Referral Inquiry Case

The referral inquiry to admission process for hospice organizations is the lifeblood of their ability to serve more people, grow, and give the gift of hospice! How organizations convert referrals to hospice care is essential to steady and reliable growth. Those organizations that have a clear mission, vision, and set of values that drive their philosophy around access are usually most successful. Unfortunately, most hospices do not have a written policy and procedure for access in place to drive solid structures and processes that lead to superior results. In other words, we leave hospice appropriate patients behind because they presented us with an obstacle.

Why would you spend one more dollar to make your phone ring any more than it already is if you cannot convert the business that is presenting? It is amazing how many hospices do not pay attention to this important growth element. The reasons for this are numerous:

  1. Most organizations do not truly understand the anatomy of the referral inquiry to admission process.
  2. The intake process is viewed as a gathering of information and verification function and not fully integrated into the fabric of the organization.
  3. Fragmentation between staff that answers the phone, especially on the weekend and after-hours, scheduling not only for an admission but first-responders to inquiry calls.
  4. A passive approach to a referral inquiry call = “let us know when you are ready” as opposed to “would 2 or 4 work to stop by?” Listening to their story, fears, concerns, all their families’ dynamics and then suggesting interventions to assist with those obstacles.
  5. The eligibility process is inconsistent and isn’t a real process. We ask admissions nurses when you have a complex patient, if you could choose one of your medical directors to work with on a case like this – which one would it be? They almost always identify one of the physicians – and the answer should be that our physicians consistently evaluate patients for eligibility in the same consistent process.
  6. There is not a sense of urgency!

Years ago, we worked with a mid-sized hospice organization that offered Hospice, Palliative Care, and Private Duty services. The CEO of the organization called us asking for help to develop an access center to address the six issues sighted above. Each one of these service lines had their own intake process.  When referral inquiry calls came into the organization, if there was not a clear idea of what service line should handle the call, the ability to serve fell in between the cracks. Instead of immediately sending someone to talk with the family to determine what service would best meet their needs, the opportunity to serve was lost. The three service lines were also very siloed. The sharing of resources rarely occurred. This cumbersome arrangement led to many waits. I hate the word wait. But in these situations, a great deal of waiting was going on. There was no inherent sense of urgency. This specific scenario is too common. Whether you strictly provide hospice services or other services, the analogy of “first to bedside wins” is a key component to a successful growth strategy.

When we work with hospices to improve their referral inquiry to admission process and increase their conversion rates, we start by assessing the structures and processes currently in place. The five areas assessed are below:

The autonomy of the referral inquiry/intake process consists of these elements.

  1. Capturing ALL referral inquiries that present to your organization. Do you know, not believe or hope, that you are capturing every inquiry that presents? Does your hospice have an operating definition of what a “referral inquiry” is? Not just a professional referral.
  2. First-to-bedside-wins!! Building capacity and first-responder abilities. Demonstrating a strong sense of urgency! Capacity can be increased without adding FTE!!
  3. Eligibility process. Preventing single-points-of-failures.
  4. Building and working a superior 90-day pending list. A well-developed 90-day pending list is a salesperson’s best friend and a way to obtain an admission NOW!
  5. Organizational collective wisdom and commitment to the process. Hospice organizations use an interdisciplinary team to care for our patients and families. Why don’t we use an organizational team approach to eliminate barriers preventing people from receiving the care they need?

So where to start? Truly understand your current reality in the areas referenced above. First, complete or commission a Mystery Shopper program to take stock in how your referral inquiries are being handled. We have completed several mystery shopping projects for hospice companies, and it is amazing how much potential business is being lost because of not having a specific protocol in place. The objective here is to widen the top of the referral funnel and assist all the people that touch your organization. If your hospice received a call from someone asking about the hospice benefit, would you consider that a referral inquiry? The answer should be yes! People do not sit around wondering about their hospice benefit unless there is something going on in their home. It is up to the hospice company to start a respectfully proactive process to determine how we can assist.

Second, review all your data for the past 12-months to determine:

  • How many referral inquiries are presented to your organization on a daily basis?
  • How many visits per day are made to referral inquiries (both professional and soft referrals)?
  • What is your throughput rate? What percentage of your visits are same day? How many days from time of referral to admission does it take?
  • Do you have the capacity to respond the same day to all your referral inquiries?
  • What is your rolling 90-day referral inquiry to admission rate?

Third, does your organization have a strong sense of urgency? Reviewing some of the data that you gathered will help answer that question. How would you respond to the following:

When a referral inquiry comes into a hospice organization, the primary objective is to immediately (same day) set up a visit to get in front of the patient and/or family. Whether during regular business hours, in the evening, or on the weekend, the person handling the referral inquiry needs to have the ability to make an appointment and have a representative from the hospice make a visit to determine how best to assist. To accomplish this, the organization must build capacity using existing resources. In addition to the intake staff, sales representatives, etc. who can make a visit?  We suggest creating a bullpen of first responders who are available to make a visit. Building a bullpen looks like this: each month, everyone from the Executive Director to the Volunteer Coordinator signs-up for 1 to 2 days per month to be in the bullpen and function as a first responder to make a visit if they are needed. This approach talks to the organization having a healthy culture of growth.

Here is a story of a unique way to build your first responders and bullpen. When I was President of Hospice Care of the West, we had a man named Tom whose wife passed away on our services. Several months after the passing of his wife, he came and met with me and said he wanted to volunteer. Tom went on to say that he did not want to push papers, but would like to be able to interact with families and patients. Tom was a ex-Silicon Valley Executive. He presented very well and was a very intelligent man. I spoke to my Chief Clinical Officer and Director of Volunteers to ask if we could train Tom to be a first responder. They thought it was a good idea and after we had legal sign off, we trained Tom and he turned out to be an outstanding representative for our hospice. Tom connected immediately with the families he visited because of his own personal story. Tom worked about 10 days per month and he made a significant difference in our ability to provide same-day visits.

Fourth, is your admission and eligibility process a best practice? In other words, is your eligibility process just that: a process as opposed to an individual making decisions on eligibility? If your eligibility process is not well thought out with key structures in place to support it, you are vulnerable to single points of failure. A process that is driven more by an individual’s own opinions and not a set of eligibility processes can be dangerous. In one hospice I worked for, there was an eligibility committee in place that reviewed all admissions that were occurring. The eligibility committee was made up of a Medical Director, Chief Clinical Officer and the Admissions Nurse who was performing that admission. With any questionable eligibility concerns, the Eligibility Committee would come together to discuss the admission and determine how to approach it.

Other aspects of the admission process to assess are:

  1. What is the length of time it takes to complete a full admission? Best practice is between 3-4 hours when using technology accelerators and a training process for admission nurses that will assist them to be efficient.
  2. What does your admission packet look like? Is it a clean, well put together booklet? Or a folder with loose papers? Many organizations want to include everything in their admission packet, but you should carefully review everything in your packet to ensure they all serve a particular purpose. This is an admission, not a time to present other pieces of information. Patients and families are overwhelmed to begin with.

The fifth element is my favorite and the one that holds the most potential for growing your census! Having a workflow for a 90-day pending list in place. A pending list is made up of all those referral inquiries that do not admit within 24-hours. The only referral inquiries that do not make the pending list are:

  1. We receive a referral inquiry, and the patient dies before we get there. A sin!
  2. The referral inquiry lives outside the service area.
  3. There is an administrative reason not to accept the referral.
  4. The patient and/or family threaten bodily harm if we follow-up.

Every other referral inquiry that does not admit within 24-hours goes on to the pending list. Even a referral inquiry that selects another hospice. In this case we would give the family a few weeks to experience the other hospice and then make a courtesy call that would go like this: “Hello, this is XZY Hospice, and we received a referral several weeks ago regarding your interest in hospice. I am calling to make sure you have all you need” The family will respond one of three ways:

  1. “Oh my god, I made a mistake. I am unhappy with the current service. They are not doing what they said they would do.” This is specifically most likely to happen if the hospice is hospital owned. In this case, we tell the family we would be happy to stop by and talk with them about their options:  “Would 2 or 4 this afternoon be comfortable with you to have a representative stop by and talk with you”
  2. They respond that all is well and the hospice is great. In this case, we would remove this patient from the pending list.
  3. The patient has passed and we offer our condolences.

Following are the typical barriers that prevent an immediate admission and the counter measures to employ.

The Intake Coordinator functions as that of an air-traffic controller of the pending list and has the responsibility for managing that list. They assure the counter measures for the barriers are being addressed. The Intake Coordinator does not do all the follow-up, but rather assures actions to eliminate the barriers that are occurring. This person also keeps track of the progress of all the people on the pending list.

The last key element is that of drawing upon the collective wisdom of the organization to eliminate barriers and assist in any way possible to facilitate an admission. In doing so, the organization takes on the ability to create a culture of growth. Here are a few examples of how to accomplish this:

  1. Each morning, the Intake Coordinator holds a brief group meeting to review all the referral inquiries received the past 24-hours. Let’s say 5 referral inquiries occurred and 3 of these referrals were admitted. Celebrate those admissions! Then ask what the barrier(s) are for those referral inquiries that did not admit and execute a plan of actions on what steps will be taken to eliminate those. Draw upon the collective wisdom of the organization.
  2. Each Friday, hold a group meeting to review everyone on the pending list. Review the barriers and determine what the appropriate next steps would be.
  3. Every day at 4:00 pm the Intake Coordinator sends out a group text to people in the organization and asks, “Has anyone today talked with someone about hospice?”  The purpose is to grow the pending list and capture people we can assist and give the gift of hospice.

It is those organizations that strive to improve and install these key elements to the referral inquiry to admission process that excel at serving more people, growing, and giving the gift of hospice.

Here is a case study that demonstrates potential results.

Case Study

This is an opportunity statement for a hospice with a census of 105 and the benefits that will result from improving the referral inquiry to admission process.

The Why

The ability to increase XYZ Hospice’s referral inquiry to admission process is the most direct way to serve more people, improve census and profitability. This is because you are focusing on people who have already touched the organization as opposed to looking for a new referral. By strengthening the organization’s skillsets, structures, and processes to convert people who already have a health challenge occurring, allow an immediate ability to serve more people, grow, and strengthen financial performance.

A quick review of XYZ Hospice’s referral inquiry to admission process showed many opportunities for improvement. For example, several mystery shopping calls demonstrated the system is underperforming and calls were not captured and potential ability to serve was lost. The pending list was not being worked to the degree possible. There was a lack of capacity to achieve steady same-day-admissions.

Following is an ROI analysis based on a set of assumptions. XYZ Hospice can adjust the information used based on your own data.


  1. Five incremental admissions per month from improvements in the process. This number is based on performance results we have achieved with other organizations.
  2. LOS of 68 based on average LOS in the State.
  3. A blended reimbursement rate for a routine day of care of $168
  4. Sixty-eight percent direct care cost


5 incremental admissions (month 1) x 68 LOS = 340 days-of-care x $168 = $57,120. 68% direct care cost $38,842 which would generate $18,278 in free cash flow.


  • 5 admissions x 12 mo. = 60 admissions
  • 60 admissions X 68 LOS = 4,080 days of care
  • 4,080 DOC x $168 = $685,440
  • Sixty-eight percent direct care cost = $466,099
  • Free Cash Flow = $219,341.

Should the process improvement only achieve 50% results, the free cash flow would be $109,671.

Other Benefits From Improving This Process

  • Improvement in LOS as patients will be admitted sooner.
  • Increase in referral source, patient and family satisfaction because of improved communication and demonstrated sense of urgency.
  • Use this work as a QAPI project.

Kurt A. Kazanowski, MS RN CHE
Managing Partner
Hospice Advisors
296 S. Main Street, #202
Plymouth, Michigan 48170