Leveraging Technology for Care Coordination in Modern Hospice Agencies

Hospice care succeeds when nurses, social workers, chaplains, physicians, aides, and volunteers all coordinate their actions towards a shared goal: patient and family outcomes. Yet many teams still operate in silos and information can move too slowly, with patients usually suffering the consequences. For hospice leaders, improving care coordination not only strengthens clinical quality outcomes, but also drives financial stability.

In hospice, care coordination is more than a clinical priority. It directly affects regulatory compliance, reimbursement, patient satisfaction, and staff retention. Well-coordinated teams respond faster to patient needs, prevent avoidable hospitalizations, and create a smoother experience for caregivers. With technology, including AI, predictive analytics, and mobile-first EMR for hospice solutions, leaders now have powerful tools to reimagine how teams work together.

This article covers best practices for coordinating care across interdisciplinary teams, while leveraging technology.

Establish a Shared Vision and Care Plan Ownership

Every patient care team member needs to see the patient’s plan of care as their shared roadmap, rather than just another document completed at the IDG meeting and forgotten until next time. High-performing teams assign clear ownership for updating goals and interventions, ensuring that everyone knows who is responsible for what. They standardize documentation language so that orders and interventions translate into measurable actions instead of ambiguous notes.

Best-in-class hospices build a culture where the plan of care drives daily work and is not merely a box to check off for compliance. Hospices should:

• Clarify roles and responsibilities for each team member in executing and updating the plan of care.

• Standardize language and documentation so that goals, interventions, and outcomes are clear and actionable to team members of all backgrounds.
• Engage caregivers and families as partners, not just information recipients, and invite their input early and often.

Improve Communication

Effective care coordination relies on real-time communication. Communication failures remain one of the most common causes of missed visits, medication errors, and patient crises. “Phone tag,” sticky notes, and once-a-week IDG updates signal inefficiency.

Leading hospices adopt best practices such as secure, HIPAA-compliant messaging platforms that allow nurses, aides, and chaplains to share real-time updates. Automation also plays a critical role. Modern EMRs can trigger alerts when a visit is missed, a medication order is updated, or a patient’s condition changes. AI-powered routing engines can analyze these updates and send them directly to the appropriate team members, reducing the burden on office staff to manually track and communicate issues.

Integrate Technology and Data at the Point of Care

Field clinicians often struggle with fragmented systems, requiring multiple logins, or even phone calls to the office, to get patient updates. This wastes time and creates risk. A mobile-first EMR with offline capability eliminates these barriers by giving staff access to the latest information at the bedside.

AI tools further enhance coordination by reviewing charts in the background and flagging incomplete documentation or missing orders before they delay billing. For example, an AI-driven review might detect that a physician signature is missing on a plan of care or that a face-to-face encounter is overdue, allowing the team to correct the issue in real time rather than discovering it weeks later. Predictive analytics can also identify patients at risk for crises, prompting proactive scheduling of visits and adjustments to the plan of care.

Reimagining the Interdisciplinary Group (IDG)

The IDG is often treated as a compliance requirement, but best practices entail optimizing the IDG for care planning, by

• Moving beyond “read-outs.” Dashboards can be used to visualize symptom trends, visit adherence, and family satisfaction scores.
• Leveraging virtual participation to allow busy physicians or other team members to contribute, especially in remote markets.
• Using AI-generated summaries to cut preparation time by pulling in key clinical notes, medications, and outcomes since the last IDG.

When IDGs are dynamic and data-driven, they become more than another meeting and lead to better care coordination.

Solidify Handoffs and Transitions

Care coordination issues frequently arise during transitions, such as admissions, discharges from the hospital to the home, changes in levels of care, or with weekend coverage. Each transition carries risk if critical information gets lost. Standardized handoff procedures and templates reduce this risk by ensuring that every clinician receives the same essential data.

Robotic process automation (RPA) can further streamline these transitions by automatically assessing task completion. Leaders who routinely audit transitions and review outcomes with their teams catch weak points quickly and can prevent repeat errors.

Measure and Act on Coordination KPIs

What gets measured gets managed. High-performing hospices monitor key coordination metrics such as:

• Time from referral to admission
• Timeliness of physician orders and plan of care updates
• Visit adherence to the care plan
• Patient/family satisfaction with communication

These, paired with financial and compliance indicators, such as late NOEs, ADR rates, and days in AR, help paint the full picture of hospice care coordination.  For example, sequential claims held for missing physician signatures can drive up AR days and signal a gap in coordination.

Invest in Training and Change Management

Technology and processes only work if people actually use them. Front-running hospices invest in training and change management. They offer cross-training so that staff understand each other’s roles and documentation requirements, breaking down silos between disciplines. They deliver micro-learning in short, mobile-friendly formats that fit naturally into the workday rather than relying on long, annual trainings.

Encourage Innovation and Agility

To enhance care coordination, hospice leaders model and encourage innovative and agile mindsets. They

• Pilot new tools (AI, predictive analytics, remote patient monitoring) in small teams, then scale based on results.
• Build cross-functional committees to evaluate technology and workflow improvements.
• Stay future-focused by anticipating CMS changes (e.g., VBID, quality reporting) and aligning processes early.

Thriving hospices integrate technology not as an afterthought, but as a core capability.

The Takeaway

Hospice care coordination across interdisciplinary teams requires timely communication, standardized processes, and effective use of technology. When hospice teams have real-time data, clear roles, and seamless workflows, patients receive better care, staff experience less burnout, and organizations see stronger performance on financial and quality metrics. Hospice leaders can deploy best practices to build the infrastructure, technological, cultural, and operational to make care coordination a competitive advantage.

Related blogs:

1. What are the key performance indicators for hospice agencies?
2. What are the top strategies to grow your hospice referrals?
3. What are the crucial skills for home health and hospice hiring?
4. Selecting the best caregiver for end-of-life care