Q&A: Carole Fisher, president and CEO of Nathan Adelson Hospice

By Richard N. Velotta

Friday, May 7, 2010 | 3 a.m.

Carole Fisher has spent most of her career in jobs that helped sick people get well. Now, she heads a nonprofit operation that helps terminally ill people die in peace.

Fisher was named president and CEO of Nathan Adelson Hospice in May 2006 after joining the organization a year earlier as executive vice president of planning and administration.

Along the way, she had executive and staff positions with Southwest Medical Associates, Behavioral Healthcare Options, Harmony Healthcare and Bridge Counseling Associates.

When named to the top job for Southern Nevada’s largest hospice organization, Fisher said, “I knew the strong reputation of Nathan Adelson Hospice as an industry leader and the amazing impact the organization was making on end-of-life care. I wanted to be a part of the team, to learn from the best and to provide care for the best.”

But like all nonprofit organizations, there are challenges in the down economy. Fisher talked about those challenges and the operation of Nathan Adelson Hospice with In Business Las Vegas.

IBLV: Most Southern Nevada residents have heard of the Nathan Adelson Hospice, but may not know where it is or how it operates. Give us a thumbnail sketch of the hospice.

Fisher: We’re a not-for-profit hospice organization and we were founded 31 years ago. It was founded by Irwin Molasky, who built the first for-profit Sunrise Hospital. He was very close to the administrator of Sunrise Hospital, and his name was Nathan Adelson. Nate had a horrific death. He died of cancer and it was very painful. Prior to that — I never met Nate — I had heard that he was a fabulous leader. He had a great ability to connect with employees and with patients. He was also an advocate of people who were in pain. He always wanted to make sure that they were helped. Isn’t it ironic that he ended up in pain and died of cancer? When that happened, Irwin and Nathan Adelson’s son, Merv, who is in L.A., said, “Never again should this happen in our community.”

They went to England and learned all about hospice and brought it to our city. It’s a fabulous story. Irwin had donated this land (at Swenson Street and Flamingo Road) to UNLV along with some other acreage. The deal was that you must lease it back to the hospice for $1 a year for 100 years, so here we are. We have two inpatient facilities. One of them is here at Swenson and Flamingo and it has 20 beds. And we have one at Buffalo (Drive) and Cheyenne (Avenue) and that has 14 beds.

One of the things that people think about hospice is that it is a place, but actually it’s a philosophy of care, and we bring that care to our clients. People often refer to our inpatient facilities as “the hospice” and we even get tripped up on that ourselves and refer to it that way. But it’s a philosophy of care. So we go to people’s homes, we go to assisted-living centers, we go to group homes and sometimes we start our care with people in hospitals. So we care for about 350 to 400 patients a day. We expanded out to Pahrump about 10 or 11 years ago, and we have about 75 to 100 patients there. We don’t have an inpatient facility there. (For) most of them we work out of people’s homes, but we have a really good relationship with an assisted-living center there.

How do families in need of hospice care find you?

Most often, a physician or a nurse will start talking with the patient or the family and begin talking about options at the end of life, and hospice is introduced. Sometimes those conversations are really challenging, even for physicians because they are trained to treat and cure, not to stop and comfort. We also do a lot of community awareness. Generally, we are a part of things when the prognosis is six months or less to live. But I need to qualify that a little because we have people who have lived under our care for years and there are those who graduate off service and get well.

How many families do you serve a year? How many can you accommodate at any one time?

We had 2,367 new patients last year and served 2,722 patients in 2009. Since our inception, we have helped more than 44,000 people. The wonderful thing about us is that most people prefer to be at home, so it’s almost unlimited. Sometimes we have a waiting list in the inpatient units so what happens is we’ll start more aggressive care in the hospital and transition it.

How is a decision reached on whether it’s best in the home?

We know that most of our population is seniors, and we know that most seniors want to die in the comfort of their own home. So we make that decision based on a couple of things. If there are caretakers at home to help, if the patient is not needing more intensive medical intervention and we can just comfort them at home, we’ll keep them home. I hear family members say, “You know, I’m in a little over my head here in terms of how to care for this person,” or maybe the pain is more acute or their (patient’s) breathing is not stable, then we’ll bring them in to the inpatient unit. We also take a lot of people from hospitals and bring them into the inpatient units, get them situated, accustomed to our service, get their medications regulated and then we transfer them.

Is there enough hospice capacity in Southern Nevada today?

There are actually about 22 hospices in Southern Nevada. We’re the largest not-for-profit. It’s very, very competitive right now. Do I think there’s a need for more capacity? Absolutely. It’s not that we need another hospice organization, but people like yourself are starting to understand more about hospice and what the benefits are. It’s not just a medical intervention. I know that there are nontraumatic deaths in our community that are going unattended, they’re not receiving hospice care. With all the hospice care in the valley, I’d say there’s about 35 percent penetration in what I would consider the appropriate cases for hospice. So you can see there’s room for improvement.

You said it is “competitive.” How and why is it competitive?

Medicare is the main funding source and Medicare funding is about to decrease. The reimbursement is generous and you could just do the minimum of care. If you do that, there is money to be made and that’s why there are a lot of for-profits in this business. We go above and beyond and we don’t stop at what’s expected or regulated by Medicare, so we do a lot of extras.

Are there Southern California hospice operations that affect Nathan Adelson?

There are hospices all throughout the country, so I would say there are some large chains of hospices, including one here in town that’s part of Odyssey Health Care. Odyssey has some in California, but they don’t necessarily impact us.

Since Las Vegas is notoriously lacking in family support — people might move here, but not their parents or their children — this can be a very lonely place to live and die. Generally, there’s not much extended family. How does that affect the dying experience and do hospice workers in Las Vegas face a more vital role than hospices in other communities where the dying person also is surrounded by family and longtime friends?

What we do to address that is that we have more than 200 volunteers and they do nothing but volunteer their time and energy. They work in a variety of capacities. Whatever they’re interested in doing, we match them up to doing that. Many of them volunteer at the bedside, so it is common that we have volunteers in senior citizen homes who are alone and bring them food and get them to doctor appointments. That’s what’s right about hospice. We really embrace that patient and take a look at all the circumstances and not just focus on the physical. In terms of other communities around the country, I don’t even know how to answer that. In recent years, when the economy was strong, we had an influx of seniors to the community. When their loved one died, they were by themselves.

What kind of difference does it make to the dying person if family and friends are nearby offering support and comfort, as opposed to a hospice worker?

I’d hate to sound judgmental, but if I were dying I would think I would want my family and friends at my bedside. We do find that many are very private about these things. I’ll give you an example. I got very close to a patient who was dying — I get close to many of them — and that patient seemed to wait until everybody was gone to die. That patient was actually in the inpatient unit surrounded by family and friends, but died alone. So I think it’s an individual process for most people.

So do I think it’s impactful if family and friends are there? My guess is it tells the story of that person’s whole life of how they lived their life, if that makes sense. There may be certain situations with alienated children, but that may have been going on for years. So it wouldn’t be a big surprise if that’s how they ended life. I know we do our best to embrace those people and that they’re comforted and that they don’t feel alone. It goes to our vision statement, which is, “No one should end the journey of life alone, afraid or in pain.” So we really strive to perfect that.

How many employees are there and what are some of their job responsibilities?

We’ve got 300 employees. I think Nathan Adelson Hospice is what’s right with health care and I say that because there’s an interdisciplinary approach to taking care of a patient. So we have physicians, nurses, social workers, certified nursing assistants and people in our spiritual care department that work at bedside, people who are trained in bereavement, full-time pharmacists. We have a volunteer coordinator who helps run that volunteer department. We have a human resources department and a finance department. We also have our Bonnie Schreck complimentary therapy program, and that is unique to our community because we do massage, pet therapy, healing touch and lotions and lavender baths and all these extras. (Las Vegas attorney) Frank Schreck and some of his friends fund the whole thing. It’s named for his wife, Bonnie, who was a patient here and died very young several years before I came here. He memorializes her with this wonderful complimentary program.

By definition, many would view this as a depressing place to work. True or untrue?

I don’t think it’s depressing at all. There are times it’s very sad. (Recently) there was a baby that had been on service for about six months, and the pediatric team recently went to the funeral. That was sad, a very sad time for them. But it was also happy for them in the respect that they were really able to help that baby and that family. It was a young teenage mother who had that baby and he had a horrible illness where most of his brain was missing, and my folks really rallied and helped that little boy. Where would that family be without hospice? It can be sad, but I wouldn’t call it depressing and we have a lot of joy. The people who work bedside with our families are amazing, talented people who want to give.

You mentioned Medicare revenue. How else does the hospice meet expenses?

Some private insurance pays for hospice. One of the wonderful things about the Nathan Adelson Hospice is that we never refuse someone because of an inability to pay. So we give away about $1 million a year in free care and that free care is for uninsured and underinsured people. We also have a very strong foundation that supports the hospice. We also have some very generous donors.

The hospice is nonprofit and has a foundation and fundraising to support the operation. How has the economy affected the foundation’s ability to generate funds?

We actually have three companies. We have our hospice, which is a (Internal Revenue Service code) 501(C)(3) nonprofit, we have a foundation which is a 501(C)(3) nonprofit and we have the Center for Compassionate Care, which is a separate company. At the foundation, we have a team that works in donor development, to write grants and we have some events.

That said, when the economy tanked in 2008, we saw a 30 percent decrease, which was pretty horrific for us to see that level of contributions not coming in. It’s very common that we get some kind of donation in the mail every day. It could be $5, it could be $50 and you’ll see in obituaries in the paper that people suggest leaving money to the Nathan Adelson Hospice. But we also have some signature events that we do. Susan Molasky, Irwin’s wife, Jane Schorr and Beth Weinberger are co-chairs for an event called the Flair for Care Fashion Show. It’s an amazing signature event in Las Vegas, a fashion show, and it’s really done well despite the horrible economy. They saw a decrease last year, most definitely. They were only able to raise about a half-million dollars.

We were fortunate that the Lincy Foundation gave us $600,000 last year. That was for uncompensated care and also to support some of our technology because even through we’re not for profit, we are very advanced with some of our technology and what we do with electronic medical systems. We were very proud of our organization last year because we acted very swiftly when the economy tanked. We did a lot to tighten up on our expenses and we did not take any money out of the foundation last year. It’s a privilege to say we accomplished that, but it’s also because of my team.

Did you have to lay people off?

We did do some restructuring through attrition and open positions that I froze, and there were a couple of casualties and it definitely was sad. They weren’t any positions that were bedside, so any nonclinical position was considered, mostly administrative support positions. We did a lot of restructuring. We had a big office suite up on the west side of town where home-case staff could land. There were supplies there. We got rid of that space, saving us about $100,000 a year. We restructured some benefits and we were able to realize some savings out of that. Because our board of trustees supported our senior leadership team and we acted quickly, we were able to weather the storm rather well. We’re managing very tightly again this year. But the foundation is starting to pick up a little bit. A 30 percent drop in donations is huge for us, but we’re starting to see that it’s not as bad right now.

You mentioned the Center for Compassionate Care. What’s that?

It’s a separate company. What we do through the center is counseling and education in the community. So we’re very committed to making sure that people who have bereavement issues — any kind of grief and loss — that we’re helping them. We get some funding from the Susan G. Komen Foundation to help people who are survivors of breast cancer but are in need of emotional support. We also have Camp Mariposa, which is a camp up at Torino Ranch, which is owned by Brett Torino. He’s a very generous man and a supporter of us. He has a ranch that we take our children up to for a week, about 70 children. It’s a time for them to realize they’re not alone. Grief and loss can be a little isolating, a little confusing, so it’s a wonderful opportunity for children to have other children that they can identify with so we do that every year.

How does the hospice measure its performance? Do you meet regularly with families that have undergone the hospice experience?

We do it in a couple of different ways. First, we’re heavily regulated so the state of Nevada has a licensing body called the Bureau of Health and they oversee us in terms of the regulations. We also volunteer to be a part of what’s called the “Joint Commission.” The Joint Commission is a governing body that has a very, very intense accreditation process, and I’m proud to say we’re Joint Commission-accredited. The Veterans Administration also regulates us because a lot of our clients are veterans.

But we do rounding with patients when they’re alert and talk to them about whether they’re having their needs met. We also do some pretty consistent rounding and checking in on families to make sure they have what they need. In addition, there’s a national survey called the Family Evaluation of Hospice Care and it’s a nationally recognized survey tool that is sent to all family members after their loved one has died. We get really good feedback that way. We’re always looking at ways to improve. We take that information very seriously. I’m happy to say we exceed the national averages.

Take us inside the room during one of these rounding sessions.

We have some very scripted questions. “My name is …, I want to make sure you’re feeling OK.” We’re looking for comfort and making sure a patient is comfortable. “Is there anything that you need from us? Is there any family you want us to reach out to? Are there any friends you want to talk to? Are there any pets you want to see?” It depends upon what stage they’re in.

We recently helped a person in the hospital that I personally rounded. He was alert. I talked to him about his pain and making sure he was comfortable and understanding where he wanted to die. Was this where he wanted to die or did he want us to try to get him home? We made sure some of his business was completed, on an emotional level. My background is in social work so it comes in handy for me. We wanted to make sure that he didn’t have anything he wanted to say to someone that hadn’t been completed. And then, addressing those spiritual-care needs, too. Making sure that if they choose, we have a spiritual-care team to work with them. So we round and it’s very scripted. With employees, we round to make sure they have the tools and equipment they need. We round to see if there’s anyone who needs to be thanked. We’re big on sending thank-you cards to people’s houses. We do a lot with recognition.

You touched on the spiritual part of the job. How does religious faith enter into this?

First, we’re so respectful of people’s beliefs. We’re very respectful and mindful. I would say there are some people that were not religious their whole life and they’re recognizing they’re about to die and they want to see a rabbi or they want to see a priest and we make that happen. Sometimes they want to have a clergyperson present while they’re talking to a family member. It eases some of that transition. So whatever they need, we’re here to help them address those issues.

We’ve heard that the economy has altered some hospice trends and that people who can’t afford health care or are unwilling to pay are taking their family members there to die. How can such a sad trend be reversed?

We have seen an increase of about 14.3 percent last year in caring for people between the ages of 41 and 64 years old. That’s quite an increase. I would say there’s probably two reasons we saw that. One, we’ve done a lot to improve our education, marketing and outreach. Someone like myself or yourself would have a better appreciation and understanding of the value of hospice. But I also think we saw a lot of people lose their insurance benefits so they weren’t able to reach out for curative care. All of a sudden, they’re in a situation at a time in their life when curative care is out of the question, and we saw more of those people come on to service. How to address that? That’s a tough one. I’d like to think health care reform is going to fix some of that when we get insurance for everybody. But I don’t know enough about the implications for the general population about health care reform. I know more about how it impacts us.

How are some of these trends shared with policymakers and legislators?

We do a lot. I’m personally very involved in an organization called the NHPCO, the National Hospice and Palliative Care Organization, so I sit on its public policy committee and participate monthly with them. Two of my senior leaders and I are going to Washington, D.C., for the annual “Hill Day,” where we go with all of our colleagues — about 400 hospice providers — and we talk with our congressional delegation. It’s a wonderful opportunity for us to talk about what’s going on with Medicare benefits. How does health care reform impact our reimbursement and other fallout? Good things and bad things. We are very fortunate at the Nathan Adelson Hospice to have a lot of congressional support. Everyone — Sen. (Harry) Reid, Sen. (John) Ensign, Congresswomen (Shelley) Berkley and (Dina) Titus — have all had a family member or loved one use our hospice. So they’re very aware of us and very receptive to talking with us.

How will the new health care legislation affect operations at the hospice?

I noticed in the legislation that children — we’re the only hospice in the area that has a full complement of services for children — are addressed. Parents are often reluctant to bring a child on service because that means it’s over. That, to them, means my child is going to die. But in the health care legislation, a child can have the benefit of hospice while seeking curative treatment. I applaud that legislation; I think it’s fabulous because now they get the benefit of that whole interdisciplinary team to take care of the emotional, physical and spiritual care issues that we do best and can address while a child still can have chemotherapy and treatments like that. So I really look forward to that legislation. I don’t know when that takes effect, but I know my team and I are very excited about that.

One of the barriers of the legislation is that the Medicare benefit for hospice is about to be reduced. We’ve already had some significant decreases and when we have 80 percent of our revenue coming from Medicare and we’re about to face another decrease, it’s horrific for a hospice our size. It’s horrific for the hospice industry. It’s very unfortunate. It puts us in the situation where we have to look for new ways to fund the extra things that we do because our goal always is to never impact the quality of care. One of the wonderful things about us is that all of our money goes into our patients, their loved ones and our employees. We don’t have shareholders at the end of the day. But this makes it more challenging when we’re talking about Medicare reductions again.

Describe the hospice’s relationship with physicians and caregivers in Southern Nevada.

We have some excellent relationships with physicians in our community. We have some excellent relationships with social service organizations in our community. The doctors definitely rely on us as experts in pain management. They look to us to help families that they’re so close with. They look to us to help them transition through such a difficult and challenging time in their lives. We have referral services in all different disciplines: oncology, primary care physicians, pulmonologists.

We also have really good relationships with our hospitals. We’re working with Sunrise and Mountain View hospitals right now in the palliative care program. We’re also doing that with the Valley Health System (Universal Health Services). It’s so helpful to work in palliative care, which is a pain management intervention. Palliative is when we take all the services we talked about and help a family and help a patient, but they’re not coming onto hospice yet. You can really help people who have a long time to live really get their situation under control. Elaine Wynn has been very supportive of our palliative care efforts and gives us a lot of support for that, so we named the program after her.

What’s the biggest challenge the hospice industry is facing?

Reimbursement, reimbursement and reimbursement. But also regulations. The regulatory environment has really enhanced its scrutiny. There are hospices, as we mentioned, for profit, across the country that are making rather large profits and because of the phenomenal growth in that area; we not-for-profits are paying a price for that. The regulation and the oversight have really increased.

How does that affect you?

It impacts us because, for instance, we’ll have claims that we send to Medicare that are sent back to us for very aggressive review. If we don’t tell our story well in that documentation, we’re not going to get paid. It becomes very problematic for our industry and problematic for our organization. You have to put more resources in to make sure you’re dotting those I’s and crossing those T’s and making sure that everyone not just does good care, but you’ve got to document and tell the story really well. We’ve had to invest a lot of money in that education to our providers.

What’s the biggest challenge the Nathan Adelson Hospice specifically is facing?

Certainly, the economy. Our donors seem a little bit more flexible with their donations, but it’s not anywhere near the level it used to be. Financial challenges are also a big problem for us. We pay close attention to that. The competition is more aggressive, and while I’d like to think we have wonderful relationships with most of the hospices in town and I applaud their contributions to hospice, there are some that maybe I don’t have as much respect for, so it makes it a little more difficult and challenging. We’re paying more attention to that this year. We’re getting our message out. I think that’s so important that a 31-year-old organization that’s the largest and is renown throughout the country and people call us for advice, that we don’t take ourselves for granted and that we make sure we’re here for another 31 years. We have to balance that mission with the business so we’re paying a lot of attention to that this year.