TL;DR: The hospice referral model is changing. While hospitals still account for 51.9% of hospice admissions, family-initiated referrals and direct consumer search are the fastest-growing channels. Three forces are driving this shift: 63 million Americans now serve as family caregivers (up nearly 50% since 2015), 80%+ of families begin provider searches online, and regulatory changes like CMS's TEAM model are reshaping how hospitals make referral decisions. For independent agencies that have relied on hospital relationships, the message is clear — the agencies that build a direct-to-family digital presence will thrive, and the agencies that don't will lose market share to competitors who meet families where they're already looking.

The Old Model: Hospital Controls the Referral
What's Changing — and Why
The Rise of the Family Decision-Maker
63 Million Caregivers: The Largest Force in Healthcare Decision-Making
How Online Search Disrupts the Hospital Referral Gatekeep
The Medicare Advantage Question: Patient Choice Under Threat?
CMS Policy Signals That Reinforce the Shift
What This Means for Independent Agencies
Building for the Family-First Future
Frequently Asked Questions

The Old Model: Hospital Controls the Referral {#old-model}

For decades, the hospice referral model was simple and hospital-centric. A patient's condition declined. The attending physician or hospitalist made a prognosis assessment. A discharge planner or case manager initiated the referral conversation with the family. The agency that had the strongest relationship with that discharge planner — or in some cases, the agency that was owned by the hospital system itself — got the referral.

In this model, the family had limited agency. They were presented with one or two options by the hospital, often during a moment of crisis, and they chose from what was offered. The hospital functioned as the gatekeeper, and the agency's growth strategy was entirely focused on maintaining relationships with hospital-based referral sources.

The data reflects this legacy: research published in the Journal of Palliative Medicine found that hospitals account for 51.9% of all hospice admissions — more than all other referral sources combined.

But that number has been declining, and the forces driving the decline are structural, not cyclical.

What's Changing — and Why {#whats-changing}

Three simultaneous shifts are eroding the hospital's monopoly on hospice referrals:

1. Family caregivers are more informed and more involved than ever. The sheer number of Americans serving as family caregivers has surged, and these caregivers are increasingly empowered to research and choose providers independently.

2. Online search has democratized provider discovery. Families no longer need a hospital discharge planner to learn about hospice options. A Google search surfaces every provider in their area, complete with reviews, quality ratings, and contact information.

3. Regulatory changes are restructuring hospital incentives. CMS's TEAM model, hospice quality reporting requirements, and the ongoing Medicare Advantage debate are all reshaping how hospitals interact with post-acute providers — and how families access hospice care.

None of these forces will eliminate hospital referrals entirely. Hospitals will remain the largest single referral source for years to come. But the proportion is shifting, and agencies that build only for the hospital channel are building on a shrinking foundation.

The Rise of the Family Decision-Maker {#family-decision-maker}

The hospice decision is almost never made by the patient alone. In most cases, a family member — adult daughter, son, spouse, or other relative — is the primary decision-maker. This person researches options, asks questions, evaluates providers, and ultimately chooses the agency.

Research from MDPI's survey on family caregiver decision-making found that family caregivers play a critical decision support role, assuming functions like gathering information, considering hypothetical scenarios, ensuring shared understanding among family members and clinicians, and facilitating values discussions with the patient.

The caregiver's influence extends throughout the care journey. According to research published in PMC on caregiver roles in discharge preparedness, caregivers who were more involved in emotional support and healthcare needs prior to hospitalization engaged more in ensuring care quality during hospitalization and at discharge — meaning the most engaged caregivers are also the most likely to independently evaluate and choose post-acute providers.

This means your agency's marketing needs to speak directly to the family caregiver — the person doing the research, reading the reviews, and making the call. The discharge planner may still initiate the conversation, but the family member increasingly decides where the referral lands.

63 Million Caregivers: The Largest Force in Healthcare Decision-Making {#caregiver-data}

The scale of family caregiving in the United States has reached a level that makes it one of the largest forces shaping healthcare decisions. Key data from the AARP/NAC Caregiving in the US 2025 report:

| Metric | Data Point | |--------|-----------| | Total U.S. family caregivers | 63 million (1 in 4 adults) | | Growth since 2015 | Nearly 50% increase | | Caregivers helping older adults (2022) | 24.1 million (up from 18.2M in 2011) | | Average hours of care per week | 23.7 hours | | Caregivers who help with medical/nursing tasks | 60%+ |

These 63 million caregivers are not passive participants in healthcare. They're managing medications, coordinating with physicians, navigating insurance, and increasingly — researching and choosing care providers online.

The Health Affairs Journal published research confirming that the number of family caregivers helping older U.S. adults increased from 18 million to 24 million between 2011 and 2022 — a 33% increase in just over a decade. This growth shows no signs of slowing as the Baby Boomer generation ages.

The marketing implication: Your website, your Google Business Profile, your reviews, and your directory listings are being evaluated not by hospital administrators — but by exhausted, emotionally overwhelmed family members who are trying to find the best care for someone they love. Content that acknowledges their experience, answers their specific questions, and makes it easy to take the next step will outperform clinical jargon and institutional messaging every time.

How Online Search Disrupts the Hospital Referral Gatekeep {#online-disruption}

Before the internet, a family's knowledge of available hospice providers was limited to what the hospital told them, what their physician recommended, and what they heard through word of mouth. The hospital's role as information gatekeeper was almost total.

Today, a family can search "hospice near me" on their phone and instantly see every provider in their area — with reviews, ratings, photos, and quality scores. They can compare agencies on Medicare Care Compare, read Google reviews, visit agency websites, and check directories like NDPAP — all before the discharge planner mentions a single name.

This changes the referral dynamic in three ways:

1. Families verify hospital recommendations. When a discharge planner suggests an agency, the family no longer just accepts it. They Google the agency name, read the reviews, and check the star rating. If the recommended agency has 3 reviews and a 3.5-star average, and a competitor has 40 reviews and a 4.8-star average, the family may override the hospital recommendation.

2. Families discover alternatives. Even when a hospital gives a specific referral, families now see other options in their search results. An agency that wasn't on the hospital's preferred list can still win the family's business if it has a stronger digital presence.

3. Some families bypass the hospital entirely. In cases where the family recognizes the need for hospice before the hospital initiates a formal referral — which is increasingly common as caregiver education improves — the family may contact an agency directly without any hospital involvement. These are direct-to-consumer referrals, and they're growing.

According to Hospice News reporting, physician offices already outpaced other referral sources in growth rate, and community-based referrals (which include family-initiated online searches) rose during and after the pandemic. The trend hasn't reversed.

The Medicare Advantage Question: Patient Choice Under Threat? {#medicare-advantage}

One of the most significant policy debates in hospice care involves whether hospice should be "carved in" to Medicare Advantage plans. Currently, hospice is carved out — meaning that even MA enrollees receive hospice benefits through Original Medicare, which allows them to choose any Medicare-certified hospice provider without network restrictions or prior authorization.

As of 2025, 54% of Medicare beneficiaries are enrolled in Medicare Advantage — about 31.4 million people. If hospice were carved into MA, those beneficiaries would potentially face network limitations, meaning MA plans could restrict which hospice agencies they could use.

Recent developments:

In May 2025, Rep. David Schweikert introduced the Medicare Advantage Reform Act, proposing that MA plans pay for hospice care
The National Alliance for Care at Home and other industry groups strongly opposed the carve-in, arguing it would undermine patient choice, create network restrictions, and fragment the hospice experience
CMS's hospice component of the Value-Based Insurance Design (VBID) model ended at the close of 2024 due to operational challenges — too few plans participated and too few beneficiaries were served
In November 2025, a bipartisan Senate letter expressed strong support for keeping hospice under Original Medicare

What this means for referral patterns: The carve-in debate matters because it directly affects whether families retain the power to choose their own hospice provider. Under the current carve-out, families can select any Medicare-certified agency regardless of their MA plan. If a carve-in occurs, MA plans could create narrow networks that funnel patients to preferred providers — likely larger national chains — reducing the role of family choice and independent agencies.

For independent agencies, the best protection against both outcomes (carve-in or continued carve-out) is building direct relationships with families. If families know your name and trust your brand before they need hospice, they're more likely to request your agency specifically — regardless of how the referral is structured.

CMS Policy Signals That Reinforce the Shift {#cms-policy-signals}

Several CMS policy developments signal a broader move toward family-centered, quality-driven care:

Hospice Quality Reporting Program (HQRP) expansion. CMS continues to expand public quality reporting for hospice, including CAHPS survey data that lets families compare providers on family satisfaction metrics. As more quality data becomes public, families gain more tools to make informed choices independent of hospital recommendations.

Caregiver training reimbursement. Starting in January 2025, CMS expanded billing codes for caregiver training, allowing compensation for teaching family caregivers direct care skills including wound care, infection control, and behavior management. This investment in caregiver capability further empowers families as active participants in care decisions.

TEAM model impact. As discussed in The Single-Hospital Dependency Problem, CMS's mandatory TEAM bundled payment model changes how hospitals evaluate and refer to post-acute providers. Hospitals will narrow preferred provider lists based on quality data, which simultaneously concentrates hospital referrals among fewer agencies and increases the importance of non-hospital referral channels for agencies not selected.

The net effect: CMS is building an ecosystem where quality data is public, family caregivers are supported and empowered, and hospital referral patterns are driven by outcomes rather than relationships. This ecosystem rewards agencies with strong quality metrics AND strong family-facing digital presence.

What This Means for Independent Agencies {#implications}

The shift from hospital-driven to family-driven referrals creates both risk and opportunity for independent post-acute agencies:

The risk: Agencies that have built their entire business on one or two hospital relationships are watching their competitive moat erode. As families gain more information and more agency in the decision, the hospital discharge planner's recommendation becomes one input among many rather than the determining factor.

The opportunity: Independent agencies are often better positioned than national chains to build authentic connections with families and communities. A locally owned hospice with strong Google reviews, community involvement, and a compassionate digital presence can outperform a national chain that has institutional contracts but no local identity.

The strategic priority: Invest in the channels that families control:

Google Business Profile — This is your digital storefront. Optimize it fully. See Google Business Profile for Hospice and Home Health.
Google reviews — Social proof that no hospital contract can provide. See Google Reviews Without Violating HIPAA.
Website content — Answer the questions families are asking. Become the trusted information source before they need your services.
Directory presence — Be on every platform families use. Claim your NDPAP listing as a starting point.
Community visibility — Speaking engagements, grief support groups, health fairs — these build the name recognition that makes families request your agency by name.
Referral source diversification — Don't abandon hospital relationships, but systematically build physician, SNF, and community channels. See The Single-Hospital Dependency Problem for the full strategy.

Building for the Family-First Future {#building-future}

The agencies that will lead in 2027 and beyond are the ones that start building family-facing infrastructure now. Here's a practical framework:

| Investment | Timeline | Impact | |-----------|----------|--------| | Optimize Google Business Profile | Week 1 | Immediate visibility improvement in local search | | Launch HIPAA-compliant review building program | Months 1–3 | Steady review growth, improved local pack ranking | | Publish 5–10 informational pages on your website | Months 2–4 | Organic search traffic from family queries | | Claim and optimize directory listings (NDPAP, Healthgrades, Caring.com) | Month 1 | Multi-platform visibility, NAP consistency | | Begin community education events (monthly) | Month 2+ | Brand awareness, community referrals | | Track referral sources by channel monthly | Ongoing | Data-driven resource allocation |

The competitive reality: In most local markets, the barrier to digital dominance for hospice is remarkably low. If your competitors have 3 Google reviews and an unclaimed Google Business Profile (which is common), a focused 6-month effort can put your agency in the #1 position in local search results — capturing the families who would have gone to whoever showed up first.

The shift from hospital-driven to family-driven referrals isn't a prediction. It's already happening. The only question is whether your agency is positioned to benefit.

Frequently Asked Questions {#faq}

Does this mean hospital referrals are going away?

No. Hospitals will remain the single largest referral source for hospice for the foreseeable future. What's changing is that hospital referrals are declining as a percentage of total admissions, while family-initiated and community-based referrals are growing. The shift is gradual but persistent — it doesn't require you to abandon hospital relationships, but it does require you to build additional channels.

How do I market directly to families without violating HIPAA?

Direct-to-family marketing is actually the most HIPAA-safe channel because it involves no interaction with patients' protected health information. Your website, Google Business Profile, directory listings, and community events are all public-facing and carry no PHI risk. The compliance challenges arise when you use patient records to generate marketing outreach, not when families find you independently.

Will Medicare Advantage carve-in hurt independent agencies?

If a carve-in occurs, it would likely hurt independent agencies that lack the scale to negotiate MA network contracts. However, the current political landscape shows strong bipartisan opposition to a carve-in, and the failed VBID pilot suggests CMS is cautious about this approach. Building direct family relationships is the best protection regardless — families who know and trust your agency by name are more likely to request you specifically, even within a network structure.

My agency has been hospital-dependent for 20 years and it's worked fine. Why change now?

Because the environment has changed around you. Hospital M&A is accelerating (16 hospice deals closed in Q4 2025 alone), hospital systems are launching their own post-acute services, TEAM is changing hospital referral incentives, and families are researching providers online before accepting hospital recommendations. An approach that worked for 20 years is not guaranteed to work for the next 5.

Sources

The families who need your care are already searching online. Your NDPAP listing connects your agency directly with those families — no hospital gatekeeper, no network restriction, no middleman. Claim your NDPAP listing →

The Referral Pipeline Is Shifting Online: What the Data Shows About Hospital-Driven vs. Family-Driven Referrals

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