Hospices face several challenges related to length of stay, recent research in Maryland has found.

Shorter hospice stays have impacts on outcomes, quality ratings, costs and staffing challenges, according to Peggy Shimoda, executive director of the Hospice & Palliative Care Network of Maryland (HPCNM).

Shorter durations of stay can result in negative end-of-life experiences for patients and their families, as well as increased financial and operational strain for health care systems. This was among the key findings in a collaborated research effort with HPCNM and Maryland-based Hospice of the Chesapeake.

“When there are short lengths of stay the families really suffer,” Shimoda told Hospice News. “There just isn’t enough time … and that creates a lot of unnecessary suffering for patients not just physically, but also psychosocially. Everything is rushed and every end-of-life decision is made under severe stress. We also have a lot of staff burnout in the industry and a lot of shortages. It’s very difficult for staff not to be able to do their job as fully in that time.”

Unraveling barriers to longer hospice stays

The recent research found that Maryland’s median hospice length-of-stay rate was 18 days throughout 2024, making it the 46th state nationally ranked. The state has a mean rate of 59 days of hospice care, which falls short compared to the national mean of 80 days. A total of 13 hospice providers participated in the study.

Maryland has among the shortest length-of-stay rates nationwide, an issue largely related to referral challenges, according to Monica Escalante, chief strategy and information officer at Hospice of the Chesapeake.

Shorter stays often have hospices struggling to provide the full range of their interdisciplinary services to patients and their families, Escalante said. Late referrals do not provide sufficient time for optimal symptom management or family support, she said. Patients often experience higher levels of physical and emotional acuity while families face greater distress and grief complications. Hospice staff are also more strained in these compressed timeframes for patient assessment and care delivery plans.

The research illustrates a growing need to dispel common misunderstandings about hospice that serve as a significant barrier, Escalante stated. Addressing the referral issues will take institutionalizing timely processes across hospital and health care systems. Additionally needed are policies that help to strengthen advance care planning and home-based palliative care infrastructure, greater incentivization of care collaboration between and more investment in education and community outreach, she said.

“Our study emphasizes that early hospice access significantly improves outcomes and reduces costs,” Escalante told Hospice News in an email. “Longer stays are associated with better symptom control, fewer emergency interventions, higher family satisfaction and lower overall Medicare spending. The implications of these findings underscore the need for a cultural and clinical shift toward earlier referral.”

Medicare spending was lower among decedents who utilized hospice 11 days prior to death compared to others, the research found. The findings suggest that earlier hospice enrollment and longer stays could be associated with reduced health care expenditures.

Recognition of the reduced spending associated with hospice could help to fuel change upstream related to referral education, according to Shimoda.

“We’d like to see our partners in the community make a bigger effort to train physicians and key personnel on how to talk to patients, and that really takes education and a lot of finesse,” Shimoda said. “It’s a difficult conversation, but the training could start in medical schools. Advanced care planning also comes into play. If people understand that even a little bit … then we can emphasize the importance of getting timely hospice referrals.”