How a Hospice Can Attract Appropriate Referrals Without Compromising Eligibility
Every hospice I have worked with wanted more referrals. Fewer wanted to talk about which referrals. That difference matters more than most growth plans admit.
A referral that turns into an admission for a patient who is not yet eligible is not a win. It becomes a recertification you struggle to support, a live discharge later, or a claim that an auditor questions. Meanwhile, patients who truly need hospice often arrive late. In 2022, the median hospice stay among Medicare decedents was 18 days, so half of those patients received hospice for 18 days or fewer (MedPAC, 2024). Those families miss much of what the benefit can offer.
So the goal is not simply more volume. It is earlier, better matched referrals from partners who understand what hospice eligibility actually looks like.
The two guardrails
Any referral strategy has to live inside two sets of rules.
The first is eligibility. A hospice patient must be certified as terminally ill, meaning a life expectancy of six months or less if the illness runs its normal course, and the certification has to be supported by clinical information in the record (42 CFR 418.22). No marketing plan changes that standard. If your referral sources do not understand it, they will send you patients you cannot admit, or worse, patients you admit and later cannot support.
The second is the federal Anti-Kickback Statute, which prohibits offering or paying anything of value to induce referrals of patients covered by federal health care programs (42 U.S.C. 1320a-7b(b)). Hospices have been warned about this directly. In 1998, the OIG issued a Special Fraud Alert on nursing home arrangements with hospices. Among the suspect practices it described were hospices supplying free staff to do work the facility would otherwise do, offering free or discounted goods to encourage referrals, and trading patient referrals back and forth (OIG, 1998).
I mention this because the strategies that work best happen to be the ones that stay well clear of both lines.
Strategies that bring the right referrals
In my experience, these are the approaches that grow referrals and protect eligibility at the same time. This is the Admission Strategy piece of my ALIGN framework in practice. If you are new to ALIGN, I walk through all five parts in How to Grow a Hospice Without Increasing Compliance Risk.
Teach eligibility, not just hospice
Most referral sources know hospice exists. Fewer know what decline looks like in heart failure, COPD, or dementia, or when it is reasonable to start the conversation. Education for physicians, case managers, and facility staff on disease specific decline and the hospice benefit itself builds trust. It also means the patients they send you are more likely to qualify. Keep the education general and clinical. It should never come bundled with gifts, free services, or anything a facility would otherwise pay for.
Say "not yet" well
Some referred patients will not be eligible today. How you handle that moment shapes the relationship. A clear explanation, a plan to reassess, and a suggestion such as palliative care tells the referral source you made a clinical decision, not a business one. Physicians remember that.
Respond fast and close the loop
Speed is one of the most legitimate advantages a hospice can offer. A same day evaluation for an appropriate patient matters to a hospital discharge planner. So does a follow up call telling them what happened. Referral sources rarely hear back, and the ones who do tend to refer again.
Go where late referrals happen
Given how short many hospice stays are, the best growth often comes from earlier referrals rather than new ones. Oncology, heart failure, and dementia care are good places to start. Patients in those settings are frequently referred in their final days, when hospice can do the least.
Build compliance into the liaison role
Community liaisons should know the eligibility basics and the referral rules as well as clinical staff do. Train them on both, document what they provide to referral sources, and have counsel review how liaisons and any contracted marketers are paid. A liaison who understands eligibility sends your intake team better referrals.
Review before you admit
A consistent clinical review before admission protects everyone. It checks that the referral, the clinical findings, and the certification all tell the same story. It also gives you data on which sources send the most appropriate patients.
What to measure
If referral growth is healthy, a few numbers should move together. I would track these by referral source, every month:
Referral to admission conversion rate
Share of admissions with a stay of seven days or less
Live discharges within the first 180 days
Time from referral to first visit
A source with high volume and a high live discharge rate is not your best partner, even if it looks that way on the census report. A source whose patients arrive earlier and stay appropriately is. I think that one shift in how leaders read their referral data changes the whole conversation.
If you would like to talk through referral strategy or the ALIGN framework for your hospice, you can reach me through the contact page on this site.
About the author
Tonia Barrier, MSN, RN, is the Founder and Principal Consultant of PAC Leadership Solutions and a DNP Executive Leadership candidate at Walden University. She is the former CCO & Compliance Officer of a multistate hospice organization, a trained End of Life Doula, and an HPNA Tennessee State Ambassador. She developed the ALIGN framework to help hospice organizations grow without trading away clinical integrity.
References
Centers for Medicare & Medicaid Services. Hospice Conditions of Participation, 42 CFR 418.22.
Medicare Payment Advisory Commission. (2024). March 2024 Report to the Congress: Medicare Payment Policy, Chapter on hospice services. Summary via National Alliance for Care at Home.
Criminal penalties for acts involving Federal health care programs, 42 U.S.C. 1320a-7b(b).
U.S. Department of Health and Human Services, Office of Inspector General. (1998). Special Fraud Alert: Fraud and Abuse in Nursing Home Arrangements With Hospices. Federal Register, 63(79).
