For over thirteen years I oversaw business development for the largest home health and hospice organization in New Jersey — the second-largest not-for-profit home health and hospice organization in the country, handling roughly a million home visits a year.
I built the hospital partnerships and led teams who sit at bedsides arranging care before a patient goes home. I worked alongside case managers, discharge planners, and population health teams across the state, and I sat in the meetings where referrals were counted, readmissions were explained, outcomes were graded, and root-cause analysis was performed.
I’m not a nurse, and I’ve never claimed to be. What I am is someone who spent his career at the seam where a hospital hands a patient back to their family — and who knows exactly where that seam splits.
Here’s what I couldn’t stop seeing.
Hospice almost always came too late
Not sometimes. Almost always.
The median hospice stay in this country is about 17 to 18 days. Researchers who study it say you need something closer to 90 for the benefit to mean much of anything. Over one in four patients die within a week of enrolling.
And patients referred to hospice from a hospital have the shortest stays of anyone — a median of about nine days.
Some die within hours.
The part almost no family knows
One piece of how hospitals are graded is a mortality index: how many patients die in their care, adjusted for how sick those patients were. It’s a serious number. It affects reputation, rankings, and reimbursement.
Most versions of that measure exclude patients who are on hospice when they die.
Not “weight them differently.” Exclude them.
This isn’t a conspiracy theory and it isn’t hidden — it’s written into the measure specifications. Clinical journals have raised the concern openly: excluding hospice deaths can create pressure to enroll patients in hospice at the very end, and some have proposed tracking the time between hospice enrollment and death specifically to catch it.
That safeguard exists because the problem is real.
I watched it from the referral side for over thirteen years. Patients who were plainly hospice-appropriate weeks earlier weren’t offered it — and then were enrolled in the final hours, when it was far too late to give the family any of what hospice is actually for.
There’s a second, quieter reason, and it’s almost more human: hospitals are also measured on patient experience. And telling a family that their mother is dying does not produce a good survey score.
Almost everyone I worked with was good at their job and meant well — it’s what brought them to health care to begin with. But incentives are quiet things, and they bend behavior long before anyone notices they’re bending.
What it costs a family
Everything.
Hospice at three, six or nine days is a formality — a form signed in a hallway while everyone is already grieving.
Hospice at ninety days is pain that’s actually managed. A nurse who knows your mother’s name. A chaplain, if you want one. A home health aide so you can rest and sleep. A social worker who tells you what the paperwork means. Time to say the things people spend the rest of their lives wishing they’d said.
That gap — between nine days and ninety — is the largest single difference between a good death and a bad one in this country. And nobody is going to explain it to you at the bedside.
They also didn’t tell you the rest of it. That an advance directive is the only reason anyone can act on wishes you never wrote down. That “we accept Medicare” means far less than you think. That the confident promise an agency makes is sometimes thinner on staffing than it sounds.
The families who suffered most weren’t unlucky. They were the ones nobody told how it worked.
I got tired of watching it. That’s the whole reason this exists.
What this site is
Most of what you’ll find online about aging at home is one of two things. It’s a law firm or an agency with something to sell, dressed up as advice. Or it’s a nonprofit brochure that explains a concept beautifully and then stops right before the part you actually needed — how to do it, who has to sign it, what it costs, what happens Monday morning.
This site is the part that comes after.
What Medicare will and won’t send to the house, said plainly, including the parts that are bad news. How much help she actually needs — the same assessment a visiting nurse runs, free, with nothing stored and nobody calling you. And, as this site grows: what in-home care actually costs, which questions make an agency uncomfortable, and how to make the paperwork legal in your state.
How I write it
Everything here cites where it came from: the statute, the CMS data, the peer-reviewed research. Every page carries the date it was last verified against that source — not merely the date someone last touched it. When a law changes, I say so on the page, in an active changelog.
I am not a lawyer and I am not a physician. Nothing on this site is legal or medical advice, and it can’t replace the clinicians and attorneys actually involved in your situation. Use it to ask them better questions.
What I have is thirteen years of watching how this system actually behaves — and no reason to be diplomatic about it.
Read how I review and update content →
The business, plainly
Aging at Home Support is operated by OnPoint Associates LLC, in New Jersey.
Some links on this site may earn a commission, and this site may earn a fee for connecting families with private-duty home care providers. When that happens, it’s disclosed on the page where it appears — not buried down here where nobody reads it. And one rule is absolute: no fee, ever, for a referral to any service paid for by Medicare, Medicaid, TRICARE, or the VA.
Every tool and every form on this site is free, and always will be. Nothing you do here is tracked back to you. The care needs checklist runs entirely in your browser; those answers never reach me.
If I get something wrong, tell me and I’ll fix it — visibly, with a date. Questions or corrections about the site itself? Email me at mark@agingathomesupport.com or call 732-216-8607. (For questions about your own situation, the care needs checklist is the best place to start.)
Sources for the claims on this page
- MedPAC, Report to the Congress — median hospice length of stay
- NHPCO Facts and Figures — hospice length of stay and short-stay proportion
- Peer-reviewed research on hospice length of stay by referral source (hospital-referred median ≈ 9 days)
- CMS Hospital Compare mortality measure specifications — hospice exclusion criteria
- The Hospitalist — on mortality-measure exclusions and the pressure they can create
Last verified: 29 July 2026 · Next review: 29 July 2027
Interpretations of incentive structures on this page are my own, drawn from thirteen years working inside the referral system, and are labeled as such. No hospital, health system, or individual is accused of misconduct. See our disclaimers.