Values in Care

    Data & Research Hub

    A research workspace, every source attached, spanning healthcare-system context, palliative and hospice evidence, health equity, policy models, spiritual care, and evidence coverage. These are evidence domains within Values in Care, not the definition of the product itself.

    Evidence snapshot last updated: August 30, 2026. Source dates, populations, and methods vary by item.

    Visualizations are for education, research context, and review. Population statistics and program rules do not provide individualized clinical guidance, and a resolving citation does not by itself prove claim-to-source fidelity.

    For clinicians and care teams

    Values in Care can support you by:

    • Offering quick, faith-and-practice overviews for family conversations
    • Providing patient-friendly explainers to share in portals or handouts
    • Surfacing myths and fears you can address directly at the bedside

    Care Program Tracker

    Public care programs most relevant to serious illness, dementia, and end-stage organ disease. Source: CMS / CMMI program pages.

    GUIDE · Guiding an Improved Dementia Experience Model

    CMMI · Jul 2024 → Jun 2032

    ACTIVE

    Eligibility: Medicare-enrolled providers serving FFS beneficiaries with dementia and their unpaid caregivers.

    ACO REACH · ACO Realizing Equity, Access, and Community Health

    CMMI · 2023 → 2026

    SUNSETTING

    Eligibility: Provider-led ACOs with strong primary care and equity-focused designs.

    MSSP · Medicare Shared Savings Program

    CMS · 2012 → ongoing

    ACTIVE

    Eligibility: ACOs participating in MSSP BASIC or ENHANCED tracks.

    KCC · Kidney Care Choices

    CMMI · 2022 → 2027

    ACTIVE

    Eligibility: Nephrologists and dialysis facilities caring for CKD stage 4-5 and ESRD patients.

    TEAM · Transforming Episode Accountability Model

    CMMI · Jan 2026 → Dec 2030

    ACTIVE

    Eligibility: Selected acute-care hospitals (mandatory in chosen CBSAs) for five surgical episodes.

    CCBHC · Certified Community Behavioral Health Clinics

    SAMHSA / CMS · 2017 → ongoing (Medicaid demo expanding)

    ACTIVE

    Eligibility: Clinics certified to deliver a defined scope of mental-health and SUD services, including 24/7 crisis care.

    MCP · Making Care Primary

    CMMI · Jul 2024 → Jun 2025

    ENDED

    Eligibility: Primary-care organizations in eight participating states; three progressive tracks.

    HHVBP · Expanded Home Health Value-Based Purchasing Model

    CMS · 2023 → ongoing

    ACTIVE

    Eligibility: All Medicare-certified home health agencies in the 50 states, DC, and territories.

    Access & Penetration

    How widely available serious-illness care is, and how late patients reach it.

    94%

    U.S. palliative-care penetration

    Share of U.S. hospitals with 300+ beds reporting a palliative-care team, per CAPC's most recent National Palliative Care Registry data.

    For families: Most large hospitals have a palliative-care team you can ask for by name, even on day one of admission.

    For clinicians: Reliable access in large centers; gaps remain in smaller and rural hospitals. Track local referral patterns.

    For organizations: Penetration is a coverage proxy, not a quality measure. Pair it with staffing ratios and consult volume per 1,000 admissions.

    Final week common

    Hospice length-of-stay: short stays

    A meaningful share of Medicare hospice decedents enroll only in the final week of life, too short for full benefit.

    For families: Earlier conversations about hospice often mean more days of support at home, not fewer.

    For clinicians: Late referrals shorten the runway for symptom control, caregiver training, and goals-of-care alignment.

    For organizations: Short-stay rate is a key utilization signal; pair with median LOS and live-discharge rate when benchmarking.

    Equity Intelligence

    Disparities by race/ethnicity, rurality, and language, from NHPCO and AHRQ primary reports.

    Lower for Black & Hispanic decedents

    Hospice use disparity by race

    Medicare hospice enrollment among Black and Hispanic decedents has historically trailed enrollment among White decedents.

    For families: If your family belongs to a racial or ethnic minority, ask early about hospice and palliative care. Referrals are often delayed.

    For clinicians: Examine your own referral patterns; standardized triggers reduce variation.

    For organizations: Stratify enrollment, LOS, and live-discharge rates by race/ethnicity and language preference.

    Persistent gap

    Rural serious-illness care access

    AHRQ's National Healthcare Quality and Disparities Report identifies rural access to specialty palliative care as a persistent gap.

    For families: If you live rurally, telehealth palliative consults are increasingly available. Ask your team.

    For clinicians: Hybrid (in-person + telehealth) consult models can extend reach without dedicated FTE.

    For organizations: Workforce planning should include cross-coverage agreements and telepalliative arrangements.

    County-level ACS estimates

    Insurance coverage, mapped locally

    The American Community Survey publishes county-level health-insurance coverage estimates, making coverage gaps visible where care is actually sought.

    For families: Coverage shapes what serious-illness care costs out of pocket. Ask about eligibility and financial counseling early, not at the first bill.

    For clinicians: Know your county's coverage picture; uninsured patients present later and need financial navigation alongside clinical referral.

    For organizations: Pair referral data with local ACS coverage estimates to see where cost, not preference, is driving late enrollment.

    Model-based local estimates

    Chronic-condition burden by county

    CDC PLACES publishes model-based county, place, tract, and ZCTA estimates of chronic-condition prevalence: the local backdrop against which serious-illness needs arise.

    For families: Local prevalence is context, never prediction: it says what a community carries, not what any person has or wants.

    For clinicians: Use PLACES to anticipate comorbidity patterns in your catchment when planning palliative capacity.

    For organizations: PLACES gives every US county the same denominator for planning. Pair it with utilization data to find under-served pockets.

    HPSA maps, three disciplines

    Clinician-shortage designations

    HRSA designates primary-care, dental, and mental-health shortage areas: the federal map of where the workforce a care plan assumes may not exist.

    For families: If specialists are scarce where you live, ask what can be done by phone, video, or a visiting team instead of assuming travel.

    For clinicians: Check whether your patient's county carries an HPSA designation before building a plan that assumes local specialty follow-up.

    For organizations: HPSA status drives federal placement and loan-repayment programs. Align palliative workforce asks with existing designations.

    Workforce Capacity

    Specialty supply vs. demand from HRSA workforce projections.

    Shortage

    U.S. hospice & palliative medicine workforce

    HRSA workforce analyses project sustained shortages of specialty hospice and palliative medicine clinicians relative to need.

    For families: Specialist palliative-care availability varies widely. Primary teams can deliver many core elements with training.

    For clinicians: Primary palliative-care skill-building (CAPC, VitalTalk) extends reach without specialist FTE.

    For organizations: Workforce modeling should pair specialty supply with primary palliative-care training adoption.

    Global Context

    Cross-country signals from WHO on palliative-care need and access.

    ≈56.8M

    People needing palliative care each year

    WHO estimates 56.8M people need palliative care each year, including 25.7M in their last year of life. About 14% receive it.

    For families: Access to comfort-focused care varies enormously by country and region. Advocacy matters.

    For clinicians: Global need is concentrated in LMICs where opioid availability and trained workforce are limited.

    For organizations: International benchmarking helps frame domestic policy debates on coverage and workforce.

    Responsible AI Governance

    The guidance governing decision-support, ambient documentation, and predictive mortality models at the bedside.

    Six core principles

    WHO guidance on AI ethics & governance for health

    WHO's 2021 guidance names six principles for AI in health: autonomy, human well-being and safety, transparency, accountability, inclusiveness and equity, and responsive, sustainable AI.

    For families: If an AI tool is used in your care, you can ask what it does, how it was tested, and who is accountable for its output.

    For clinicians: Document AI-assisted recommendations alongside your own clinical reasoning; never let a model carry the final say in goals-of-care discussions.

    For organizations: Map vendor AI claims to the WHO principles before procurement; align with the NIST AI RMF for operational risk controls.

    AI RMF 1.0 + Generative AI Profile

    NIST AI Risk Management Framework

    The NIST AI RMF 1.0 (2023) and its Generative AI Profile (NIST AI 600-1, 2024) provide a voluntary risk-management framework U.S. health systems are increasingly adopting for clinical AI.

    For families: U.S. regulators expect AI used in care to be tested, monitored, and governed, not deployed and forgotten.

    For clinicians: Ask your vendor which AI RMF functions (govern, map, measure, manage) they have evidence for before relying on a tool clinically.

    For organizations: Use the AI RMF as the spine of an AI governance policy; pair with WHO principles for ethical framing.

    Multistakeholder assurance

    Coalition for Health AI: assurance standards

    CHAI publishes assurance standards and a model card framework adopted by major U.S. health systems to evaluate clinical AI tools.

    For families: Many large hospitals belong to coalitions that vet AI tools before they reach the bedside.

    For clinicians: Request a CHAI-style model card for any predictive model embedded in your EHR, including mortality and deterioration scores.

    For organizations: Adopt CHAI assurance reporting as a procurement gate alongside HIPAA, NIST, and WHO controls.

    Device & Biotech Oversight

    Regulatory ground for AI-as-device, equipment, and therapies that intersect with serious-illness care.

    Risk-based pathway

    FDA oversight of Software as a Medical Device

    FDA's Good Machine Learning Practice guiding principles (jointly with Health Canada and the UK MHRA) and the Predetermined Change Control Plan guidance frame how AI/ML medical software is cleared and updated.

    For families: Some software in your care is regulated as a medical device. That means FDA reviewed it before it shipped.

    For clinicians: Check whether the AI tool you're using is FDA-cleared, what its intended use is, and whether it has a PCCP for safe updates.

    For organizations: Map your AI inventory to FDA SaMD classifications; pair with NIST AI RMF for residual operational risk.

    International standard

    Medical device risk management: ISO 14971

    ISO 14971 is the recognized international standard for application of risk management to medical devices, referenced by FDA and EMA.

    For families: Manufacturers must follow a structured risk-management process before a device reaches patients.

    For clinicians: When evaluating a device, ask the manufacturer how ISO 14971 was applied, especially for AI-enabled and connected devices.

    For organizations: Procurement contracts can require ISO 14971 documentation as a baseline.

    What's Changing in 2026

    Program dates and policy changes to watch this year, each cited to its source.

    GUIDE Model enters its second performance year

    CMMI's dementia-care model continues with expanded participation and the respite benefit available to caregivers of beneficiaries with dementia.

    HOPE assessment is the active hospice quality instrument

    Medicare-certified hospices submit HOPE data, including patient-reported symptom impact and preferences.

    Global palliative-care need and access

    Published global estimates describe serious health-related suffering, palliative-care need, and access. Interpret them within the population, year, and methodology of each source.

    56.8M

    Need palliative care

    25.7M

    In last year of life

    61M

    Serious health suffering

    14%

    Currently receive care

    Global Serious Health-Related Suffering (Millions)

    74% increase from 1990 to 2021

    1990 is derived from the cited 74% increase and the 2021 figure; the source states the change and the endpoint, not a year-by-year series.

    U.S. hospice utilization

    The figures below describe Medicare hospice use in the cited 2022 cohort; they are not current-plan eligibility guidance or estimates for every population.

    Medicare Decedents Receiving Hospice (2022)

    49.1% of Medicare decedents in the cited 2022 cohort received at least one day of hospice care. The complement (50.9%) is 100 minus the cited 49.1%.

    Enrollment in 2022

    1.72M

    Medicare beneficiaries enrolled in hospice care in the cited 2022 data.

    Healthcare-system context

    Medicare, Medicaid, and other payment or delivery models can shape how participating organizations are paid and measured. They do not determine what treatment an individual person should choose, guarantee a particular service, or establish that a Values in Care prompt is reimbursable.

    The cards below are rendered from the same source registry used elsewhere in the Data Hub. Program status, dates, and claims are kept separate from Values in Care's own directional interpretation.

    HOPE

    Hospice Outcomes & Patient Evaluation

    Active
    Performance window
    Oct 2025 → ongoing
    Published scope
    All Medicare-certified hospices (replaces HIS).

    HOPE replaced the Hospice Item Set for Medicare-certified hospices beginning October 1, 2025, with required admission and HOPE Update Visit (HUV) assessments.

    GUIDE

    Guiding an Improved Dementia Experience Model

    Active
    Performance window
    Jul 2024 → Jun 2032
    Published scope
    Medicare-enrolled providers serving FFS beneficiaries with dementia and their unpaid caregivers.

    GUIDE began July 1, 2024 and runs for eight years through June 2032, providing comprehensive dementia care including a per-beneficiary-per-month payment, 24/7 support, and a respite benefit.

    MSSP

    Medicare Shared Savings Program

    Active
    Performance window
    2012 → ongoing
    Published scope
    ACOs participating in MSSP BASIC or ENHANCED tracks.

    The Medicare Shared Savings Program launched in 2012 and remains Medicare’s permanent accountable-care program for participating ACOs; CMS publishes annual performance and savings results.

    ACO REACH

    ACO Realizing Equity, Access, and Community Health

    Sunsetting
    Performance window
    2023 → 2026
    Published scope
    Provider-led ACOs with strong primary care and equity-focused designs.

    ACO REACH performance years are 2023 through 2026; the model advances accountable care with health-equity requirements and capitation options, and 2026 is its final performance year before transition.

    CMS says ACO REACH ends after 2026. Its successor, the voluntary Long-term Enhanced ACO Design (LEAD) Model, is scheduled to run from January 1, 2027 through December 31, 2036.

    KCC

    Kidney Care Choices

    Active
    Performance window
    2022 → 2027
    Published scope
    Nephrologists and dialysis facilities caring for CKD stage 4-5 and ESRD patients.

    Kidney Care Choices launched in 2022; the CKCC options were extended through 2027, while the KCF option ended after 2025. The model tests value-based payment for advanced CKD and ESRD care.

    TEAM

    Transforming Episode Accountability Model

    Active
    Performance window
    Jan 2026 → Dec 2030
    Published scope
    Selected acute-care hospitals (mandatory in chosen CBSAs) for five surgical episodes.

    TEAM is an active mandatory episode-based payment model running January 1, 2026 through December 31, 2030 for selected surgical episodes in chosen CBSAs.

    CCBHC

    Certified Community Behavioral Health Clinics

    Active
    Performance window
    2017 → ongoing (Medicaid demo expanding)
    Published scope
    Clinics certified to deliver a defined scope of mental-health and SUD services, including 24/7 crisis care.

    The federal CCBHC demonstration began in 2017. CCBHCs deliver a defined scope of coordinated mental-health and substance-use services, including crisis services, under federal certification criteria and Medicaid prospective-payment arrangements.

    HHVBP

    Expanded Home Health Value-Based Purchasing Model

    Active
    Performance window
    2023 → ongoing
    Published scope
    All Medicare-certified home health agencies in the 50 states, DC, and territories.

    The Expanded HHVBP Model adjusts Medicare fee-for-service payments to home health agencies based on quality performance, applied nationally starting CY 2023 with the first payment year in CY 2025.

    MCP

    Making Care Primary

    Ended
    Performance window
    Jul 2024 → Jun 2025
    Published scope
    Primary-care organizations in eight participating states; three progressive tracks.

    Making Care Primary launched July 1, 2024 but CMS ended the model early on June 30, 2025. Its original design used three progressive primary-care tracks across eight states.

    What these models can tell you

    They describe program design, participating organizations, reporting requirements, payment structures, and policy timelines. They can help explain the system around a decision.

    What they cannot tell you

    They do not establish a person's values, prove that one care option is preferable, or replace plan-specific coverage information and individualized clinical advice.

    Health equity context

    Population-level inequities can reveal barriers in systems and access. They should not be converted into assumptions about an individual person or community.

    78%

    of people estimated to need palliative care live in low- and middle-income countries, according to the cited global source

    74%

    increase in the cited estimate of global serious health-related suffering from 1990 to 2021

    Equity & Access

    This section deliberately publishes fewer claims than earlier versions. We retain source-bounded findings and expose the remaining review queue rather than turning heterogeneous studies into unsupported group scores or local generalizations.

    Policy-literature signal

    Access inequities affect multiple populations

    A Rutgers policy review summarizes documented palliative- and end-of-life-care inequities affecting historically underserved populations, including racial and ethnic minority groups, LGBTQ+ people, people with learning disabilities, people experiencing homelessness or poverty, people in remote or rural areas, and people in prison. This is a synthesis signal, not a single comparable effect size across those populations.

    Peer-reviewed review

    Black faith communities can be a setting for ACP education

    A 2020 literature review identified five published local advance-care-planning initiatives in Black faith communities. Its implementation themes included faith leadership, trust, cultural competence, use of existing ministries, and attention to health disparities. The review supports those implementation lessons; it does not establish that every church-based program produces the same clinical outcome.

    Read the review
    Program description

    Louisville offers a community-partnership example

    The Center for Health Care Strategies describes a Louisville serious-illness initiative that engaged faith leaders in needs assessment, planning, and community partnerships. We treat it as an implementation example, not an effectiveness trial or proof of a measured outcome.

    Read the program description

    What we are intentionally not claiming

    • No synthetic “barrier score” ranking populations against one another without a transparent, validated methodology.
    • No conversion of a group’s share of hospice users into a population utilization rate unless the source supports that denominator.
    • No local-community superlatives or epidemiologic statistics unless a current, authoritative source is linked to the exact claim.
    • No assumption that race, ethnicity, religion, disability, geography, language, sexual orientation, or another identity predicts an individual person’s care preference.

    These areas need stronger review before we quantify them.

    A reviewer can contribute one source, correct one interpretation, or recommend a better denominator. Review applies only to the specific item reviewed.

    Review this evidence →
    • Native American and Alaska Native hospice access and utilization metrics
    • Rural distance, workforce, and hospice-access measures
    • Language access and interpreter-related decision barriers
    • Disability access, communication support, and caregiver burden
    • LGBTQ+ serious-illness and hospice access
    • Current Southeast Michigan local access and demographic indicators

    Verify hospice providers directly

    For provider-level decisions, use regulator and Medicare tools rather than community generalizations. Values in Care does not rank or endorse local hospice providers.

    Spiritual care as an optional care domain

    Palliative-care frameworks recognize spiritual care as a quality domain. Training, availability, relevance, and desired involvement vary by person and setting.

    • The National Consensus Project Guidelines identify eight domains of quality palliative care; spiritual, religious, and existential aspects are addressed in Domain 5.
    • EAPC materials address education and training for spiritual care in palliative-care practice.
    • Values in Care presents faith, spirituality, and worldview only when a person chooses that context. It does not infer treatment preferences from identity.
    Spiritual-care resources

    Coverage & data transparency

    What this research workspace covers, where current depth is concentrated, and how readers can inspect the source trail.

    Current worldview coverage

    Values in Care currently includes sourced material across 14 faith traditions and worldviews. Much of this evidence base was developed first for serious-illness and end-of-life decisions; it is now treated as one optional contextual layer within the broader product.

    Explore traditions & worldviews

    Data transparency

    Quantitative figures should resolve to a cited source or a disclosed derivation from cited values. Derived quantities are labeled as such. Unsupported quantities, artificial scores, and unresolved estimates should be omitted or clearly marked for review rather than presented as fact.

    View full bibliography

    Key sources & references

    Source-linked records are available throughout the page. The broader bibliography currently contains 254 citation records across the product.

    World Health Organization

    Global palliative-care facts and estimates

    The Lancet Commission

    Serious health-related suffering and access

    NHPCO / National Alliance

    U.S. hospice facts and figures 2024

    National Consensus Project

    Clinical practice guidelines, 4th edition

    European Association for Palliative Care

    Spiritual-care education material

    NJ State Policy Lab / Rutgers

    Palliative-care inequities context

    Download the citation dataset: JSON · CSV · BibTeX · RIS · methodology

    Data integrity statement

    Visualizations on this page use cited public sources or disclosed derivations from cited values. Source resolution, automated validation, and citation presence are useful controls, but they do not substitute for human claim-to-source fidelity review. Where evidence is incomplete or interpretation is required, the safer state is to narrow, label, or omit the claim.

    Evidence snapshot last updated: August 30, 2026. Time-sensitive items require shorter review intervals than evergreen background evidence.

    Values in Care is an independent educational resource. It is not medical advice. For an individual healthcare decision, use appropriate qualified clinicians and other professionals relevant to that decision.