Hospice and palliative care services can improve the quality of life for rural residents of all ages who are
dealing with serious illness or injury.
Hospice provides care to people experiencing terminal illness with a life expectancy of six
months or less if the disease runs its natural course. It is based on the belief that
everyone has the right to die pain-free and with dignity. The focus is on compassion, caring, and quality of
life, not curing. It helps patients and their families live life to its fullest.
Palliative care — also called comfort care, supportive care, or symptom management
— is specialized care that treats the symptoms or suffering related to an illness at any stage of the
diagnosis. It can be
integrated into any healthcare setting and is delivered by a team of healthcare professionals with support from
a palliative care specialist, if available. Palliative care is associated with better quality of life, improved
symptom management, and higher patient satisfaction. Although palliative care is a key component of
hospice care, palliative care is not restricted to patients with terminal conditions.Palliative Care or
Hospice Care? compares these services.
According to the Hospice services
chapter in the March 2022 Report to the Congress: Medicare Payment Policy, as of 2020 there
hospices, down from 950 in 2010. The report notes that
although the number of rural hospices decreased, the percentage of rural Medicare decedents using hospice
services increased over this period. In 2020, 17% of hospices in the United States were located in rural areas.
What types of services do hospice and palliative care provide?
Hospice is designed to provide care for people who are likely to die within six months, if their disease
progresses at its expected pace. It provides medical, emotional, and spiritual comfort.
According to the MLN publication Creating an Effective
Hospice Plan of Care, all CMS-certified hospice agencies must provide and follow an individualized plan
of care for each patient. The plan of care must include all services to palliate and manage the terminal illness
and related conditions of the patient. These services may include some or all of the following, depending on the
Medical care provided by doctors, physician assistants, and nurses
Medications for pain relief or symptom management
Social work services
Physical, occupational, and speech-language therapy (including help with swallowing)
Grief and bereavement counseling for the patient and family members
Medical supplies and equipment related to the patient's diagnosis
Hospice aide and homemaker services
Goals of care discussions
A member of the hospice team can be reached at all
times to answer questions and to visit patients when needed. Intermittent nursing visits are scheduled to assess
and monitor patients' conditions and treat symptoms. This can include giving injections and setting up IV
medication. Hospice professionals and volunteers can also teach caregivers and family members ways to help their
Patients whose conditions improve can choose to suspend hospice care and may resume services later on, if they
wish. Re-election of hospice benefits is allowed by Medicare, Medicaid, and most insurance companies. Hospice
also offers bereavement services for family members and caregivers for up to one year following the patient's
While palliative care is an important component of hospice care, it is also provided to patients who have
advanced chronic diseases and other serious illnesses but are not necessarily expected to die within a few
months. A terminal prognosis is not required to receive palliative care. For example, a chronic obstructive
pulmonary disease (COPD) patient may receive palliative care to manage anxiety, discomfort, or insomnia related
to breathing difficulty. According to the Center to Advance Palliative Care's document Serious
Illness Strategies for Health Plans and Accountable Care Organizations, effective palliative care
Identify the right population needing palliative care, and adjust services as patients' needs change
Provide expert management of pain and symptoms
Help patients and their families with decision-making regarding treatment and services
Support family caregivers through education, counseling, and respite care
Provide timely and appropriate care night or day to avoid unnecessary 911 calls, emergency department
visits, hospitalizations, and intensive care
Core values of both hospice and palliative care include:
Patient- and family-centered care
Holistic relief of physical, emotional, and spiritual suffering
Interdisciplinary case management
How are hospice and palliative care providers reimbursed for their services?
Medicare pays hospice providers a daily rate for all services regardless of the services provided each day.
Typically, there is no out-of-pocket cost for a patient receiving hospice care. The hospice provider assumes
responsibility for all care related to the patient's terminal diagnosis and related conditions. Medicare
reimburses hospice providers for four different levels of care to meet the needs of patients:
Routine home care – the most common level of care provided, accounting for 98% of hospice care in
2019. Routine home care is reimbursed at one rate for the first 60 days of care, and a lower rate for every
subsequent day of care.
Continuous home care – home-based care for a short-term symptom crisis that requires eight hours of
care or more per day.
Inpatient respite care – care provided in a facility setting for up to five days to provide respite
for an informal caregiver.
General inpatient care – short-term inpatient care to manage symptoms that cannot be managed in
The level of care a patient receives can change throughout their time on hospice care.
Although most states have a hospice benefit as part of their Medicaid programs, states are not required to
include hospice as part of Medicaid. Medicaid
hospice reimbursement is based on the Medicare hospice reimbursement rates.
Traditionally, when a patient enrolled in Medicaid Advantage (MA) elects to receive hospice care, traditional
fee-for-service Medicare becomes financially responsible for hospice care and most other Medicare services,
while the MA plan retains coverage of supplemental benefits. Beginning January 1, 2021, the Centers for Medicare
and Medicaid Services (CMS) began to test the Hospice Benefit
Component of the Value-Based Insurance Design (VBID) Model. Participating Medicare Advantage plans will
be responsible for all traditional Medicare services, including hospice care.
According to the 2020
NHPCO Palliative Care Needs Survey Results Summary, Medicare Part B was the most common source of
palliative care reimbursement. Unlike hospice care, however, there is currently not a specific Medicare benefit
for palliative care. Instead, Sustainability
Strategies for Community-based Palliative Care explains that palliative care teams can often bill
traditional Medicare for advance care planning and care management services. Licensed clinical social workers
may also be reimbursed for mental health services provided to patients receiving palliative care services in
some situations. As a result, patients experience variation in access to palliative care services. Patients may
also be responsible for a copayment for these services. Palliative care programs also receive reimbursement from
contracts with commercial payers, hospitals or other partnerships, philanthropies and grants, the Medicare home
health benefit, and arrangements with Accountable Care Organizations and Medicare Shared Savings Plans.
Who offers hospice and palliative care in rural areas and in what settings are they provided?
Community-based hospice and palliative care is the most familiar model in rural areas and is usually organized
by health professionals and volunteers. These providers may serve one or more rural areas. Hospice care is
typically provided in a patient's home, including an assisted living facility or nursing home, but it can also
be provided in an inpatient facility.
of Changes to the Medicare Hospice Benefit compares rural and urban hospice ownership status and
facility type (see Table 1 below). In rural areas, there are more government-owned hospices, more
hospital-based facilities, and fewer freestanding hospices. The report states that hospital-based hospice
facilities are more prevalent in rural areas than in urban, which may be due to hospitals in many rural areas
being the only source of healthcare.
Who is included in rural hospice and palliative care teams?
Hospice and palliative care are provided by interdisciplinary teams that help patients approach the end of life
with comfort, peace, and dignity.
Hospice teams often include, but are not limited to:
Home health aides
Bereavement and spiritual counselors
The patient and his or her family are considered part of the hospice team, as well.
Physicians, nurse practitioners, and physician assistants are recognized by Medicare as designated hospice
attending providers, though nurse practitioners and physician assistants have restrictions regarding certifying
a terminal illness and conducting face-to-face encounters. Clinical nurse specialists and outside attending
physicians cannot be attending providers, nor are they authorized to perform face-to-face encounters. These
meetings are required before the first 180 days and every 60 days thereafter. For rural hospice programs that
may not have a physician or nurse practitioner available at all times, these requirements can be difficult to
fulfill. After patients have been admitted to a hospice program, the interdisciplinary team formulates a written
plan of care.
The Consolidated Appropriations Act, 2021, included a provision formerly known as the “Rural Access to
Act.” Beginning January 1, 2022, physicians, nurse practitioners, and physician assistants at Rural Health
Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) will be able to serve as attending providers for
hospice patients. Historically, physicians employed by RHCs and FQHCs were unable to serve as attending
physicians because RHCs and FQHCs are paid a fixed all-inclusive payment for all services to Medicare
How can palliative care be used in rural communities to improve the quality of life of people dealing with
Rural populations tend to be older and experience higher rates of disability and chronic disease than urban
populations. Due to the shortage of healthcare professionals in many rural areas, rural residents may not be
able to easily access their providers to address emerging or worsening symptoms of an illness. Palliative care
teams can support these patients to alleviate not only the physical effects of their condition, but the
emotional, social, and spiritual effects as well. Sustainability
Strategies for Community-based Palliative Care also highlights that palliative care services can allow
patients to continue to receive care in their communities.
What challenges are faced by rural palliative care organizations?
Palliative care programs also experience their own unique challenges. As noted in the Rural Monitor
article Community-based Palliative Care: Scaling Access for Rural
Populations, medical professionals as well as lay people sometimes confuse palliative care with hospice
care, and mistakenly assume that palliative treatment is appropriate only for people who are nearing the end of
life. The same article notes that although hospice care is covered by many insurance plans as a benefit,
palliative care typically is not.
What challenges are faced by rural hospice organizations?
Providing hospice and palliative care in rural areas involves challenges such as shortages of family caregivers,
financial reimbursement problems, lack of qualified staff, and travel distances.
The policy brief, Perspectives
of Rural Hospice Directors, presents the results of a 2013 phone survey of 53 rural hospice directors
and key staff from 47 states. The most important issues identified by these hospice directors were:
Financial issues, such as reimbursement and operating costs
Rural factors, including population change, economics, culture, and geography
Stringent federal regulations and policies, such as the requirement for face-to-face visits for
recertification of hospice patients
Workforce issues, including challenges in recruiting and retaining staff, and staff burnout
Relationships with other health providers, and competition for resources and patients
Technology issues, including limited access to broadband and connectivity problems
What challenges are faced by the rural hospice and palliative care workforce?
of Rural Hospice Directors identifies heavy workloads, wearing multiple hats, and limited options for
training as challenges for the rural hospice workforce. Other challenges for the rural hospice and palliative
care workforce can include:
Coping with fear and anger among patients and families who are having difficulty accepting the patients'
illness or injury
Emotional stress of caring for dying patients with whom they have close relationships
Safety concerns related to traveling to remote areas with poor roads and communication infrastructure
Lack of training programs geared specifically toward medical professionals who wish to specialize in hospice
and palliative care
Low retention rate among rural hospice staff
Physical stress related to lifting heavy weights
Salaries that may be lower than those earned by medical professionals in other specialty areas
Work in some cases may be only part-time
Skill set for a variety of complex chronic conditions may be required
Scheduling such that hospice and palliative care providers may routinely work alone and without support
Fewer medications and less medical equipment available in rural pharmacies
How do rural hospices utilize volunteers?
According to the National
Hospice and Palliative Care Organization's Facts and Figures, hospice is the only Medicare provider type
with Conditions of Participation that require at least 5% of patient care hours to be provided by volunteers.
These community members offer a valuable service to rural hospice and palliative care agencies when they provide
direct patient care, clinical support, and other general supportive services to supplement the work of hospice
Low patient volume, affecting the ability to achieve a successful scale of operation
Significant cost of electronic health records (EHRs) and data submissions, as well as difficulties in
implementing EHR systems
Increase in regulatory costs
High infrastructure costs
Strategies to increase financial viability for hospice providers can include:
Becoming a nonprofit 501(c)(3) organization, which allows the hospice to accept donations, major gifts,
bequests, and planned giving
Offering home and outpatient services in residences or home-like settings
Holding community fundraisers throughout the year
Charging a room and board rate for care in a hospice home at the routine level
Offering all 4 levels of hospice care: routine home care, general inpatient care, continuous home care, and
inpatient respite care
Enrolling patients early in their diagnosis
Leveraging telehealth (virtual and telephonic) visits to supplement in-person visits
What strategies can help make a rural palliative care service financially viable?
Strategies for Community-based Palliative Care, a summary of two roundtable discussions conducted by
Stratis Health in 2018 with 9 rural palliative care programs, highlights that in addition to Medicare and other
payers not having a distinct palliative care benefit, only some members of a palliative care team can bill for
direct services. This document also offers examples and resources to support rural community-based palliative
care programs including traditional billing and reimbursement, grants and philanthropy, value-based contracting,
and emerging opportunities such as the development of a palliative care benefit other new payment models for
rural healthcare providers. The National Academy for State Health Policy has also compiled several reimbursement
strategies for state health programs to implement to promote sustainable palliative care services for
How do rural hospice providers compare on quality of care and patient satisfaction measures?
According to the 2015 article Quality of Hospice
Care: Comparison Between Rural and Urban Residents, rural hospice patients and their families were more
likely than their urban counterparts to report high levels of satisfaction with overall care and pain and
symptom management. Of the 331 rural people surveyed, only 3 patients were not satisfied with the hospice care
they received. The researchers suggested that the high ratings for rural hospices may be due to:
Rural communities' connectedness
Services being delivered quickly, as providers know the patients' needs
Highly individualized care, provided by nurses who ensure that patients receive excellent service
Neighbors who are aware of patients' needs and are willing to help
Medicare.gov's Care Compare tool allows users to find and
compare hospice agencies in their area in terms of the quality of patient care and caregiver experience compared
to national averages.