Hospices are in a season of change upon the implementation of the 2026 finalized payment rule and a new quality reporting system, the Hospice Outcomes and Patient Evaluation (HOPE) tool.

Both implemented on Oct. 1, the final rule and HOPE tool have hospices facing a tough learning curve, said Katy Barnett, director of home care and hospice operations and policy at LeadingAge.

Staffing training has been a key to keeping pace with the regulatory developments this fall, Barnett said in a recent Hospice News ELEVATE podcast.

“The [HOPE tool] is one of the biggest changes to come to hospice in a long time,” Barnett told Hospice News during the podcast. “It’s a lot to manage and coordinate and a lot of education and training. There was a lot of concern from the stakeholder community that folks just weren’t prepared for this.”

The HOPE tool replaced the Hospice Item Set (HIS) quality reporting system and includes new standardized measures that examine hospice care throughout various points in a patient’s experience.

Hospices’ mounting concerns with the HOPE tool have centered around the ability to ensure that their electronic medical record (EMR) systems have the appropriate technological capabilities to remain compliant, Barnett indicated. This is a challenge, given the many variations in EMR systems that exist, she added. Educating staff on the nuances of new quality reporting requirements alongside technology training has been no easy feat for hospices.

“You can do all the training in the world … but until you see [the HOPE tool] in your environment and in an EMR system that you’re used to, it’s really hard to connect the dots,” she told Hospice New. “There’s a lot of inconsistencies between EHRs, so that’s really our concern in this implementation time period. I think we’re going to see a lot more questions come in over time. There’s a lot more unknown, and we’ll probably see more updates to the HOPE guidance manual in the future.”

The HOPE tool includes new requirements related to missed symptom follow-up visits (SFVs). Hospices are required to provide SFVs within two calendar days of a follow-up visit for patients with moderate to severe symptoms and pain identified during assessment. The additional bedside time may add travel and staffing costs for hospices, as well as clinical capacity issues, according to Barnett.

Hospices have navigated the new quality system alongside changes in the U.S. Center for Medicare & Medicaid Services (CMS) 2026 final rule. The rule included changes to face-to-face attestation processes. Providers also recently lost the ability to do face-to-face recertifications via telehealth as pandemic-era flexibilities expired.

Other significant updates in the final rule included stipulations that a physician member of the interdisciplinary group (IDG) may recommend admission to hospice care, rather than the medical director alone, which aligns Conditions of Participation and Conditions of Payment.

The staffing-related change could be beneficial in helping hospices to do more with less resources during a time of rising demand and workforce shortages, according to Barnett.

“For hospices that have multiple physicians as part of their team … this spreads the burden beyond the medical director,” she said during the podcast. “It’s taking the burden off of the medical director and recognizing that physician as clinically eligible to admit patients, to go through the process, to lead clinical teams.”