Most hospice patients arrive following a hospital discharge, in the middle of a medical crisis, already dying within days or even hours. Any hospice provider can change this pattern by building partnerships with local hospitals, skilled nursing facilities, and the medical records teams who hold the key to earlier identification.
The Cost of Waiting
Picture this scene.
A daughter sits beside her father’s hospital bed as the discharge planner mentions hospice for the first time. He’s 82, has advanced heart failure, and barely survived his fourth hospitalization this year. The family has 48 hours with him after enrollment. No time to adjust his medications to reduce the fluid crushing his lungs, no weeks to help him record messages for his grandchildren, no months to prepare his wife for the practicalities of living alone after 58 years of marriage.
This happens thousands of times every day across America.
Patients arrive too sick to benefit from symptom management that could have eased their breathing weeks earlier, too exhausted for the spiritual support they desperately needed, too close to death for families to access respite care that might have prevented caregiver collapse. The grief afterward carries a particular weight—families haunted by what might have been possible if they’d known sooner, if someone had identified their loved one’s eligibility before the final crisis.
Finding Patients Before They’re Dying
CommonSpirit Health at Home CEO Trisha Crissman has outlined a strategy that any hospice provider can replicate, regardless of size or budget. Her organization is deploying eligibility triggers in electronic health records that automatically flag patients whose declining trajectories suggest they might qualify for hospice services. They’re working directly inside physician clinics, specialty practices, and ambulatory centers where patients receive ongoing care.
The technology already exists in most healthcare systems.
Medical records personnel can configure alerts based on specific criteria: repeated hospitalizations for the same condition, declining functional status documented across multiple visits, combinations of diagnoses indicating life-limiting illness, and medication patterns suggesting disease progression. These aren’t expensive artificial intelligence systems—they’re practical applications of data that healthcare organizations already collect.
Crissman’s team also places patient navigators directly in clinical settings where they can review flagged records, consult with treating physicians, and initiate conversations about hospice eligibility before the next emergency department visit. Navigators build relationships with clinic staff, making it easier for busy physicians to refer appropriate patients.
What Earlier Access Changes
Crissman describes the transformation as creating a “womb-like envelope” around patients who are navigating difficult healthcare decisions during uncertain times. Early enrollment means hospice teams can prevent the next crisis rather than simply responding to one that’s already happened.
Consider the difference.
A patient enrolled six months before death has time for her hospice nurse to recognize subtle changes in her breathing pattern, adjust her diuretic dosage, and prevent the fluid overload that would have sent her back to the emergency room. Her chaplain visits regularly enough to help her work through complicated feelings about her estranged son, giving her months to decide whether she wants to reach out before she dies. Her social worker connects her husband with a caregiver support group where he learns practical strategies from others who understand what he’s facing, reducing his isolation and preparing him for the changes ahead.
The interdisciplinary team has space to build trust, discover what matters most to this particular patient, and deliver the comprehensive care they are trained to provide.
Beyond Individual Patient Care
Earlier hospice enrollment creates ripple effects throughout healthcare systems. Patients who receive timely hospice services have significantly fewer emergency department visits in their final months, reducing strain on already overwhelmed emergency services. They experience shorter hospital stays when acute care is necessary, freeing beds for other patients.
Healthcare costs drop measurably. Hospital administrators notice improved quality metrics and better family satisfaction scores. These outcomes make hospitals eager to partner with hospice providers that can demonstrate their impact on the broader system.
Hospice staff experience something else entirely—the fulfillment that comes from delivering care the way they envisioned when they entered this field. Nurses have time to teach families comfort-care techniques, proactively manage complex symptoms, and witness meaningful moments when patients aren’t fighting for every breath. Social workers can address anticipatory grief, facilitate family meetings to resolve conflicts, and ensure advance directives reflect patients’ actual wishes.
Building Partnerships That Work
Start with a conversation.
Hospice providers can approach hospital case managers and discharge planners with specific data about readmission rates for patients with life-limiting illnesses, offering to collaborate on earlier identification. Provide examples of how eligibility triggers work in electronic health records to make the technical implementation feel manageable rather than overwhelming.
Skilled nursing facility administrators face similar pressures around repeated hospitalizations and emergency transfers. Demonstrate how partnering with hospice providers can stabilize their sickest residents, improve quality indicators, and reduce costly acute-care episodes.
Medical records teams need clear criteria for configuring alerts: Which diagnoses trigger review? What combination of declining functional assessments should generate flags? How often should the system run these checks? Work collaboratively to refine the parameters, recognizing that the first iteration won’t be perfect but will improve through ongoing adjustment.
The goal isn’t perfection—it’s creating systems that identify even 20% more eligible patients before they’re actively dying.
Your Next Move
Hospice providers: Schedule meetings with your local hospital’s quality improvement director and palliative care team leader. Bring data on the average length of stay for hospice patients, readmission rates, and family satisfaction scores. Ask about their current challenges with high-utilizing patients who have life-limiting conditions.
Hospital administrators: Identify five diagnoses that generate the most repeat admissions in your facility. Pull six months of data. Request a meeting with hospice providers in your community to discuss collaborative strategies for identifying patients.
Skilled nursing facility leaders: Review your emergency transfer logs for patterns. Which residents return repeatedly? What might earlier hospice involvement have changed? Reach out to local hospice medical directors to explore partnership possibilities.
Medical records staff: Begin mapping your current EHR capabilities for generating alerts based on diagnosis codes, functional status changes, and utilization patterns. Document what’s possible with existing technology before assuming you need new systems.
Compassion Crossing Academy — Free and paid online courses are available to teach caregivers, nurses, social workers, chaplains, end-of-life advocates, and educators, including death doulas, how to confidently coordinate complex care.
The Death Deck is often a wonderful conversation starter.
Compassion Crossing, LLC, via Peter M. Abraham, BSN, RN, EOLD, offers on-site services in Madison County, KY, as well as in the seven nearby counties—Clark, Estill, Fayette, Garrard, Jackson, Jessamine, and Rockcastle—and provides virtual options when no local provider is available.
Hospice Buddy: Although Jamie Haberman, RN, CHPN, isn’t a certified end-of-life doula, her virtual services are highly valuable.
Currently, no official organization regulates end-of-life doulas (EOLDs). Remember that some EOLDs listed in directories may no longer be practicing, so it’s important to verify their current status.
End-of-Life Doula Schools
Before you consider a death doula school, please volunteer with a local hospice provider as a “companion volunteer” to gain experience with strangers who are dying, as well as with family and staff dynamics. The author also recommends reading the article Economic rant: The death doula crisis we aren’t talking enough about, as most death doula schools do not emphasize that being a death doula is a calling rather than a career.
The following are end-of-life (aka death doula) schools for those interested in becoming an end-of-life doula:
Compassion Crossing Academy: Although it isn’t a dedicated death-doula school, it offers unique classes that can help death doulas expand their practice. It serves as an important resource for individuals looking to deepen their understanding and grow in this meaningful profession.
Remember that there is no official accrediting body for end-of-life doula programs. Certification simply shows you’ve completed an unaccredited course and received a certificate of completion. It’s advisable to have discovery sessions with any death doula school you’re considering — even if it isn’t listed here — to see if it meets your needs. Also, ask questions and reach out to references, such as former students, to assess whether the school provided a solid foundation for launching your own death doula practice.
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