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SPECIAL REPORT 2018

THE REGION’S BUSINESS MAGAZINE

Casa de la Luz Hospice

COMPASSION EDUCATION INNOVATION


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Casa de la Luz Hospice:

More Than a

Place

A Mission of Education Hospice is an often-misunderstood practice in this country. While 1.65 million Americans benefit from hospice each year, many don’t understand what it is or where it’s practiced until they or a family member becomes a hospice patient. Casa de la Luz Hospice, the largest hospice provider in Southern Arizona, is celebrating its 20th year in business and is on a mission to educate the community that hospice is compassionate care for end-of-life patients. It’s not necessarily a place as it is a collection of professionals offering multi-disciplinary and integrative care to the patients and their families. Most patients are cared for inplace – at their home or their assistedliving facility – and patient comfort and dignity are given highest priority. 172 BizTucson

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Dr. James Nicolai, medical director at Casa de la Luz, said it’s critical for the medical industry and for patients and their families to understand exactly what the term “hospice” means. “Part of what we’re doing in the community is educating on the need for hospice and its importance. We’re passionate to relay this to folks,” he said. “Ninety-seven percent of all hospice patients stay at home. Having the choice is huge.” Founded by Lynette Jaramillo, now the CEO, and Chief Clinical Officer Anges Poore, Casa de la Luz has helped end-of-life patients and their families since 1998. Casa de la Luz is Spanish for “house of light.” Jaramillo said that to her, the name means “we’ll bring light to people’s homes or where they are at

end of life. Many search for faith at end of life.” The name also was inspired by an experience her son had while sitting with his dying grandfather. Her son saw a light coming through the window just as his grandfather passed away. The partners started out with a sevenyear plan and have grown the company steadily since. They currently have a workforce of about 275 and on average maintain 110 active volunteers. In April 2018, the National Hospice and Palliative Care Organization recognized Casa de la Luz for its increased professional and organizational capacity to provide quality end-of-life services to veterans and their families. Casa organizes an awards ceremony, given while the patients are still alive, and the www.BizTucson.com


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donation of a blanket specific to their military branch of service. Casa also is active in numerous local organizations and has won awards from the Tucson Metro Chamber, Society for Human Resource Management and others. Jaramillo and Poore credit their longevity in the business to always putting patients and their families first, offering them the best possible care and remembering that while they and their staff deal with end-of-life situations on a daily basis, for the patients it’s their one and only time. This is clearly illustrated in Bob Sagar’s story about his experience with Casa. He faced a number of challenges earlier this year with his wife, Judi, who suffered from multiple sclerosis. The first www.BizTucson.com

Part of what we’re doing in the community is educating on the need for hospice and its importance. We’re passionate to relay this to folks. – Dr.

James Nicolai Medical Director Casa de la Luz Hospice

By Christy Krueger

challenge was convincing her to accept hospice, which she eventually did. “Judi loved the gals who took care of her,” Bob said. “The quality of individuals who helped her were the most caring I’ve met. They were always respectful of Judi’s needs.” On March 1, Sagar ended up in the hospital after falling on some stairs and fracturing his back. Since he couldn’t be home for Judi between the hospice caregiver visits, he placed her in Casa’s respite care. By March 12, Judi was failing and arrangements were made to transport Sagar for a last visit; his wife passed away two days later. “I don’t know what I would have done without Casa,” Sagar said. “They were great. What you don’t learn from continued on page 174 >>> Fall 2018

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PHOTOS: COURTESY CASA DE LA LUZ

and Compassion


BizHEALTHCARE continued from page 173 the doctors or the hospital is that this help is available and Medicare pays for it all – it didn’t cost us a penny. It was kind of an amazing experience.” Casa is able to offer a number of treatment options to its patients. Some are widely used in hospice, others are more unique, such as Casa’s agitation program. Poore, who is a registered nurse and handles the clinical end of the business, explained that agitation in the hospice realm is often part of dementia and being elderly. “They get anxious and it can be hard to manage at home and sometimes in facilities. We use a variety of tools. A weighted blanket makes them feel secure and we use things to keep their hands occupied. We help them be more relaxed.” Pet therapy and music therapy are also used with success. Many wonder how hospice care is initiated, what the process involves and how patients pay for it. Anyone can make a referral for hospice services, which initiates an evaluation from a nurse. Then, two doctors must certify that the patient has six months or less

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to live. They generally are the patient’s doctor and a hospice doctor. The patient has to agree to discontinue any aggressive treatment. “The benefits are defined by Medicare, and most insurance companies follow it,” Jaramillo said. Medicare sets the payment rate, and there is a wage index by state or county. “Medicare pays us a per-diem amount.” What’s interesting, she added, is that Medicare pays more at end of life than for health maintenance. “Hospice saves money, gives better care and is cost effective for what you get.” Sometimes a patient comes along who needs hospice care, but doesn’t have insurance and can’t pay. “We still take them,” Jaramillo said. “We budget 2 percent of our income to cover this. We call it community service.” Casa de la Luz utilizes a multi-disciplinary approach to care, and each patient is considered individually as to the patient’s needs and wants. “The team,” said Poore, “may include home health aides, social workers, RNs, MDs and volunteers from the companion program.” Casa also employs music thera-

pists and chaplains. “Social workers help with funeral planning. About 38 percent die within the first seven days. That doesn’t give the team a lot of time,” Jaramillo said. For Casa, the average length of hospice services is 66 days. Bereavement programs for the families are an important part of Casa’s service, and it’s a Medicare requirement. “It’s mandated by the federal government to do it for 12 months. We do it for 13 months,” Jaramillo explained. “It could be ongoing counseling, there are support groups and one-on-one.” A valuable part of the bereavement process is a quarterly memorial service for families of loved ones who have passed in the previous three months. Employees of Casa also have access to bereavement support. “We have an EAP, employee assistance program,” Jaramillo said. “It’s hard to be open with someone you work with.” She encourages staff to be involved in the community so they have balance in their lives. And Casa has a quarterly employee recognition ceremony. “We call them angels.” Biz

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PHOTO: BRENT G. MATHIS

WOMEN WHO LEAD

Agnes Poore and Lynette Jaramillo Co-Founders, Casa de la Luz Hospice

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Founders’ ‘Wildest Dream’ Leap of Faith Leads to Business Success By Christy Krueger When the home health company that Agnes Poore and Lynette Jaramillo worked for in the 1990s was sold, it gave them the opportunity to take a leap of faith and start their own business. Jaramillo began by reading a book about achieving dreams, a book that motivated her to step beyond her doubts. “Casa is my wildest dream,” she said. “I followed the steps in that book. We got a small business loan. Now it’s gone beyond my wildest dream. It’s our legacy.” Jaramillo needed a partner and Poore was the logical choice. They planned, set objectives and made financial arrangements. Since both expected a two-year start-up period before being in the black, it was important that their husbands go for the idea. And they did. While Jaramillo and Poore ran the business, the husbands served as volunteers. Poore joked that she and her partner know more about each other’s family finances than their husbands know about their own. Right from the start, the entrepreneurs knew they wanted Casa de la Luz to be a for-profit hospice. While Medicare pays nonprofit and for-profit hospices the same and it mandates the same regulations, there were a variety of reasons to go the private route. Said Jaramillo, “I believe in free enterprise. I believe we can do a better job. We can make decisions on a per-patient basis. And I didn’t want to answer to a board – just me and my partner to make decisions.” www.BizTucson.com

Poore and Jaramillo set a goal of caring for 100 to 125 patients at any given time. “When we reached 40, we celebrated,” Jaramillo said. “We had slow, steady growth for 20 years. We’ve taken care of over 20,000 patients in our community. “All patients got the care they deserved. We have unique facilities not offered otherwise.”

We’ve taken care of over 20,000 patients in our community. All got the care they deserved.

– Lynette Jaramillo Co-Founder and CEO Casa de la Luz Hospice

To some extent, Medicare regulations had a hand in Casa’s growth. “Hospice started as a volunteer movement,” Jaramillo said. “Years later, Medicare started paying for it.” Poore pointed out that after starting the business, Medicare began adding new rules, requirements and reporting. During their seventh year in business, in order to keep up, it became necessary to automate. This, in turn, gave them the ability to handle additional patients. And with Medicare’s increasing involve-

ment with hospice, more people became familiar with the concept. “There are some benefits to regulation,” Poore said. “Hospice should grow.” Dr. Suresh Katakkar, a semi-retired oncologist and Casa’s first referring physician, shares the hospice philosophy and hopes awareness of its mission continues to spread. “Casa is complete care – spiritual, they’re with you all the way. The nurses are absolutely proficient, not just in taking care of the patient, but in all aspects of the person. That’s how I took care of my patients – from diagnosis to death or recovery. That’s what hospice does. Casa hires people who come to talk to you; it’s very important. Many patients are afraid, so you need psycho-social support. I can see that what I was practicing, Casa de la Luz is practicing.” He also has personal experience with Casa. Katakkar’s wife was a patient 10 years ago and he became a patient in 2017 when he almost died of a spontaneous subdural hematoma. “I was in hospice three weeks and they gave me excellent service.” As more of the population understands the hospice process and the baby-boom generation ages, Casa’s staff expects a tidal wave of change. “In the next five to seven years, there will be huge growth and those people want to be in control of their world at end of life,” Jaramillo said.

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PHOTO: BRENT G. MATHIS

Casa Hospice at The Fountains inpatient unit

Kanmar Place, residential hospice home

Dr. James Nicolai

Medical Director, Casa de la Luz Hospice

Casa Hospice at The Hacienda inpatient unit

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Facilities Offer ‘Cozy’ Setting for Hospice

Options for Care Outside the Home

PHOTOS: COURTESY CASA DE LA LUZ

By Christy Krueger

Casa de la Luz started in 1998 as a hospice that offered care in the home setting – including assisted living and nursing facilities if that’s where the patient was living. Not long after launching the business, founders Agnes Poore and Lynette Jaramillo realized there was also a need for Casa de la Luz to have its own facilities as an option for patients. Three years later they purchased a house on Tucson’s northwest side that became Kanmar Place, the first of three Casa de la Luz facilities. Residents at Kanmar are given routine homecare, Poore said, in addition to hospice treatments. “Longterm care insurance may pay for room and board, and Medicare pays the rest,” she said. Piper Frithsen, a registered nurse and the administrator at Casa de la Luz, described the five-bedroom Kanmar Place as a cozy, home-like setting for patients. “We provide holistic care. It feels like home – calm and serene. It’s a place of peace for me.” And it’s the only one of its kind in Southern Arizona. Since opening Kanmar Place, Casa has added two inpatient acute care units, both located on Watermark Retirement Communities campuses. Casa Hospice at The Fountains, adjacent to Northwest Medical Center, opened in 2004 with nine beds. Casa Hospice at www.BizTucson.com

The Hacienda, near River Road and Campbell Avenue, opened in 2017 with 12 beds. “It’s like intensive care for hospice patients,” said Dr. James Nicolai, Casa’s medical director.

My mother stayed at Kanmar Place for the last month of her life. It’s a very pleasant home – peaceful, nice view outside. – Dr.

John Z. Carter, Physician

Also offered at both inpatient units is respite care, where hospice patients who are living at home can stay for up to five days to give family members a break. From 2017 to 2018, Casa’s respite days increased 164 percent due to the opening of Casa Hospice at The Hacienda. Whether patients are at home or in one of Casa’s facilities, the hospice care

follows the same integrative, multi-disciplinary approach. Nicolai said he is a strong believer in the methodology. He comes from a background of integrative medicine and wellness practices, including his work at Miraval Arizona resort and spa and the University of Arizona. Hospice was a natural transition for him. “One of the focuses I’ve had as a physician is healing, and I was part of the integrative medicine program at UA with Dr. Andrew Weil,” he said. That included the study of hospice and spirituality in medicine. “It’s seeing people as more than just bodies. Hospice has to do that at the end of life. I found the idea is very much a part of what hospice is, combining traditional and alternative medicine and using what works.” Some of the alternative practices used at Casa, Nicolai said, include music therapy, pet therapy, herbal supplements and healing touch. “We’re open to effectiveness when it leads to comfort – one of our highest M.O.s.” Frithsen came to Casa from a hospital nursing background. “After 23 years in acute care, I almost forgot why I went into healthcare,” she said. “Hospice is holistically about the patient. In end-oflife care you feel like you’re really making a difference.” Both Nicolai and Frithsen have obcontinued on page 180 >>> Fall 2018

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Administrator, Casa de la Luz Hospice

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PHOTOS: COURTESY CASA DE LA LUZ

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Piper Frithsen

continued from page 179 served the difficulties many healthcare providers have with end-of-life discussions and the concept of discontinuing aggressive treatments. Therefore, they go into the community and offer presentations on the hospice care process and suggestions on how to start the end-of-life conversation with patients. “Hospice isn’t a failure of the treatment plan or physician; it’s progression of life, a continuum,” Frithsen said. Dr. John Z. Carter is a local family medicine and geriatrics physician who understands the value of hospice and is on board with Casa’s mission. “They are very patient and family-oriented, and I like their end-of-life philosophy of doing what is best for the patient. That’s foremost for me,” he stated. He personally experienced hospice twice – his mother and brother were Casa patients. “My mother stayed at Kanmar Place for the last month of her life,” he said. “It’s a very pleasant home – peaceful, nice view outside.” Carter’s brother, a Tucson neurosurgeon, passed away in 2010 in Casa hospice care. “So I’ve been at the other end of the spectrum.” From a physician’s standpoint, Carter is appreciative of Casa’s availability. “If I meet with a patient Friday afternoon and we’re thinking of hospice, I can call and on Saturday morning someone is at the house enrolling them in the program. The nursing staff is very accommodating.”


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PHOTOS: COURTESY CASA DE LA LUZ

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Dr. David Jaskar

Doctor Set and Lived High Standards at Casa de la Luz By April Bourie Editor’s Note: Dr. David Jaskar passed away shortly after the interview for this story. BizTucson appreciates Dr. Jaskar for providing his viewpoint on hospice care as a practitioner and a patient. We offer our sincere condolences to the family. Contracting polio at age 12 solidified Dr. David Jaskar’s decision to become a medical doctor. “He was a real jock and could have pursued those interests,” his wife, Maria, said. “The experience really increased his interest in medicine.” Years later, Jaskar went on to become Casa de la Luz’s first medical director where he set the organization’s high standards of allowing patients to die with dignity. He died while in hospice care from Casa de la Luz. “When people are ill, they want caring, understanding and empathy,” Jaskar said. “Caretakers must be humble and provide for their patients’ comfort and spiritual needs.” To that end, Casa de la Luz has a holistic team of caregivers, including nurses, social workers and chaplains, who provide for their hospice patients’ needs. Jaskar started out as a pharmacist, then earned his medical degree at the University of Wisconsin in 1971. He went into private practice, specializing in rheumatology, which led him to attend a rheumatology conference in 182 BizTucson

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Tucson. He quickly fell in love with the area and decided to move here, obtaining a fellowship in rheumatology at the University of Arizona. It led him to increase his medical reach into the field of geriatrics. In 1987, he was urged by Dr. Alan Crosby, a colleague at the Southern Arizona Veterans Administration, to apply for the medical director position at the VA. “I had other choices at the time, but I am so glad that I went there,” Jaskar said. Then, in 1991, he started an award-winning hospice and palliative care unit at the VA. In 1998, when Lynette Jaramillo and Agnes Poore started Casa de la Luz, they attended the Arizona Geriatrics Conference in Phoenix and heard a presentation by leading palliative care physician and author Dr. Ira Byock. “We immediately bought his book ‘Dying Well’ and read it cover to cover,” Poore said. “I wrote to him because it was clear that we needed a medical director that shared his passion and values regarding end of life. I asked if he could help us find someone like him.” Byock didn’t know anyone in Tucson, but suggested Dr. Paul Rousseau, the medical director at the Department of Veterans Affairs Medical Center in Phoenix. Poore and Jaramillo explained

to Rousseau their desire to find the right medical director for their new hospice organization. Although he was interested, he was not able to leave his position in Phoenix and recommended Jaskar. “We found out that he was one of only two hospice and palliative care certified doctors in Tucson. We arranged to meet Dr. Jaskar at the VA on Rodeo Day in 1999,” said Poore. “I remember it vividly because Dr. Alan Crosby, whom Dr. Jaskar shared an office with, was wearing cowboy boots, and he only did that on Rodeo Day.” After the meeting, Jaskar agreed to become Casa’s first medical director while continuing his position at the VA. “Dr. Jaskar was the first person we hired. He took a huge leap of faith with us,” said Poore. In addition to serving as medical director at Casa and the VA, Jaskar educated the community about hospice as a presenter and Bioethics Committee chairman for the Pima County Medical Society. “There’s so much people can give if they choose to do so,” he said. “It doesn’t disturb me to be a patient here. The collaborative team approach is good, and they take great care of me.”

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Artwork Integral to Hospice Message Calendars Spread Throughout Community By April Bourie Bettina Mills creates artwork that is colorful and uplifting and conveys a positive image of everyday things. Her work is influenced by Diego Rivera and Mexican heritage. Mills’ paintings – a dozen of them – can be found hanging in Casa de la Luz Hospice facilities and offices, but it is the images she creates each year for the company’s calendar that makes an impact on the Tucson community. “We get requests every year for our calendars, which we distribute regularly to Casa business partners and referral sources,” said Meredith Ford, communications manager at Casa de la Luz. “We also provide them to anyone who would like one. In addition to Bettina’s attractive artwork, we layer messages about hospice throughout the calendar. It’s an inviting way to share what we do.” Mills’ family told her at age 10 that she should be an artist. “I drew all day long, and my father and grandfather were artists, so they told me that’s what I should do when I grow up,” she said. Born in Germany, she was 13 when her family moved to Tucson where she eventually got her bachelor’s degree in graphic design and illustration at the University of Arizona. Today, she is a freelance artist, work184 BizTucson

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ing in acrylics, watercolors, colored pencil and scratchboard, a reverse process where the paper is inked and the artist scrapes out highlights to create an image. Mills first designed graphics for the company. Now the calendar is the main project she creates for them, although she also does occasional small projects on the side. “My calendar artwork has evolved into its own style,” Mills said. The images in the calendar are original acrylic paintings on canvas that reflect the season when appropriate. She also has featured her own rescue dog, a heeler mix named Nikolai, in some of the images. It takes approximately one year to create the calendar, Mills explained. She sketches from December through March. Painting begins after that, usually completed by September. Layout begins in October, followed by printing in time to distribute the calendars for the holiday season. This year, the timeline is moved up a bit to be ready for Casa de la Luz’s 20th anniversary celebration on Nov. 9. The calendar is a creative way to promote Casa de la Luz’s services, but it also provides a benefit to Mills. “It is therapeutic for me to paint the images for the calendar. It’s good for the soul and gives me inner peace.”

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Susan Villarreal & Julie Evans Casa de la Luz Foundation

Foundation Supports Those in Need Families’ Way of Saying ‘Thanks’ By April Bourie The Casa de la Luz Foundation was created to solve a financial or emotional need of hospice patients and family members.

Perspectives,” “Dealing with Grief in the Practice of Caregiving,” and “History, Evolution and Present-Day Celebrations of Day of the Dead.”

Two years after Lynette Jaramillo and Agnes Poore formed Casa de la Luz Hospice, the foundation was borne from families who appreciated the care given to their dying loved ones.

Services provided by the foundation focus on making hospice patients and their families as comfortable as possible. It can be basic, such as providing money for housing and utility bills, or more involved, like the time the foundation arranged for a homebound patient to visit Tohono Chul Park just so she could get out of the house, said Susan Villarreal, the foundation’s board president.

“Patients’ families wanted to give them money to help others in hospice as thanks for taking such good care of their family members,” said Julie Evans, executive director of the Casa de la Luz Foundation. “So they decided to create the foundation.” The purpose of the charitable organization is to educate the Tucson community about hospice services and to supplement services provided to patients of limited means and their families, no matter who is providing their hospice care. A guide called “Five Wishes” is an educational tool provided by the foundation to help people determine their end-of-life medical care preferences, as well as who they want with them and what comfort measures should be provided. “By the time people arrive at the end of life, it may be too late to make these decisions,” Evans said.

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Another of the foundation’s educational programs is the annual End of Life Conference, which this year will be held Nov. 2 at the Westin La Paloma. A variety of sessions will be presented, including “Food, Grief and Death: Cross-Cultural

Items are also provided to soothe agitated patients, including stuffed animals, games or weighted blankets. Free bereavement books and journals are distributed throughout the community for those grieving the loss of a loved one, and referrals to grief support groups organized by Casa de la Luz Hospice are provided. All of the foundation’s programs are funded by donations which are usually made in memory of loved ones who were previously in hospice. Bereavement group participants often donate to thank the foundation for its support. Donations are accepted on the foundation’s website, www.casafoundation.org. “When the foundation was formed, Agnes and Lynette saw that people with limited incomes were going without,” Evans said. “Our hope is that we will grow to support a multitude of hospice patients, no matter where they are receiving hospice services.” Fall 2018 > > > BizTucson 185

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