care industry is heard loud and clear in Washington.

Susan Ponder-Stansel: I’m the CEO of Alivia Care, which was formed in 2020. It’s the parent company of Community Hospice, one of the largest and oldest independent nonprofit hospices. We’re headquartered in Jacksonville, Florida.

We serve a broad area from the Atlantic coast to the Gulf Coast and also cover Southeast Georgia. We’re entirely nonprofit and mission-driven, community-based. In addition to hospice, we provide PACE, home care, private duty services, and palliative care in both hospitals and in-home settings. We’re always looking for opportunities to expand our services and fulfill our mission, which is to improve the experience of patients and families living with serious illness. That’s what we’re about.

HN: Excellent, thank you. So, big question: What are the top issues or concerns facing hospice providers in 2025? Susan, why don’t we start with you and go down the line?

Ponder-Stansel: Well, I think all of us are keeping a wary eye on whether the hospice Medicare benefit will become part of Medicare Advantage. That would be a major change—not just in operations but in how we deliver care. Given some of the recent turbulence and rapid changes, we can’t rule it out. Many of us are seriously looking at what that shift would mean for our organizations.

Another big issue is the increasing cost of doing business—both in terms of delivering clinical care and meeting regulatory and administrative demands. Everyone is feeling margin compression, and we’re all trying to figure out how to maintain our missions while ensuring we have the margins to support them.

Levy: Yeah, I’ll build on what Susan said. A lot of the pressures we’re facing are regulatory or government-related. Whenever there’s a new administration or Congress, there’s a combination of consternation and opportunity. So we’re not just watching for headwinds—we’re actively looking for where this administration and Congress are leaning when it comes to value-based care.

Hospice has a role in that, and we need to make sure policymakers understand that hospice isn’t just something that happens at the end of the continuum. It should be fully integrated throughout the continuum of care. That’s why having those conversations early is key—to show we’re in the game and ready to be part of the broader care transformation.

From a regulatory standpoint, any time we talk about regulations, the question is: are they helping or hindering us? This administration has actually asked for feedback—asking us to submit regulations we think are burdensome or distract from care delivery. So there’s a real opportunity there, and we plan to submit our recommendations.

All of this could change quickly, though. The Office of Management and Budget cleared the fiscal year hospice proposed rule just last night, so it could be released as early as this afternoon—maybe around 4:15.

HN: Is that a good thing?

Levy: We don’t know yet—we haven’t seen it. This is the annual rule that sets payment updates. Traditionally, in the first year of a new administration, the proposed rule tends to be fairly benign. But “traditionally” isn’t a word we can always rely on right now.

Walker: These are some amazing leaders in the industry. I think I would add is—the only thing I would be remiss in not saying is, you know, being a physician or a clinician that’s at the bedside, it’s all of what they described, but still delivering that care, the compassionate care at the bedside that we’re supposed to. It’s our “why.” All of us are here because we got hooked somehow—and most of the time it was at the bedside, caring for someone who was struggling or suffering. I think that’s the biggest challenge as leaders in communities and companies. It’s really easy to just get focused on those [non-clinical demands]; it consumes us, right? And I’m grateful for people like Scotland and the Alliance that are doing that kind of work for us so that we can maintain our focus on the bedside. I think that, to me, is the biggest headwind, because I feel it. When you move from a role—because I do both. I split my time doing bedside care as a hospice medical director, and I do this chief medical officer role as well. It’s really easy to get consumed by the regulatory burdens and all of those things. So, to me, that’s one of the biggest headwinds: just maintaining our focus where it’s supposed to be.

Levy: I’d add one thing just on regulatory burdens. There was a hearing before the House Ways and Means Health Subcommittee about three or four weeks ago, and Jonathan Fleece, the CEO of Empath Health based here in Florida, was the witness for the home-based side. He was prepared to answer a question about his experience with audits, because he was going to tell them that once they get to the ALJ level, he had a 100% overturn rate. So there’s obviously something missing between the initial round and when it gets to the ALJ. I mention that because there’s an article this morning in Inside Health Policy where CMS has been tasked by the DOJ to identify $2.7 billion in contracts that need to go. So again, what is a headwind right now could potentially become an opportunity—if we’re able to tell that story. To Darryl’s point, this is a regulatory and bureaucratic burden that takes away from very needed resources—both time and money—to provide high-level care that patients deserve. What we’re trying to do with the Alliance is, anytime we’re talking about hospice policy—whether it’s payment, regulatory, or some big redesign, or the potential for Medicare Advantage—we must keep in mind that these are patients who have made the decision to forgo curative care so they can be comfortable in their last days of life. So whatever it is we’re talking about, it has to come back to that central point, and we want to continue to remind policymakers that whatever policy is made must ensure that the goal is not inhibited.

HN: So where do you see the biggest potential for growth right now? Dr. Walker, why don’t we move in the opposite direction?

Walker: Sure. I think there are various opportunities. We work in a similar space, where we provide care in multiple settings and multiple types of care—home health, hospice, palliative care, home-based caregiving, those types of things. And it’s hard to pick one out. Our company is really locally driven and adapted to the local needs of the local markets. We’re not a traditional top-down structure—we’re more of a flat leadership structure. So, the answer typically varies depending on the market. Some of our agencies are pursuing relationships with hospital systems, because that’s where many patients are. Each community is a little bit different, too. Some communities have better penetration of palliative care, so some patient populations are more ready for hospice earlier. I think one of the biggest areas of opportunity is coordinating integrated care across the post-acute continuum, allowing patients to “age in place”—but in our minds, that means aging in place within the same group of people that can support and serve them. I think Alivia Care has a similar vision, and I love that, because it’s best for the patients. One of the biggest challenges patients face is bouncing between care settings, companies, and care philosophies. So, I think that’s the biggest opportunity: uniting and coordinating care so patients can age in place—from a support standpoint—even if that includes multiple companies. Anyway, there are lots of answers to this, but that’s the one I like best. And you? What’s your perspective?

Levy: I’ll offer a little bit of a different take since I’m not taking or receiving referrals. I think from an Alliance standpoint, as we’re talking about advocacy, what would be helpful to hear from members is: what are your referral relationships like, and how are workforce issues impacting those relationships? If you’re having concerns or issues with referral partners because you’re not able to take on as many new patients who need hospice, what does that mean for the system? That’s the kind of information we need to be providing to the administration through rulemaking and comments. We need to say, “Look, the hospice benefit is not being fully utilized because our referral partners are struggling to get patients to us—we don’t have the clinical staff available to accept them.” And that’s partially because of an insufficient inflationary update over the past five years—or whatever the reason may be. But that’s the kind of information providers can give us at the Alliance to help tell the story. And you can also tell that story individually to your local congressmen and senators. There’s a lot going on right now, but that doesn’t mean this issue shouldn’t be front and center.

Ponder-Stansel: Well, to echo something Scott said, this could be an opportunity or a threat. But I think there’s a lot of growth going on in what we call “substitute competition”—special needs plans, full-risk primary care, health plans that own all the means of production for the continuum of care. One opportunity for hospices is to make the case that others can’t do it as well as we can—and here’s why. That’s an industry challenge: being able to demonstrate that just because you have a lot of ARNPs doesn’t mean you can deliver end-of-life care that truly avoids burdensome transitions and honors patient preferences. I also think there are opportunities in senior living, as Darryl mentioned. Long-term care populations are declining. My generation—the baby boomers—we’re not going to nursing homes; we’re looking at assisted living and senior living. So, to the extent that hospice programs can bring the continuum of care to those settings, that’s a great opportunity. That includes not just medical care, but also the full interdisciplinary team services—because I worry that hospice is becoming so medicalized that we’re losing the value of those other services. Finally, if you look at the top ten discharges from hospitals—COPD, CHF, ESRD, even dementia—those patients are already in our care, but we still get them late. There’s a big opportunity to engage them earlier and help their other doctors understand our value. Also, we’re not reaching diverse populations adequately. Take African Americans, for example—they’re more likely to suffer from those chronic conditions, but hospice isn’t serving them in proportion. So, we have an opportunity to do better outreach and make hospice more accessible and acceptable to those communities.

Walker: Thank you. Picking up on something you said about senior living—Hospice News did a survey earlier this year where respondents said senior living represented the biggest area of potential growth for referrals. Could you talk a little bit more about those opportunities? Maybe what those companies are looking for from hospice?

Ponder-Stansel: I’d be glad to. There’s a lot of competition in that space—it’s like fish in a barrel with a lot of people under one roof. It’s definitely more visible than going from home to home. What we’ve seen in our service area is that those who are successful offer additional upstream or wraparound services—care navigation, home health, Part B therapy services, home-delivered primary care, those sorts of things. They allow people to receive everything they need in one place. For hospices that may not be able to offer all of that, we always say: build, buy, or partner. Can you be a partner to those who do have home health or Part B therapy and extend your reach that way? People want the continuum of care—the “easy button”—where the care follows them, rather than them having to adapt to whatever reimbursement or care model you offer. That’s the key—but yes, lots of competition.

Walker: Yeah, our parent group owns a large number of assisted living communities, so that’s a big part of our focus too—how do we deliver the care they need? And as we all know, based on the payment and regulatory structure for assisted living communities, it’s challenging. Hospital systems are pushing patients out sooner due to different payment structures, so the level of care needed in SNFs and assisted living has increased significantly over the years. That means you now have much sicker patients in assisted living facilities, and the payment and regulatory structures haven’t kept up. Susan’s point is exactly right—what those facilities need is a higher level of care delivered at the bedside. That’s what we call provider services—our mobile primary and palliative care groups with nurse practitioners supporting those facilities. That’s a huge need. And the other big thing is coordination—the healthcare system is incredibly complex and confusing. Patients and families often don’t know what to do, who to ask, or where to go for help. So, as you said, coordinating care at a higher level in that space is crucial.

Levy: When Darryl talked about the increased acuity level we’re seeing—patients getting pushed out of hospitals sooner and the pressure that brings all the way down the care continuum to home health and hospice—I think that’s something policymakers in Washington don’t fully appreciate. Not to jump over to home health policy, but even PDGM was supposed to be a payment model focused on higher-acuity patients, and yet the government doesn’t seem to be aligning with that. So, what you’ve all discussed is something we need to really drill down on.

HN: Are you seeing any improvement or changes in the workforce? I’m sure this is a question on many people’s minds right now. Susan?

Ponder-Stansel: Well, for hospice, I think we’re in a different situation. Again, just looking at our different types of care within our organization, our clinical staff are mostly full-time—they consider it a calling. It’s a different workforce. I think all of us probably still have those issues with certified nurse aides and home health aides because they tend not to stay as long. But we’re not seeing it as acutely—yet.

I think we will, because, again, just looking at the demographics of our workforce—the age of our licensed clinical social workers, the age of our RNs—they’re going to exit the workforce in the next five to six years. And when you look at the number of people leaving compared to the number coming up behind them, there’s clearly a gap.

So I think one of the things that all of us are going to be looking at is how we make sure that our very precious clinicians are not only compensated well so they stay with us, but also that we’re not wasting their time doing things that technology could do, or that someone with a lower-level license—or even paraprofessionals—could handle.

That’s a big challenge for all of us right now: looking at what I call “the stupid stuff” that we have our RNs or LCSWs doing, and making sure we treat them as a scarce resource—eliminating tasks that don’t require their level of expertise or could be delegated so their time is used more effectively.

Levy: Unfortunately, I think the workforce issues are going to have to be solved by business leaders, because I don’t see the government stepping in with some magic plan to help us solve this overnight. Maybe over time, as things settle a bit, but I don’t foresee any massive workforce policy initiatives—at least not in this current environment over the next couple of years—that will relieve the pressure.

Walker: I mean again, at the end of the day, what you’ve said is just the truth. I think the pandemic—even though we’re five years removed—we’re still recovering from it. And like Scott said, it’s really up to local business owners to figure it out.

What Susan said—I love that. To me, it’s about connecting those workers back to their why. During the pandemic, so many people got distracted from that. I mean, people could make a similar wage at McDonald’s as they could working at the bedside. That’s what we saw on the front lines. It was challenging, and so turnover happened.

We’ve got internal initiatives focused on turnover, but the real issue is: how do we connect people back to their why? Why are they doing this job? Why would you do this job? That’s a big part of it—staying focused on the patients, on the bedside, on the mission, and on the purpose behind it all.

To me, that’s one of the big ways we can address it. It’s still a problem, for sure—the workforce is still a problem—but I do think it’s starting to stabilize, especially as we focus on reconnecting people to their purpose.

Technology is huge. Over the last year and a half, we did a big overhaul using Home Care Homebase, streamlining the workflow for our bedside clinicians. Like you mentioned earlier, they shouldn’t be wasting time clicking useless boxes or doing unnecessary tasks. We’re helping them practice at the top of their license.

Ponder-Stansel: Can I do a quick follow-up to Jim on this topic? One of the things the Alliance is working on is an image campaign to help RNs—especially—see that care in the home is a viable and rewarding career path.

In Florida, we have a Center for Nursing that collects data on nursing graduates and where they plan to work. Almost 85% plan to work in hospitals or other brick-and-mortar settings. But when you look at where healthcare is going, it’s shifting away from buildings and into the home.

Now, not everyone is called to that environment. It’s unique. It’s challenging. You’re out on the road. You’re seeing patients in less controlled conditions. But I really think we need to get the message out there: this is where the jobs are going to be, and this is where you can reconnect to your why.

That’s something I hear again and again—especially from those delivering care: they feel they can really connect with their purpose. It’s less transactional and more about truly caring for the whole person. So I think we’ve got a lot of work to do to shift that perception and attract people into home-based care.

HN: Thank you for that additional perspective. A quick follow-up for the providers on stage: where are you seeing the greatest need in terms of specific occupations? Is it the clinical teams? The back office? Is it everyone? Dr. Walker, would you start?

Walker: Yeah, I wish I had stats to better answer this, but it really continues to be that bedside care. In our companies, we try to bring aides into our IDG meetings. They provide critical insights, and we make sure they know they’re contributing—not just to bedside care but to decision-making.

Honestly, I often say that my job—as medical director—is the easiest one. The hardest job is the one at the bedside, and that’s the aides who care for patients directly. That’s the space where I see the biggest need. Unfortunately, it’s also on the lower end of the pay scale, which makes it harder to maintain a stable workforce. And that’s frustrating because it’s the most important piece. Every time we’re in an IDG meeting, it’s the aide who brings forward something crucial that drives clinical decisions. I wish that dynamic were different—or at least more balanced—because it would stabilize everything.

Ponder-Stansel: I think we always need nurses, social workers—those kinds of clinicians. None of us are turning people away because we have too many. But one of the areas we’ve struggled with the most is certified nurse aides and home health aides. That’s a huge limiting factor for non-skilled and private duty care. It’s just very hard to find those people.

Best-in-class turnover is 65%. The average is 85%. That’s a huge churn, and we really need to figure out ways to retain those folks because they’re essential to so many lines of service.

Another surprising area of struggle? The back office—especially finance and accounting. There’s stiff competition, and people can easily find high-paying remote jobs and leave quickly. The pandemic changed expectations. People want flexible work arrangements—remote or hybrid. A lot of organizations weren’t ready to make that shift.

I think going forward, it’ll be a real challenge to figure out who can have flexible work, even among RNs and LCSWs. People are seeking better work-life balance, and we, as employers, have to figure out how to meet that need while still meeting the needs of our patients.

Levy: Can I ask a quick follow-up—have you all shifted in terms of who you’re hiring now versus pre-pandemic? Were you looking only for clinicians with prior home health or hospice experience before, or were you open to new grads? Has that changed?

Ponder-Stansel: Well, for hospice, we did require prior experience. Honestly, I’m not sure of our current stance—my COO is sitting there, and he’s the expert on that. Are we hiring nurses now without any experience?

We’re not hiring inexperienced nurses for home care. Especially in the home—you’re on your own. It’s a tough environment to throw a brand-new clinician into.

HN: So, are you seeing increased technology adoption in the space? What types of technology are hospices investing in right now?

Levy: With home health and hospice being excluded from the “meaningful use” dollars under the ACA, the fact that we’ve advanced as far as we have speaks volumes. That’s a credit to the innovation and dedication of the people in this room—people who’ve committed their careers to this work.

I keep going back to the Washington perspective—because it’s my job—but I think a lot of those big conversations around interoperability and EMRs overlook our industry. There are still providers who aren’t very advanced, and they’re going to get left behind as we push further into tech.

We need to make sure this digital divide doesn’t create access issues for rural America. That needs to be front and center in the discussion.

Walker: For me, it’s twofold: streamlining clinician workflows so they can focus on care, and ensuring availability of information across care settings.

I can’t tell you how many times patients have had adverse outcomes because we didn’t get discharge info in time. Having access to hospital records quickly is huge. So yeah—what you said, exactly. Thank you. And Susan?

Ponder-Stansel: Well, to echo what everyone else has said, I think it’s really about having workflows and technology that help clinicians avoid spending an inordinate amount of time documenting. One of the things on the horizon is the need to have access to our own data—so we can really understand what’s going on with the patients in our care. Especially if we’re working across a continuum of care or are in any sort of risk-bearing arrangement, that access becomes crucial.

And I think that’s been one of the challenges with some electronic health records—just being able to extract the data and derive insights from it. For hospice specifically, one of the things we’re exploring is predictive or AI analytics that could help us recognize when patients are nearing their final days—say 15 days, 10 days—because most hospices just follow a cadence of visits, maybe once a week or every 10 days.

With our scarce resources, if we’re focusing on good outcomes, we should really be titrating our visit frequency and care intensity to where the patient is in their end-of-life process. Clinicians have intuition, of course, but a lot can happen when they’re not in the home, when they can’t lay eyes on the patient. So I think analytics here represent a major opportunity. Any hospice that can leverage that will be ahead of the game, especially because we know how impactful those final-days visits can be—and how much avoiding burdensome care transitions improves outcomes.

Another thing I’m really pushing for is better technology tools that make it easier for our patients to communicate with us—and for our clinicians to communicate with them. In this day and age, we still have clinicians on the phone making appointments, while families act like air traffic controllers coordinating who comes to the house and when.

Wouldn’t it be nice—Domino’s can tell me who’s delivering my pizza!—if we could tell patients and families who’s coming to their home and when to expect them? And if they could simply say, “Yes, make a visit today,” or “No, don’t—here’s what’s going on.” I think that kind of tool would make a big difference in patient satisfaction.

Walker: I think you’ve probably heard it from all of us, but it’s this: stay focused on your patients and what they need. That’s where you change lives—right at the bedside. Taking care of them the way they need to be cared for. Try to keep all the burdens—operations, regulations, all that stuff—try to keep that out of the way of the magic that happens at the bedside. That’s where lives are changed. So that’s my advice.

Levy: I would piggyback off what Darryl said. I think that’s where the Alliance really comes in—to help hospice leaders. For those of you who are leaders in the room, plug in with us at the Alliance so we can hear directly from you. That helps alleviate the worries your clinicians carry.

If we’re talking about regulatory burden and how we can help, we need to know about it. We have a voice—so let’s use it. But our voice at the Alliance is only as strong as what we get from our members. So please, make sure you’re engaged with us so we can help amplify that voice, get the regulatory relief we need, and speak as one. Because if we’re divided or saying different things, it’s easy for them to tell us no.

Ponder-Stansel: I’d add: focus on being able to clearly capture and articulate the outcomes that are unique to quality hospice care. You need to be able to speak about those outcomes and share them with potential partners and referral sources.

And, as Darryl mentioned, be easy to do business with. We deal with a lot of burdensome, arcane processes and regulatory requirements—and I’ve seen some hospice programs push that burden onto their customers, whether it’s the referral source or the patient’s family.

That shouldn’t happen. I always say: speed to care really matters. That first call—to say, “Come and admit me to hospice”—is a hard one to make. So getting there quickly is incredibly important. And making sure we’re always focused on what our customers need from us—that’s essential.

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