Home-Based Medical Care and Hospice: Why Continuity and Coordination Matter

When a patient is living with a serious illness, recognizing when hospice may be appropriate is not always straightforward. Changes in condition can happen gradually, particularly for people living with dementia. Families may struggle to understand what those changes mean, and conversations about hospice may be delayed until a crisis makes decisions more urgent.

A recent study published in Health Affairs Scholar examines a potentially important connection: the relationship between home-based medical care and hospice use. The findings raise questions for hospice organizations about continuity of care, relationships with community providers, and how patients and families learn about hospice before they reach a crisis point.

What the Research Found

The study, Closing the Hospice Gap: The Value of Home-Based Medical Care, examined Medicare fee-for-service beneficiaries who died in 2019 and were eligible for home-based medical care before death. The researchers analyzed data from more than 585,000 people, with an average age of 83.5 years. More than half had dementia.

Home-based medical care refers to ongoing medical care delivered in a patient's home or certain residential settings by physicians or advanced practice providers. It is different from hospice care, although the two may serve patients with overlapping needs at different points in the course of an illness.

Researchers found that beneficiaries who received home-based medical care had 34% higher odds of using hospice than those who did not receive this type of care.

The study also examined hospice length of stay. Among patients who enrolled in hospice, those who had received home-based medical care were less likely to have very short stays of one to three days or prolonged stays exceeding 180 days.

These findings are notable because hospice organizations face challenges in helping patients access services at an appropriate time. Some patients enter hospice only in the final days of life, while others remain enrolled for extended periods and may face questions about continued eligibility. Length of stay alone, however, does not tell us whether an individual received appropriate care. The circumstances and needs of each patient matter.

The researchers found similar associations between home-based medical care and hospice use among people with and without dementia. The findings concerning very short hospice stays were particularly relevant to patients with dementia, for whom determining prognosis can be difficult.

The study does not establish that home-based medical care causes higher hospice use or more timely enrollment. It does, however, provide a reason to examine what ongoing relationships between clinicians, patients, and families may contribute.

The Value of Knowing a Patient Over Time

One possible explanation for the findings is continuity.

A clinician who sees a patient regularly over months or years may notice changes that are difficult to recognize during an isolated medical visit. The clinician may understand the patient's usual level of function, know the family's concerns, and have a clearer picture of how the illness is progressing.

That familiarity can create opportunities for conversations about future care before decisions become urgent.

For families, these discussions may take time. They may need to understand what declining function means, what care options are available, and how hospice differs from other services. They may also have concerns about whether choosing hospice means giving up on their loved one.

A trusted clinician who already knows the patient and family may be well positioned to address questions and introduce hospice as an option when it is appropriate.

This may be especially important for people living with dementia. The course of dementia can be unpredictable, and decline may occur over an extended period. Recognizing when a patient may meet hospice eligibility criteria requires clinical judgment and an understanding of the patient's overall condition, not simply a diagnosis.

Ongoing relationships do not eliminate the uncertainty surrounding prognosis. They may, however, provide a stronger foundation for recognizing changes, discussing goals of care, and coordinating the next steps.

What This Means for Hospice Organizations

For hospice leaders, the study points to an opportunity to look beyond the referral itself and examine the relationships that precede it.

Hospice organizations often invest in outreach to physicians, hospitals, nursing homes, and other referral sources. Home-based primary care providers may be another important group to engage, particularly because they care for people whose medical needs make travel to a clinic difficult.

These relationships should involve more than occasional introductions or requests for referrals. They should help community clinicians understand hospice services, the referral process, and how to obtain guidance when a patient's condition changes.

Hospice organizations can start by asking several practical questions.

Do local home-based medical care providers understand when to consider a hospice referral? Clinicians may recognize a patient's decline but remain uncertain about eligibility, the appropriate timing of a referral, or how hospice can support the patient and family. Clear educational resources and accessible communication channels can help address those questions.

Can clinicians easily reach someone at the hospice when they have concerns? A straightforward process for discussing a potential referral or requesting an evaluation can reduce unnecessary friction. It should support clinical assessment rather than encourage referrals for patients who do not meet eligibility requirements.

Are hospice and community providers communicating effectively? With appropriate patient authorization and privacy safeguards, communication can help ensure that relevant information about the patient's condition, goals, and care needs is available when decisions are made. The goal is a coordinated transition when hospice becomes appropriate, not simply a higher referral count.

Are outreach efforts focused on lasting relationships? Hospice leaders can evaluate whether their community partnerships provide meaningful education and communication or consist mainly of periodic marketing contacts. The quality of the relationship may matter as much as the number of providers on a referral list.

These questions are relevant to clinical leaders and administrators, as well as staff responsible for community outreach and business development. Building effective relationships requires coordination across the organization, with a shared understanding that the objective is appropriate access to care.

Coordination Matters, but Eligibility Still Matters

The study should not be interpreted as evidence that earlier hospice enrollment is always better or that longer hospice stays are inherently problematic. Hospice eligibility must be based on the patient's individual clinical circumstances and applicable requirements.

Nor does the research demonstrate that every patient receiving home-based medical care will benefit from hospice. Some patients will continue to need other forms of medical care, and their preferences and goals may change over time.

The study also has limitations. It used Medicare fee-for-service data from 2019, before the COVID-19 pandemic, and its findings may not fully reflect current care delivery. Because it was observational, differences between patients who received home-based medical care and those who did not may help explain some of the results. The researchers could not establish a direct cause-and-effect relationship.

These limitations are important, but they do not diminish the value of examining how different care providers work together.

Looking Beyond the Referral

Hospice care does not begin with a referral form. It begins with a series of decisions, conversations, and observations that help determine when hospice may be appropriate for a patient and family.

The findings from Health Affairs Scholar suggest that home-based medical care may be associated with greater hospice use and fewer extremely short or prolonged hospice stays. One possible explanation is that ongoing relationships give clinicians more opportunities to recognize changes and discuss care options over time.

For hospice organizations, the practical question is how to strengthen those connections. Better communication with home-based medical care providers may help ensure that hospice is considered when appropriate, rather than only after a crisis.

The larger lesson is that access to hospice depends not only on the services a hospice organization provides, but also on how effectively it connects with the broader network of clinicians caring for people with serious illness.

Read the study: Closing the Hospice Gap: The Value of Home-Based Medical Care