Hospice Quality 5-Star Rating: What It Measures and How to Improve Performance

Families choosing hospice care often need to make decisions during an emotional and time-sensitive period. Medicare Care Compare gives them several ways to compare hospice providers, including publicly reported quality measures and a five-star caregiver rating.

For hospice organizations, that star rating can be easy to misinterpret. It does not combine all CMS quality measures into a single score, nor does it directly reflect all aspects of clinical care. Understanding what contributes to the rating is the first step toward using it meaningfully.

This article explains how the hospice quality 5-star rating is calculated, what the underlying survey measures, why ratings can change, and how hospice teams can use the data to identify areas for improvement.

What Is the Hospice Quality 5-Star Rating?

On Medicare Care Compare, the hospice quality 5-star rating refers specifically to the Family Caregiver Survey Rating derived from the CAHPS Hospice Survey.¹ CMS converts caregiver responses into a one-to-five-star scale, with more stars representing more favorable reported experiences.

That distinction is important because hospice providers report several other quality measures to CMS that are displayed separately.

Hospice Care Compare currently includes information from three primary sources within the Hospice Quality Reporting Program:

• Hospice Outcomes and Patient Evaluation data

• Medicare claims

• The CAHPS Hospice Survey²

Claims-based measures, such as the Hospice Care Index and Hospice Visits in the Last Days of Life, can provide information on patterns of care, while assessment-based measures capture other aspects of hospice services. Those results are not combined with CAHPS data to create the caregiver star rating.²

As a result, a hospice can perform well on one set of measures and less favorably on another. The star rating should therefore be viewed as a focused measure of the family caregiver experience, rather than a single summary score for the hospice’s entire quality program.

The CAHPS Hospice Survey is completed by a family member or friend after the death of a patient who received hospice care. It asks about areas such as communication, timely help, symptom support, respect, caregiver instruction, and emotional support.¹ These responses form the foundation for the publicly reported caregiver rating and related experience measures.

What Does the CAHPS Hospice Survey Measure?

The original CAHPS Hospice Survey produced eight publicly reported measures. A revised survey began with patients who died during the second quarter of 2025. The revised version added a care-preferences measure and changed portions of the communication and caregiver-training measures.³

The survey covers several major areas:

Communication With the Family

Caregivers report how consistently the hospice team:

●      Explained information in an understandable way

●      Listened to questions and concerns

●      Shared updates about the patient’s condition

●      Communicated expected arrival times

Communication failures ripple across the caregiver experience. A nurse may provide clinically sound care, but the family can still report a poor experience if no one explained what symptoms to expect or when the team would return.

Getting Timely Help

The survey asks whether caregivers received help as soon as they needed it, including in the evenings, on weekends, and on holidays.¹

It captures more than telephone response time. Call handling, triage, after-hours staffing, scheduling, and whether caregivers even know whom to contact all feed into it. A caregiver who reaches a staff member quickly but does not receive clear guidance may still feel that help was delayed.

Respect for the Patient

Caregivers report if the hospice team treated the patient with dignity and respect and if staff appeared to care about the patient as a person.¹

Small interactions shape these perceptions, including: 

• How staff introduce themselves

• Their tone

• Attention to a patient’s preferences and cultural background

• The way they communicate during personal care

Emotional and Spiritual Support

The survey asks about the emotional support caregivers received during hospice care and after the patient’s death. It also addresses support for religious or spiritual beliefs.¹

Scores here reflect the whole interdisciplinary team from nurses and social workers to chaplains, bereavement staff, aides, and volunteers. Good documentation and communication across that team keep families from having to repeat their wishes.

Help With Pain and Other Symptoms

Caregivers report how well the hospice helped address pain, difficulty breathing, constipation, anxiety, and sadness.¹

These results capture how the caregiver perceived symptom support rather than clinical assessment of symptom severity. A family may remember symptoms as poorly managed simply because no one explained the treatment plan, how fast it should work, or what to do if things got worse.

Training the Family to Provide Care

Caregivers are asked if the hospice team gave them the instruction needed to care for the patient. Topics have included pain medication, breathing problems, restlessness, agitation, and medication side effects. The revised survey uses a broader question about teaching caregivers how to address the patient’s care needs.³

Teaching should be specific and repeated as the situation changes. Written instructions rarely stand on their own; demonstrating a task and asking the caregiver to show it back confirms they can do it when it counts.

Care Preferences

The revised survey includes a measure addressing whether care respected the patient’s wishes and if the hospice team listened to what mattered most to the patient or caregiver.³

It rewards hospices that document goals and share them across the team. Preferences raised at admission should stay visible as the patient’s condition changes.

Rating and Recommendation

Caregivers rate the hospice on a scale from 0 to 10 and indicate how likely they are to recommend it. For the public rating measure, CMS looks at the percentage of caregivers who select the most positive responses. A hospice rating of 9 or 10 is considered the highest response category for the individual rating question.³

How Is the Hospice Quality 5-Star Rating Calculated?

CMS calculates CAHPS Hospice Survey measures using top-box scoring. A top-box score is the percentage of respondents who selected the most favorable response to a question. Examples may include “Always,” “Yes, definitely,” or a rating of 9 or 10, depending on the question.³

Scores are adjusted for factors that could affect how caregivers answer, including survey administration mode and characteristics of the patient and caregiver population. This process, known as case-mix adjustment, is meant to make comparisons between hospices fairer.³

The public star rating converts caregiver survey results into a scale ranging from one to five stars. More stars represent a more favorable caregiver experience.²

Hospices also need enough eligible survey responses for CMS to calculate and publicly display results. A missing rating is not automatically a sign of poor performance; it often just means the hospice did not collect enough completed surveys that period, or qualified for an exemption.

Hospices with at least 50 survey-eligible patient and caregiver pairs during a reference year generally must participate in the CAHPS Hospice Survey to receive their full Medicare Annual Payment Update. Hospices below that threshold may apply for an annual size exemption.¹

Care Compare data also reflects earlier periods rather than current-month performance. Hospice quality data is generally refreshed quarterly, while the caregiver star rating is updated every other quarter.⁴ As a result, operational changes made today may take time to appear in the public rating.

How Hospices Can Work Toward a 5-Star Rating

A five-star rating usually reflects consistent caregiver experiences throughout the full hospice stay. Focusing only on survey reminders or discharge practices will not address issues that began at admission.

A structured improvement plan can start with the steps below:

1. Review Measure-Level Results

The summary rating can identify a performance issue, but measure-level and question-level data help identify what happened.

For example, a lower timely-help score may be related to:

●      Delayed return calls

●      Unclear after-hours instructions

●      Inconsistent escalation procedures

●      Staffing gaps during weekends

●      Caregivers calling the wrong number

●      Slow medication or equipment coordination

Breaking the measure into specific workflow points directs teams toward concrete fixes rather than a vague goal to “improve satisfaction.”

2. Standardize Caregiver Teaching

Caregiver instruction is an ongoing process, not a box to check at admission.

A consistent process may include:

1. Assessing what the caregiver already understands

2. Explaining the task using plain language

3. Demonstrating the task when appropriate

4. Asking the caregiver to explain or show the steps back

5. Providing written or digital reinforcement

6. Documenting what was taught and what requires follow-up

The team can then reinforce the same guidance during later visits and calls.

3. Connect Clinical Care With Communication

Strong clinical care may not lead to a strong caregiver rating when families do not understand the plan.

A patient’s shortness of breath may be treated exactly according to the plan of care, but the caregiver can still feel unsupported if no one explains how fast the medication should work, what to watch for, or when to call again.

Training has to cover the clinical actions and the communication that builds trust.

4. Use Complaints and Calls as Early Signals

After-hours calls, service complaints, medication questions, missed visits, and documentation audits can provide earlier warning signs than public star ratings.

Grouping these events by CAHPS topic turns them into early signals. Repeated medication questions usually point to a caregiver-training gap. Complaints about arrival times suggest a communication problem, and calls about unmanaged symptoms are a cue to review triage, teaching, or follow-up.

Example: Improving Timely-Help Scores

Consider a hospice whose caregiver rating declines from four stars to three stars. Question-level results show lower scores for help during evenings and weekends.

The hospice reviews its call records and finds that calls are usually answered quickly, but caregivers often wait for a second staff member to return the call. Documentation also shows inconsistent guidance about what families should do while waiting.

The organization introduces a standard triage script, defines escalation timeframes, trains staff on symptom-specific instructions, and audits a sample of after-hours calls each week. Managers also review repeat calls within a 24-hour period.

That work targets the experience behind the score, not the score itself.

The hospice quality 5-star rating gives families a quick read on caregiver experiences, but it is only one input. Hospices should weigh it against the individual CAHPS measures, claims-based data, assessment measures, complaints, call patterns, and their own care outcomes.

The work starts by identifying where caregiver expectations and actual care diverge. Closing those gaps, through clearer communication, faster support, respect, and practical teaching, is what leaves families with an experience they remember well after hospice care ends.

References

1. Centers for Medicare & Medicaid Services. “CAHPS Hospice Survey.” https://www.cms.gov/medicare/quality/hospice/cahpsr-hospice-survey

2. Medicare.gov. “Family Caregiver Survey Rating for Hospice Agencies.” https://www.medicare.gov/care-compare/resources/hospice/family-caregiver-survey-rating/

3. Centers for Medicare & Medicaid Services. “Hospice Quality Reporting Program: Current Measures.” https://www.cms.gov/medicare/quality/hospice/current-measures

4. Centers for Medicare & Medicaid Services. “CAHPS Hospice Survey Care Compare Data Refresh Schedule.” https://www.cms.gov/files/document/hqrp-cahps-hospice-survey-care-compare-data-refresh-schedule-fact-sheet-march-2023.pdf

5. Centers for Medicare & Medicaid Services. “Hospice Quality Reporting Program Requirements and Best Practices.” https://www.cms.gov/medicare/quality/hospice/hqrp-requirements-and-best-practices