Future-Proofing Care: The Challenges We Face in Hospice and Palliative Care | Part One

In Part One of this forward-looking series, Chris Comeaux unpacks the foundational challenges shaping the future of hospice and palliative care. Drawing from nearly a decade of strategic research and collaboration with healthcare leaders, he introduces a powerful framework built around eight core challenges that every organization must navigate.  From intensifying competition to shifting reimbursement models, this conversation equips leaders with a clearer lens to anticipate disruption and respond with intention.

What emerges is not just a list of problems—but a strategic roadmap.  Chris explores how “hypercompetition” is reshaping referral patterns, how financial pressures demand organizational agility, and why workforce shortages require a complete rethinking of care delivery.  Throughout the episode, the emphasis remains on proactive leadership: understanding the forces at play, asking better questions, and positioning organizations to thrive—not just survive—in a rapidly evolving landscape.

Ultimately, this episode serves as a call for healthcare leaders, nonprofit executives, and hospice professionals to rethink traditional models.  By embracing innovation, diversifying services, and aligning care with what patients truly want, organizations can future-proof their mission and remain deeply relevant in the years ahead.  

Key Takeaways

• The future of hospice and palliative care is shaped by eight major challenges, including competition, reimbursement, workforce, and demographic shifts.  
• Hypercompetition is accelerating, including both direct competitors and “substitution” models that can divert referrals.  
• Reimbursement pressures are expected to tighten, requiring organizations to become more efficient while exploring new revenue models.  
• Workforce shortages are a structural reality, demanding an “outside-in” approach that aligns staffing with evolving patient needs.  
• Long-term success depends on organizational ambidexterity—the ability to optimize current operations while innovating new care models simultaneously.  

If you’re leading in hospice, healthcare, or the nonprofit space, this conversation is just the beginning.  Subscribe to the podcast, in Part Two, where we go deeper into solutions and strategies you can apply immediately. Share this episode with your leadership team, and start the conversation: Are we truly prepared for what’s ahead?

Co-Host:
Cordt Kassner, PhD, Publisher of Hospice & Palliative Care Today & CEO and Founder of Hospice Analytics 

Host:
Chris Comeaux, President / CEO of Teleios, Author of The Anatomy of Leadership

Teleios Collaborative Network   /   https://www.teleioscn.org/tcntalkspodcast

Transcript

Leadership With Cause And Purpose

Melody King 0:00

Everything rises and falls on leadership. The ability to lead well is fueled by living your cause and purpose. This podcast will equip you with the tools to do just that. Live and lead with cause and purpose. And now, author of the book The Anatomy of Leadership and our host, Chris Comeaux.

Chris Comeaux 0:22

Hello and welcome. I'm excited today, but maybe I'll say something different. I'm nervous today. I have my good friend Court Kastner with me, and we're going to reverse role. So first off, welcome, Cordt. Good to have you.

Cordt Kassner 0:34

Chris, thanks so much. It's great to be with you.

How The Eight Challenges Emerged

Building A Hospice Future Council

Chris Comeaux 0:36

Yeah, thanks for agreeing to do this. And so I've been wanting to do this podcast for quite a while. I did one similar, um, I think it was either four or five years ago, where I talked about some interesting research we were doing. You participated with us, which I'm going to talk about that in a second. But the reason why I'm nervous, I'm always excited when I get to hang out with you, but I'm nervous because I've got to do most of the talking and the answering of the questions. I'm thinking, I wonder if this is how my guests feel all the time. Probably so. Probably so. But thanks for agreeing to do this. Our listeners may be like, wait a minute, this is not the beginning of the month, the top news stories of the month. So, no, so we're actually going to talk about something. So let me talk about like how we got here. In the early days of TCN, which by the way, we just uh ended our eighth year, celebrated our birthday on March 23rd. So by the time our listeners are listening to this, it's not too far off. Um, but March 23rd is always a great time to remember. So now we're going into our ninth year. So this is about almost nine years old. In the early days of TCN, we I have a really good friend who mentored me in strategic planning. She's actually got a degree in strategic planning. And she taught us, I'll call it a very uh sophisticated version of a SWAT or a more advanced version of a SWAT. And so we used that framework and then we kept adding new organizations to TCN. So the pool of brilliant CEOs increased as we were using this tool. And many of you have been in those boardrooms or retreats before, and you got the big tablet sheets that you stick on the wall. And we kept using those questions and kept getting these great answers of what are the challenges that we're facing? In fact, I was thinking this morning as I was preparing a couple years ago, my sabbatical, a good friend and I went on a camping trip. Well, if you're going on that kind of trip, you know, you prepare. But what you really want to know is what are the challenges that we're going to face? Well, that is exactly what we were after with this process that we were running with our CEOs, the meeting that we uh were doing it within, we call it our visioneering meeting, which is a really cool term. And so we kept having those sheets of paper, we kept putting them in an electronic tool, and we kept kept distilling it. We kept distilling it. And then finally, probably four years ago, maybe five, we came to the conclusion, the first version is there's seven challenges that are facing every hospice and powder care program. One of them was so meaty or just like big, it ended up birthing another. So then we ended up with eight challenges. And so those eight challenges, I'm gonna list them right now, which is hypercompetition, reimbursement and financial, workforce, patient and family demographic shifts, regulatory and political, technology, speed of change, re-culture, that's all one, and then the mental health crisis, which by the way, that one was parked under the patient-family demographics. But the more we kept wrestling with it, it kind of birthed its own because it's so big onto its own. So we had these great challenges. If you're going on a journey, if you're doing a strategic plan, you can have these great ideas of where you're going. But if you don't know the challenges you're going to face, you can have a plan that is not practical. So we knew that we were on to something with this like challenges. In fact, Cordt, the other thing I see frequently, modern healthcare and others, at the end of each year, they'll survey CEOs and say, hey, what are the things that concern you? This is really what this is, but it's actually much more research-based. And it feels very true. We presented this to many boards, organizations. In fact, I'm uh reason why I want to do this podcast is I really want this to be a resource for boards, especially nonprofit boards, as they're like, well, where do we need to navigate our organization to? Well, wait a minute. What are the challenges we're going to face? So two years ago, and I approach you as many of um national experts, uh, I have a good friend. So on this podcast, frequently I talk about Dr. Lee Thayer. He was just an incredible mentor in my life. He was Stephen Covey's mentor. Well, a peer of his, he who he actually used to teach with, is a guy named Bruce Peters. And I utilize Bruce as as a mentor quite a bit since Dr. Thayer has passed on back in 2020. And Bruce was talking to me about this concept called a future council. And I'm like, that's cool. Tell me more about what is a future council. And the more he shared with me, I'm like, we can do this. We have brilliant people within the hospices that we work with. They have amazing boards of directors. Like my own board chair was actually the CFO for a Fortune 50 company. And so we have these amazing resources in our boards. And I'm blessed to know amazing people like Court Kastner. What if we took our own TCN team, member C-suite teams, board of board of directors, folks that want to participate, recruit some national experts like the Court Casters of the world, and let's bring them together. And we're going to call these future councils, but they're going to be themed by these challenges: hyper competition, reimbursement, workforce, patient family demographics, regulatory political technology, speed of change, reculture, mental health crisis. So last year, Cordt, you joined us and we had several meetings where we wrestled with these challenges. And that's what I'd like to talk about today. I'd like this to be a resource to hospice and powdered care programs. Now, I mean, we can't unpack all of this in an hour podcast, but I want to give them the framework so they could use it in their own organizations because our heart and passion is especially community-based nonprofit hospices, to navigate and thrive into the future. And if you know the challenges you're going to face, better chance you can navigate it.

Cordt Kassner 6:18

Well, it's so cool that you took the time and effort because these it is not intuitive to sit down and identify what are the major challenges, those those mega themes that that are impacting hospice and palliative care and serious illness. But you took that challenge on. Tell us more about it. If you were to walk us briefly through each of the eight challenges, what did you find?

Competition Becomes Opportunity

Chris Comeaux 7:03

Yeah, so I'll talk about the process a little bit, then I'll tell you what we found. And so, and of course, you got a front row seat to this, but at a minimum we had three meetings. Many of the groups probably had five. I think we all told had I think 1800 hours, man and woman hours throughout the network. Wow. And what we first did is we unpacked the challenge. Like, well, what do you mean by um hyper competition? And then what we ended up is getting a much more, I'll say, extrapolated definition of the challenge. In fact, I'll read the summary. Then we would create like an executive summary on each of those challenges. And that's what I'd like to pay forward to our listeners. Like, what do you mean by hyper competition? Here's the executive summary. And then the beautiful thing, and and we'll we'll preserve this for our Tilios members, uh, but what where we ended up landing the plane is what are the strategies and solutions that we can actually deploy given the challenge? Um, and then you were part of this amazing day last November of 2025 where we brought all of that work together. It was a huge day. It probably felt like drinking through a huge fire hose because you were we were reporting out 1,800 hours of work amongst all these amazing group of people that we're actually working with. But now we have these beautiful, I'll call them toolboxes of strategies. And here's a really cool thing, and I think you influenced us on this, Cord. As we started this, and you know, you were part of the technology group, which you know, talk about futuristic, right? And artificial intelligence, there were some awesome conversations. And we said, you know, if we list a bunch of strategies and solutions, they could be antiquated in literally 24 or 36 months because things are moving so quickly. And we thought, well, we don't want to do this work that then gets antiquated in just you know a short period of time. And then someone said, Hey, what if we also codify the questions that we need to keep asking? And I think that was like a huge add-on. So the definition of done for each of our groups was the strategies we could deploy and what are the questions that we need to still keep asking. So let me kind of back up then and I'll take one at a time, Cordt. And if you want to ask a follow-up question, but let's take competition first off. And by the way, for our listeners, I know some of you are just auditorial listeners, about half, but the other half of people are on our YouTube. I this is when you really want to probably start subscribing to YouTube, because we're actually going to put a slide. Um, Jeff Hafner, our executive producer, is going to add a slide for each of these. And the reason why it's it's I'll read it, but the reason why the slides are important, Cordt, you were part of this too. As humans, we have to communicate in words. But the reality is we think in terms of pictures. Every one of these groups came out with some awesome visuals that, like you think about anytime we're in a meeting right now, we have AI that captures the discussion. Wouldn't it be cool if some future version of AI would also actually draw pictures based upon what we actually discussed? This group did, or our future councils did, and there's as much wisdom in those pictures as there actually is in the words that we actually use. I won't belabor it, um, but at least kind of know if you, again, I hope many of our listeners will start subscribing to our YouTube channel and see the visuals because there's some really cool wisdom in the picture. So the first one was hyper competition. And what I love about a couple of these groups, they even reframed the title of the challenge. This is one. Instead of calling it hyper competition, they basically said competition. And the first line was from challenge to opportunity. Um, we had an amazing national expert, um, Carla Davis, who actually we did a podcast earlier this year, and she kind of admonished us in a good way that where you guys see hyper competition, a lot of other people are seeing opportunity. In fact, the Chinese symbol for crisis and opportunity is actually the same symbol. So if you're seeing the visual, you actually see that. So this is what the group came to the conclusion about the challenge. Competition is accelerating at a great rate. This is direct competition in the form of other hospices in your market as well as upstream substitutions. So there's competition and substitution competition, and I'll explain that in a second, all of which make the current rate of referrals coming into your hospice empowered care program and how you get those referrals severely challenged in the future. And in the midst of all these challenges are incredible opportunities, some of which are rediscovering the basics and the fundamentals of this brilliant care model and new innovations that can be deployed. There is so much wisdom packed into what I just said. Just one of which people may go, what the hell do you mean by substitutions? Um, years ago, I think it was either a video or it was a case study, and it was talking about this concept of substitution competition. And one of the examples was, Cordt, let's say you and I are like in the breakfast food market. Say you and I had a franchise of a McDonald's or a Chick-fil-A, and we're making breakfast food. But there's a juicing store that opens up very close by, and people are like, I'm gonna start eating healthier, and they go and get a like, let's say a smoothie in the morning time. All of a sudden, our our breakfast sandwiches aren't selling because people are getting healthy smoothies. That's an example of substitution competition. And you go, okay, that's interesting, but what would be a corollary in our world? Well, a pace program would be an example of substitution competition, where a pace in your market may get people on that hospice and powdered care space. So it's a substitution for what you do. Now, the cool thing in our world in healthcare, there's a term called frenemies and cooperation. In each of those challenges, there's amazing opportunity. There are amazing ways that you could partner with people. So let me stop there because there's so much cool stuff. Again, this is why like the challenge is just one part, almost the headwaters, of all this other great thought and strategies and solutions and opportunities that you could deploy.

Cordt Kassner 13:08

Well, I'm I'm curious if the group was leaning towards a recommendation for hospices to stay in their lane to be the very best in the world at the services they're providing for hospice? Or were they suggesting maybe hospices should diversify and go into palliative care and pays and home base, you know, more volunteers and and not just volunteers, but the non-duty non-medical private duty, you know, lines of you know, service lines that are available. Should should hospices stay focused on what they're doing, or should they try to take over or collaborate with those upstream partners? Uh how does that work?

Chris Comeaux 13:55

This is where attorneys drive you crazy because they say it depends, but there's wisdom in there because there's so much knowledge. It depends, but as a broad brush answer to your question, yes, you diversification is pretty critical because as you look at this challenge, um, I think one of the early visuals, we had a picture of a big, beautiful stream, a river. And basically we said that river is going to fracture into multiple tributaries, which is gonna get into one of our other challenges. And as those tributaries of reimbursement fracture, how you get referrals will change. And if you don't set up, like picture a grist mill and some of those old beautiful rivers, and all of a sudden the river moves, if you don't set up grist mills on those other rivers, you may find that your referrals trickle very almost nothing. So diversification is a smart strategy. Why I say it depends, I wouldn't paint that broadly broadly if I was working with a hospice program, because we'd look at, okay, where are you strong today? If if your hospice program is not even close to world class, you could actually harm yourself by diversifying. It's almost like I don't even have this one thing down, and now I'm going to try to do four and five things. So it is a little bit more complicated. This is why we have a Teleios team. We'd love to work with people to navigate that. But as a broad answer, yes, if you don't diversify, you may find the volume of people you get to care for today severely diminished as this challenge plays out into the future.

Cordt Kassner 15:19

And for competition, for that challenge, were there questions they were posing for the future to keep in mind for the next future council?

Chris Comeaux 15:29

Yeah, 100%. I think we had, on average, I think we had somewhere between 15, and we ended up stratifying the question categories into questions that have a shorter, like we need to answer these more immediately. And then we had some questions that were like broader. So here's a perfect example, Cord. Will the V bid, the value-based insurance design carvin, come back around? That's a question that actually had some immediacy to it, because if it does, it really does change how quickly that river may divert. And so, again, for each of these challenges, we had at least on average about 10 to 15 questions like that. And then as we further stratified them, we saw you you got to answer these questions pretty quickly, or we could keep wrestling with these other questions over the course of time. So, to get to the others, what do you think? Can we go to the next one?

Reimbursement Shrinks And Splinters

Cordt Kassner 16:18

Yeah, is competition was the first challenge. What was the second one?

Chris Comeaux 16:21

Yeah, reimbursement. And so um, so reimbursement, where is it going and when? Which kind of gets to your question that you just asked. So obviously, the competition and the reimbursement as all these challenges, probably if we graphed them, they'd be like a Venn diagram with multiple circles kind of on top of each other. Reimbursement is more than likely going to shrink. Now, many people go, well, how the hell do you know that? Always laugh that it's called the centers for Medicare and Medicaid innovation because you could look at what they did to the rest of healthcare, and it's probably coming to a theater near you or coming to a healthcare entity near you. We know home health and hospitals and skilled nursing facility, there are a multitude of regulatory and other things that ultimately resulted in a per unit reimbursement less than you get today. And so you just take the hope tool, for example. Is the hope tool gonna pay us more money? Well, it depends. Depends upon what your scores look like. But hope is one of many examples where on a per day basis, they're gonna probably reimburse us less as you go more into value-based care, et cetera. Now, um, actually, we have a podcast with Robin Heffernan about the Medicare Advantage uh Carve-in, about the V-BID Carving. And she makes a great point that even in value-based care, theoretically, you could get paid more because you could take on more risk. So I get there's an exception to some of the things I'm talking about, but it's generally based upon how we're reimbursed today, it's probably gonna be on a per unit basis less. And there are a multitude of ways that the government will accomplish that. Oh, by the way, we're gonna go bankrupt by 2033, which was baked into this challenge. Um, if the government doesn't do something about that, we could just look at the shutdown. Was it 2018? I think with the first time that we got the budget neutrality thing implemented. If you remember, what the government said was we can't make a decision, so we're just gonna penalize everybody across the board. Picture 2033, oh crap, Medicare is gonna go bankrupt. Can we be adults and actually redesign the whole thing? Or are we just gonna go ahead and penalize everybody and just do an across the board cut? That's the type of stuff that we're concerned about that's baked into that challenge. Therefore, it's imperative that we maximize reimbursement via multiple strategies while simultaneously figuring out how to be more lean and efficient and innovating into the future with new service lines via build by our partner. And then we end up finding out there's a term. You know, when I was young, my mom used to say, can you walk and chew gum at the same time? There's actually a corporate term called organizational ambidexterity. It goes to your thing earlier, Court, about, hey, is this about just doing hospice or is it about diversifying? The actual term or the the sophisticated word is called organizational ambidexterity. Can you keep improving the current business while you innovate into new businesses? And if you can't, you're not very or you're not very ambidextrious as an organization, hence the term organizational ambidexterity. And then if those of us or those are listeners that are on YouTube, they can see on the visual, um, there's several books that have been written about this, but Jim Collins wrote a book, How the Mighty Fall. And the reason why we included that is if you just have your current business and it gets less and less and less on a day-to-day basis as far as reimbursement, you kind of follow that bell-shaped curve down, which is why you want organizational ambidexterity. You want to extend that curve while you're developing new businesses. So all of that wisdom came out of that challenge.

Cordt Kassner 19:54

So please tell me the picture they came up with was more than a dollar sign.

Solving Workforce With Outside-In Design

Chris Comeaux 19:58

Yeah, it was no actually, there never was a dollar sign, which is so cool because it just shows, I mean, just there's such incredible people we get to work with in the hospice and powder cure space, and they're so stinking smart. Like they may not know there was a term called organizational ambidexterity. That was our job as the team to go back and do the research after these meetings. We come back and go, hey, you know that thing you were describing? There's a term for that. It's called organizational ambidexterity. And now we have a term. Now it's part of our lexicon going forward. So you want me to go to the next one? Because this is the third, it's the one everybody would go, no kidding, man. Like if you ask people, go, hey, if you haven't done the research and you would guess the challenges that we face, I guarantee you is the first one they all come up with in healthcare workforce. And so, due to the silver tsunami, now I'm going to chastise myself for a second. We we've had a great podcast last year with the John A. Hartford Foundation, Marcus Escobedo, who is brilliant. And he chastised me. He's like, you need to quit using that term. I'm like, why? If you're standing on a shore and a silver tsunami is coming, there ain't a damn thing you could do about it. You just stand on the shore and look at the crash. I'm like, that's brilliant reframing. But yet, in the context of this challenge, it does at least tell you there's this huge wave of elderly people that are aging that are coming upon us. So, due to the silver tsunami, as well as shifting demographics within that age demographic, there will be more demand for healthcare workers than there will be of supply. It's a math problem. Will there be enough people to serve? And no matter which way you RNs, social workers, CNAs, physicians, there are different numerical shortages no matter which way you spin it. You may go, well, then what the hell do we do about it? Which we'll we'll get to that a little bit when we get to the prescription at the end. So we must really understand what the customer wants? Again, so many brilliant people we worked with on this court. Like, if you just keep doing what you've done, you're gonna get what you've always got. And if you get what you always got at a time, When you have a workforce shortage, you are screwed. So they came back and said, let's go back to one. What does the customer want? And oh, by the way, it's going to get to another one of our challenges. The customer is changing as we speak. The greatest generation has been our customer. The baby boomers are going to want something different. Well, why would we ask what the customer wants? Because if you don't shift what the customer wants, you may waste workforce that are not deployed where you need it. It's about understanding your mission and redeploying your workforce to meet what the customer truly wants. So rethink and reimagine our work and how we do it, then design the team, recruit the people, and create the work in new and innovative ways to navigate the workforce challenge, going from outside in rather than inside out. That's a huge piece of wisdom. And having grown up 30 years in this work, sometimes we're too inside out as opposed to outside in. We just look at, well, I need more nurses. Where am I gonna get well? Wait a minute, how are we deploying our nurses? Um, we just need more social workers. How are we deploying our social workers? What are they focused on? Because they may be focused on things that have been important to the greatest generation that might shift with our shifting uh customer. So there's so much cool wisdom that came out of this group.

Cordt Kassner 23:23

You know, I find it I find it interesting in context of the competition and even the reimbursement, the first two challenges that you've discussed. In terms of workforce, when we think of particularly substitute competition, I think most hospices are are thinking about this from a highly specialized provision of service when if we're thinking from the outside in, like what is it the patients really want? They really appreciate the CNA. So why aren't we expanding more into the non-medical private duty and say under the hospice benefit, you get these services. However, if you need help, want help, walking the dog, making the meal, you know, whatever, have some light housekeeping, we also offer a private duty non-medical to just help with those day-to-day needs. And like I think that would be really well received from the patient and family perspective. But rather than then generalizing the services, we we tend to think about the the specialized. Um but what questions came out of the workforce challenge? Questions for the future.

What Baby Boomers Actually Want

Chris Comeaux 24:40

Yeah, actually, some of the one you're just alluding to. In fact, it's a little bit of a rabbit trail separately. Every year we actually repurpose one of those visioneering meetings specifically for marketing, because it's not been something as nonprofit hospices that we've done well. In fact, one of our first speakers we brought in was Miriam Grant, who worked for CoverGirl, who worked in this amazing marketing space and then became a pallicare nurse practitioner. And if you guys, I'm not stealing a um, this is not a spoiler alert. If you hear Miriam present one time, stop with the old hands. We show a picture of these old hands, and that's our marketing piece because she's chastising us that we've actually created this brilliant model, but our marketing sucks. And so through that, um, we actually did a survey and because we've got the baby boomers. So, what do the baby boomers want? And Court, you just nailed it. They want more of that housekeeping. Now, you're alluding to one thing that's a diversification strategy, which is private duty, which is it depends. I wouldn't recommend that across the board. We've got a lot of operational expertise to help people determine if that's a good thing for them. But guess what? If you go back to the COPs, that actually is within our actual COPs of hospice. That like light housekeeping is part of, so maybe we might, that's a perfect example of can we reread the hospice benefit and rediscover some things that have always been there? And there was a question that it was worded so brilliantly, but basically said that is how can we keep looking with fresh eyes that there may be shifts in the model that the customer is actually asking for, we've lost touch with that we could redeploy. Maybe it's not this huge medicalized model, not detracting from having great physicians involved in nursing, but instead of just continually doubling down on those resources, are there other resources that the customer is asking for that well, oh well, we don't do that. Well, the customer's asking for it. Yeah, so that was a huge question.

Part Two Preview

Cordt Kassner 26:35

So that's three. What's number four?

Jeff Haffner 26:37

Don't miss part two of this episode coming this Friday.