Carole Fisher

By Nicole Lucht

Friday, Feb. 20, 2009 | 2 a.m.

The grim reaper she is not. As chief executive of the nonprofit Nathan Adelson Hospice, Carole Fisher has the uncanny ability to bring sunshine to a dreary topic: hospice and palliative care. And that is what hospice is about — alleviating the pain — physical and otherwise — as a patient transitions from life to death.

Fisher spoke with In Business Las Vegas about the economy’s effect on Nathan Adelson’s fundraising, expansion plans and staffing issues.

IBLV: What is the mission of Nathan Adelson Hospice?

Fisher: We’re very committed to making sure that no one has to end their journey of life alone, afraid or in pain. Our goal is to make sure people have what they need at the end of their lives. We don’t just focus on the patient. We’re very involved with the whole family; that’s what’s so wonderful about hospice care.

It wasn’t until about three decades ago that hospices made their way to the U.S. from Great Britain. In your opinion, what is the value of a hospice?

It’s almost, what doesn’t hospice do for a family? Hospice is what is right in health care, because hospice embraces not just the patient, but it embraces the entire family and all the loved ones who are involved. We address physical issues and symptoms, and we’re experts at managing pain. And then we take a look at the emotional needs of a patient and the family. They’re going through such a tough time, so that’s another thing that’s right with hospice care. Then we look at the spiritual issues and everything is tailored to an individual, to a patient and the family. So each person has an individualized treatment plan. That’s really unique in health care — to have that kind of attention to all different disciplines of a person’s life.

Tell us how you came to join the hospice.

I was working in a for-profit business in the health care industry and having a great time. But I really wanted to get back to a mission-driven organization where it’s not about the bottom line, not about your shareholders, but it’s what you do for each and every person. And so, here I am, and I made that transition and I’m very grateful I did.

Death is a tough subject. What are people’s reactions when they learn you operate a hospice?

Well, some people are very hesitant to talk about death. It’s such a sensitive topic. It’s the unknown. We’re very fearful to talk about what we don’t know. And isn’t it amazing how we embrace birth and we embrace life, and then when it comes to such a critical time, and really enjoying someone’s life and acknowledging that and recognizing it, we shun away? When people approach me, the first thing I usually hear is, “Boy what you do is wonderful,” if they’ve been involved in hospice. It’s amazing, if I have my badge on or a Nathan Adelson T-shirt on a weekend and I’m out and about, people will usually stop me because they’ve had an experience either with our hospice or another hospice. So folks are very appreciative and complimentary of the work that we do. But some people do shy away and have a hard time talking about what’s unknown to them and what’s uncomfortable.

How many patients does Nathan Adelson care for annually?

We help over 2,500 patients a year, and every day we have about 350 patients on service. As you know, we take care of people in their homes, we take care of people in nursing homes and assisted living and group homes — wherever a person is residing.

We’re so fortunate to have two inpatient units. We have 20 beds over here at Swenson, right behind UNLV, and then we have 14 inpatient beds over on the west side of town.

Are those usually full?

Yeah, we usually are full. We usually have a waiting list. I will say, though, that over the last several months we have seen a decline in our census. It’s tied to a couple of things. One is our hospitals have been a little slower than normal. I think some of it is the economy and some of the challenges that people are having. I’m sure that you’ve heard a lot about how people aren’t reaching out for health care right now. They are just doing their best to stay afloat financially. So, unfortunately, sometimes when people don’t go to the doctor, they wait until the last minute and get very, very, very ill. That has resulted in low census here in the valley for all health care providers.

What are the hospice’s revenue sources?

About 85 percent of our revenue comes from Medicare. Because in hospice, mostly it’s seniors who are using the benefit, so most of those seniors have Medicare coverage. We also have many people my age and unfortunately, younger, who use their commercial insurance and then in our particular hospice, we take in the indigent. We’re very committed to making sure that no one has to go through this transition in their life without our help. We never refuse care for anyone. So we give away about $1 million a year in uncompensated care, but aside from that, about 85 percent, I would say, is from Medicare.

What’s the average stay for a patient?

Well, it depends on what their (health) issues are, but most patients are with us a couple of weeks. We do our best to really make sure that we’re reaching out sooner. I hear so many times that “I wish I would have known about you sooner.” And so, we’ve really been committed to educating the community so that (people) sign on to our services a lot sooner.

We’ve been working with the physicians and the people who make those referrals — case managers in hospitals — to really educate about the value of hospice because it’s so sad when someone’s here for just a day or two, or they get here and then they die in our hospital so quickly.

But sometimes it’s very common that people could be on hospice for several months. It is a (Medicare) benefit with a prognosis of a life expectancy of six months. And sometimes people are here longer. It’s also really common that people get better when they join hospice. It’s almost as if they’re relieved they have all this support, so sometimes they feel better. That’s great. We want people to feel great and enjoy this time in their lives.

In the average case of a patient who comes to Nathan Adelson for care, what is the cost for the patient, to the insurance companies and to government sources?

What’s wonderful about hospice is that there are no co-payments for Medicare recipients. So, if you have Medicare, you pay nothing. Medicare reimburses us. Medicare has four different levels of care that it reimburses us for. One is inpatient, one is for routine home care. One is for respite care, and that’s when a family just needs a break and so it reimburses for that. And then one’s called continuous care. So there are different levels of reimbursement.

Most insurance companies will pay some contribution to hospice. Just today we were working with an insurance company that would pay only 50 percent. That family is challenged with that other 50 percent. We are going to write that off and we’re going to make sure that they get the care they need so that money’s not a barrier. Of course, if they can help contribute to some of that so that we don’t have to dip into our foundation, then that’s what we’ll do. Most insurances cover some portion of hospice, with Medicare covering all of it.

You mentioned family care. Can you elaborate on that?

We have full-time social workers who are available to help family members with what is such a difficult and sensitive transition for the family. We often work with children. We work with husbands, wives, grandparents, whoever needs assistance. And then we have a full-time spiritual-care department. We have chaplains available to everyone of all faiths who are available to work with people and meet their needs. And we have a bereavement department. So after someone has been on our service for 13 months, we are very committed to that family. We will check on them and give them as much support as they need. Some of that support is in group sessions, some of that’s individual. Some of that’s just a phone call, just reaching out and letting people know we care and that we’re here if they need us.

What makes Nathan Adelson different from its competitors?

Wow. Well, at Nathan Adelson we go above and beyond. Everything that we do is driven to meet, like I said, the patient’s needs and the family’s needs. We have extra things that we do. So, for instance, we have a volunteer base of 200 outstanding, committed citizens in our community who do a wide variety of things. They go to people’s houses and help them if they’re alone. They sit with people in the inpatient unit if they need that help. They answer telephones. They’re just very committed to do whatever it is that they (the staff and patients) need. We have a very, very strong complementary therapy program. By that, I’m referring to people who bring in pets, mainly dogs, that come in and visit with patients and their loved ones. We do massage. We have massage therapists who are available for patients and to help them. It really is a great resource for patients for pain management. It’s an additional cost, so we have some huge supporters in the community who help offset those expenses.

What else do we do? We have physicians who are full-time employed physicians — very unusual for hospices. Many physicians at other hospices have their own private practice, and so they are very busy seeing other patients also. But our docs are our docs. They are committed to our patients. They see them every day if they are in the inpatient unit, and our physicians go to houses. They make those home visits that are so essential and really set us apart from other hospice providers.

You mentioned pain management. I think a lot of people don’t understand that in hospice care, the doctors aren’t trying to cure the patient. Rather, they are trying to make them comfortable. Is that correct?

Yeah. Our goal is to make sure that pain — which is the No. 1 thing that most patients are interested in having managed — that we address that as quickly as possible. Our doctors are a whole medical delivery team. They’re experts in managing pain.

We have full-time pharmacists. That’s another thing that makes us unique. We have full-time pharmacists in each inpatient unit so that they can address in real time the managing and administration of the medications necessary to manage pain.

Can you further elaborate on the networking between the hospice and hospitals? Do you reach out to hospitals?

Most of the referrals we get to our inpatient units are actually from the medical hospitals here in our community. So here at this campus, we have great relationships with Sunrise Hospital and Desert Springs. We work very closely with all the hospitals: St. Rose (Dominican Hospitals) and the Valley Hospital and all the other hospitals in our community. Centennial (Hospital) has been a very big supporter of ours on the west side of town.

How that relationship works is that the case managers are helping those patients have a discharge plan and we will help accept them into our facilities and get them on our services. A lot of seniors really want to die at home. So we do our best. Sometimes we need to bring them into our inpatient units so we can help get them comfortable and get the right medication regime going, and then we’ll move them to their home.

Let’s talk about Medicare and the recent cuts. How have they affected the hospice?

We’re in for some tough times — not just with the challenges in the community, but certainly with the Medicare reimbursement cuts. Nathan Adelson Hospice is reimbursed by region, and our region actually had a slight increase this year. But come October, we’re going to have a significant decrease, and it will be to the tune of about three-quarters of a million dollars for us annually. So we are doing our best to prepare for what lies ahead starting in October.

There is a lawsuit pending now between the National Hospice and Palliative Care organization and Centers for Medicare and Medicaid (the funding agency), so they’re trying to work this through and we are certainly supportive of those efforts and hope that there’s a positive outcome. But as of today (Jan. 8), there’s not a positive outcome and so we’re preparing for those cuts.

How are you preparing?

Well, we’re making sure that every person who is working in this organization, whether they’re paid or not, is aligned to our overall goals that weigh up to the overall mission of the organization. You know, in nonprofit, sometimes we have such big hearts that we want to be everything to everyone. We have to be very careful and cautious with our resources — so if it’s not related to end-of-life care, we have to call in other experts to support the families in that time. We’re making sure everyone’s aligned to what our mission is. And then we’re being really good stewards to our resources.

We have a very big going-green campaign going on right now. We were just adopted several months ago by Harrah’s Entertainment and some other folks and companies that joined together ... and did a lot of renovations in our inpatient unit. Next door (to the administrative offices), the inpatient unit is the third (oldest) in the country and so it had some age to it. It’s matured, so they came in and did all new restrooms, a whole new roof. They just did so many enhancements for us to help energy savingwise, and so now we’re building on those.

I just spoke with the whole organization last week about how we’re getting rid of using Styrofoam, for instance. It’s good for the environment to stop that practice and it’s also a cost-savings for us. We’re looking at very creative ways to go green and make sure that it helps save money and prepare for the future.

Do you think the hospice will have to cut back on services or staff?

No. As a matter of fact, we just did some restructuring several months ago. In that restructuring we did not touch any positions that were by the bedside. We make sure that our restructuring is in administrative areas, (that) they’re nonpatient care areas. My goal, and the board of trustees goal, is to not in any way decrease the level of quality care we provide. Keeping that integrity of care is so important to us. I would hope that we can do our best to reduce expenses wisely, use our resources very wisely and not impact care at the bedside.

What toll is the economy having on Nathan Adelson’s fundraising efforts?

Boy, we’re really feeling the effects of the economy. It’s been really tough for us and we’ve had to respond rather quickly and dramatically. Our donations and contributions are down over 20 percent. People want to help us, but they can’t help us as much as they have in the past. We’ve had to really take a look at making sure every time we spend a dollar, it’s a dollar spent very, very wisely. So the impact of donations and contributions has really hit us hard. The other thing we’re feeling is more people without insurance, many folks who just don’t have any coverage anymore, who are of that commercial population of health care, not Medicare, not the seniors.

What’s the status of the Henderson Adult Day Care Center and Hospice?

We were given 11 1/2 acres in Henderson. We had enough money through federal and local commitments, grants and funding sources, to build the adult day care. So, it’s ready, it’s done, it’s amazing. It’s ready to go. I just got the keys last week and we’re partnering with Nevada Senior Services and it’s going to run that adult day care. We’re very excited to have it as a business partner. We want to stay committed to doing what we do best and that’s hospice. And it does what it does best, and that’s adult day care.

Attached to that adult day care building is about 1,800 square feet that is just ours. We’re going to get that licensed and have some counseling services available out there for the community of Henderson. We’ll have our home care office — people who help people on that side of town — deploy out of there and have that as a home base.

Now the hospice, we have about seven more years until we have to build the building. But we’re very short in the funding. It’s a little challenging right now with the economy, so when I say we’re a little short, we’re probably about $10 million short of funding for that building.

What was the estimate to build that?

I think it was about $12 million. I forget the number. Actually, we’re probably almost $12 million short then.

I understand that there was going to be some collaboration between Nevada State College and the Henderson location, if that is to be built. Do you have collaborations with other universities or colleges to bring in nursing students?

We do a lot of collaboration with all the universities, even for pharmacy students and medical students. It’s wonderful. Right now, we lost our funding for our nurse apprentice program and that was such a disappointment because we were training nurses and able to pay them. Many times the nurses would stay with us. That’s a grant that we lost from MGM (Mirage). It had so many commitments and it couldn’t continue to fund that for us. But we do have very strong relationships for all the schools, all the departments on different levels — social workers, the pharmacists as I mentioned, and physicians, as I mentioned. That’s nice, but it’s not as strong with the nurses right now because of that lost funding.

Will you seek different ways to fund this?

One of the things that we’re so fortunate that we have is a full-time grant writer. She works at our foundation. As an organization it’s wonderful to have that type of resource available. She’s always writing new proposals and sending those out. The nursing apprentice program is one of our priorities to maintain that funding. We also have several other projects that we want to make sure we have funding for. One being Camp Mariposa. Are you familiar with that camp?

The one for children?

Yeah, what a wonderful thing we do. Each year we go out. Last year we had two camps. We partnered with (developer) Brett Torino out at his ranch. Are you familiar with his ranch?

Yes, I’ve been to his ranch.

Isn’t it wonderful? This year we’re only going to do one camp, but we already have money for the camp. (Sen.) John Ensign’s foundation gave us some funds, and the (Las Vegas Motor) Speedway foundation gave us some funds. But we want to make sure we can maintain that in the future, also.

These are children going through the grief process?

They’ve already gone through the grief process, so last year we had almost 80 children who had experienced grief and lost — some with our hospice and some not. But they’ve lost family members — mothers, fathers, sisters, brothers, grandparents — very, very sad, heart-tugging, heart-wrenching stories. It’s wonderful that they get to come together and have a weekend where they don’t feel alone. We have wonderful stories from that. Last summer, one of the little boys had said to his mom before he got dropped off, he said to her — and I had the opportunity to speak with her at the closing ceremony — he said to her, “Is anyone going to laugh at me if I cry?” You could just tell the pain he was in and that he felt uncomfortable sharing that. When she picked him up, he was like a whole new boy. He was just so excited because he wasn’t getting laughed at and, indeed, he could cry safely with other children and learned that he was not alone. Camp Mariposa is just a wonderful service that we do.

What about volunteers? Are you having more of a reliance on them during these economic times? And on the same note, are you finding it more difficult to recruit volunteers?

You know, it’s very interesting. I think people want to volunteer right now. People are very committed to giving back and in hard times, and in Las Vegas, what a wonderful community we have with people rallying together to help those in need. We’re finding our volunteers as committed as ever, and more committed than ever to helping do whatever we need to do to be here another 30 years and make sure that we provide the care that we’re dedicated to providing. We have no shortage of volunteers. We have a great volunteer department. They do everything and anything. That’s another wonderful thing about Nathan Adelson Hospice. If you want to volunteer, you come to us and tell us what you’d like to do and we’ll partner you with that activity. Some folks just want to meet and greet people and they want to sit at the front desk. Some people want to get by the patients and with the families. It’s all individualized, almost like our care is individualized. We individualize what volunteers want to do for us.

Are a lot of the volunteers people who have had previous experience with hospice?

Yeah, and we ask people to wait. We really encourage people to wait about a year so they can work through their grief. But it is very common for people who have had experiences with hospice — with our hospice or other hospices. Sometimes people will move to Las Vegas and they just want to get involved with our hospice because they’ve been involved with another nonprofit hospice somewhere in the country.

What other challenges does Nathan Adelson face?

There’s always a challenge in health care for nursing. Qualified nurses. We have done a wonderful job of making sure that our benefits and our salaries, our compensation packages, are competitive. Knock on lots of wood — we have been really blessed with recruiting and retaining competent staff. But that’s always a challenge in health care.

Our biggest challenge this year is going to be the donor development and continued commitment from the community. We have some wonderful events that we do throughout the year. As you know, we do our Flair for Care fashion show and last year raised almost $1 million with that event. (This year) we’re already behind in contributions for that. We’re not horribly behind, but we’re seeing that we’re a little bit behind where we were this time last year as we prepare and get ready for that event this May.

Will you still do the butterfly release this year?

Yeah. The butterfly release is such a wonderful event and it doesn’t cost much to do. It raises some money for us, definitely, but it’s such a wonderful event because so many loved ones come out and they purchase a butterfly. It’s not a lot of money, so it’s affordable for so many. They release (the butterfly) as everyone’s together. It’s a beautiful event. So, yeah, we will continue the butterfly release.