How Karen Rubel Built a Gold Standard Nonprofit in a Saturated Healthcare Market

[0:00]  you have to be your own advocate because the people in the hospital are like, "Oh yeah, we can keep her alive. We just shove a tube down her throat and get her all wired up." And I kept saying she doesn't want that, right? And I don't want her to come back and haunt me, right? So I want to make sure I do what she wants. Um, but I knew that because she had been very very clear about it.

[0:19]  We didn't talk about it all the time. We didn't talk about it except maybe once or twice in probably the last 15 years, but I was very clear that that's what, you know, she wanted to have happen. And then that led to a conversation with my sister and I and you know, then um her she had four sisters and so they all talked about it. So it just it doesn't it might not happen today, but it's important to really have those conversations. All right, everybody. Welcome back to a brand new episode of the Heart and Hustle Podcast. Now, I have to be incredibly honest, and I'm going to be

[1:05]  very selfish in today's conversation, but this is one of my favorite leaders who is sitting across this digital table with me. We have the CEO of Nathan Adden Hospice here with me today. Today we're going to learn all about Karen Rubil's Heart and Hustle. Karen, thank you so much for joining me on the show. This is long overdue. I can't believe I finally got you here, but I'm so excited to tell your story. Yeah, thank you. It's great to be here. All right, so what first question I want to ask you is what does heart mean to you today, especially in the world of business, especially what you guys do in the hospice space. Yeah.

[1:37]  So, for me, um, you know, heart has a couple of, uh, different meanings in the business space, right? I've spent um pretty much all of my career in the nonprofit business space. Um and so with nonprofit businesses comes mission, vision, value. Um not unlike the for-profit space, but it's just it just is a little bit different. Um and I think you know certainly when I came to hospice you know leading with heart is you know certainly you know pretty simple uh because of just the subject matter that you're dealing with because you're dealing with people who are really at their most vulnerable and their families that are at their most vulnerable um and even your employees, right? And so um leading with empathy is really important. making sure that you

[2:26]  listen, making sure that you, um, connect everything that you do to purpose, right? And so, um, I think that those things are important when you're talking about heart. Well, you know, I want to put a pin in something that you just said there, which is kind of the heart that's involved, right, in providing services. Um because later in our conversation, I want to put a little bit of a teaser out there for everybody, but I want to talk about the periphereral proliferation of the hospice organizations that are not leading with heart that are now creating competition and honestly kind of creating a bad image for this important endof life transition of care that you guys do so well. So, I want to put a put pause in that, but in order for us to kind of really dive into how this became your hustle, I really want you to spend a couple minutes talking about how we got to where we're at here today, where we got started, what happened in your

[3:14]  career, and what kind of brought hospice to the front of your opportunity for be able to put so much passion into the space. Sure. Sure. So, um, I've been at Nathan Edison Hospice for 18 years. I only wanted to be here a year. Uh I was in a job with a a a boss that I it just wasn't working out right and I was just looking for something new. So um this is my first hospice my first and only hospice job 18 years later. Um but I uh I'm from the Midwest, grew up in the south suburbs of Chicago. Um was a teacher. That's what I wanted to do with my life. You know, when you're a kid and you're thinking what do you want to do with the rest of your life? I always wanted to be a teacher. I was really drawn to that. Um, and then I got into it and I'm like, "Oh, no. Oh, no, no,

[4:02]  no. I'm not doing this for the rest of my life." So, it was lots of challenges, lots of things that I didn't realize uh happened with that. And then um had the fortune to a good fortune to um be asked to do some fundraising for the school that I was uh uh teaching at. They needed to find some cash. Um, and so started, you know, just kind of dialing, working with their donors, getting some money. Um, and really liked that, right?

[4:29]  And thought, "Oh, I think I could do this." And realized that there were people out there that did that for a living. Like, "Oh, all right. That's pretty good." Um, so then had the good fortune of finding a a nonprofit in the northwest suburbs of Chicago. They hired me to do their development. Um, and then uh ended up moving to Las Vegas uh for no other reason than I just wanted to get out of the cold, right? Right. I was tired of plugging in my car, tired of, you know, just being so so cold. And I had a a good friend that lived in Las Vegas and would come here, visit her on vacation. And uh and it was, you know, in 2000. It was, you know, everything was new and they were the city was growing. And I had seen an ad in a trade paper for fundraisers for UNLV. So I thought, "Oh, this might be interesting,

[5:17]  right?" Sent my resume off and I thought, "Oh, they're never going to call me." and they called me. I was like, "Wow." And then they, you know, came out here, did the interview and they offered me the job. So, I started in uh at the University of Nevada, Las Vegas. Um and then uh went to work for a foundation in town and then ended up in the hospice. Uh my my my boss at UNLV had retired and he was doing the search for the vice president for development here at the hospice. So, that's really how I got here. I mean, what did uh you know, I we have a a saying in our family that everything happens for a reason, right? You know, and I actually heard Matthew McConna talking about this on a podcast recently that kind of like really hit me in the heart. He said, you know, when we're young and we're moving through life, we think everything happens by chance. The introduction, the

[6:05]  conversation, running into somebody at a Starbucks, right, who you might not have met, but you guys hit it off and you become lifelong friends or even partners. And when you get a little bit older, you start to have a different perspective on how it seems like everything is connected and you're in the exact position because you're here today because you're supposed to be. I want to reverse a little bit, Karen, and talk about something that I think is one of your superpowers that you might not recognize, which is being able to pivot and change directions. So many people, right, early in their career think that they're going to pick a career right out of college and they're going to be in that for the rest of their life. But then they start having those conversations with themselves where they're unfulfilled. Maybe they're not enjoying it. It wasn't what they thought. But too many people end up living their entire life out in that career and never being able to pivot.

[6:51]  How did you build the strength to be able to say, "I thought this is what I wanted ever since I was little, but now I'm not going to go in this direction." So, you had to be brave and be strong to kind of go in a different direction, which I sure wasn't easy. Yeah. You know, I I think that um the pivot really is uh when I was younger, I was a little restless, right?

[7:12]  I was like, "Okay, I'm doing this teaching thing, but I'm not really sure this is what I wanted to do." So, I went back and got a master's degree in administration, and so I thought I wanted to be a principal, right? And so, um then kind of got other, you know, other types of jobs in education. Um, and so there was just like this trying to figure out, right, what I wanted to do. And so, you know, I just took a chance. I quit that teaching job without another job and worked for um the the Democratic National Convention, had come to Chicago that year. And so, I got a job selling t-shirts, right? I was like, okay, I'll do that for a while and see kind of what happens. Um, but I also think there's something uh I I took a class years ago uh and the gentleman, it was a leadership class, talked about

[8:00]  luck, right? And so you could say things happen for a reason, but you also get kind of lucky, right? And you just fall into these uh relationships with people or you meet people and it it it's kind of you're just lucky. Like I've met I was lucky enough to meet a couple of people in my professional life that really just took a chance at the end of the day. really just took a chance on me um and uh allowed me to kind of get where I am today. How do you kind of think about that early experience, if you will, right, of somebody taking a chance on you? Has that formed how you look at young upcoming stars potentially who you've come across in your personal professional life and will more willing to give them a chance like you were given? Yeah. Yeah. I I very much believe in giving people a chance. if people

[8:47]  want to um take on another opportunity or take on that next leadership role, okay? You know, let's let's give it a try, right? Let's see if this is really something that you want to do. Um now, there's all kinds of conversations about that, about how hard that is, right? Everybody wants to be the boss, but when you get into that situation where you are the boss, it's it gets hard. Like, you have to deal with a lot. There's a lot of, you know, um, making sure that people are okay. Making sure that people have what they need to do their jobs.

[9:17]  You never know what mo and it's not really motivate, but but what inspires your employees is very different for each of the employees. And you got to always kind of be keeping that in mind. Even how you're communicating. Some people like, you know, the phone call all the time or the check-in and some people just like to be left alone. So, um, yeah, it's it's interesting. Yeah, it sounds like you know we've given lots of people here um opportunities right over the the 18 years that I've been here in hospice if they wanted to you know be the manager or I'll see something in them that maybe they don't see and I'm like I think you should do this you know and sometimes they say yes and sometimes they're like no I have no interest in doing that. There's a there's an amazing quote. Um the author

[10:04]  of the book is uh slipping my mind right now, but he says, "You lead others by letting them know what you expect of them, which often may exceed what they expect of themselves. The beauty is in the stretch." What do you kind of think about the ability for you as a leader to see something in somebody else, push them maybe beyond their boundaries of comfort, but recognizing once they get into that next phase, they're like, "Oh, I can actually do this." It's like an empowering process. Yeah. So, I've had two people uh in my professional life that have done that. My first fundraising job outside of the teaching um you know, he was he I didn't have any experience when I interviewed with this gentleman in the northwest part of Chicago and he just called me the next day and he said, "I don't know what it

[10:51]  is. You have no experience and I don't know why I'm doing this, but I want to hire you." Right? And so he provided me the opportunity to have that job, provided a lot of teaching and coaching and then just kept pushing me, right? Stretching like I want you to go and do this. I want you to go and do this. Um and the same thing here, right? When I started here, I was um the vice president for development. I was fundraising and that was easy for me, right? Um, but you know, the CEO at Nathan Addison Hospice just kind of g kept giving me these other duties like I think you should try this, I think you should do that. And so it really just creates like a path for people, right?

[11:32]  And so, you know, I am a firm believer in that, right? To, you know, just challenge people, right? This is your stretch assignment. Let's see what you do with it. You know, some people succeed at that and some people don't. Some people love it and they want another one and they're like, "Okay, I'll do that." And then some people are like, "No, I mean, it's a process of rounding out our skill set, right?" And you know, one of the conversations I often have on the podcast is how important it really is to learn where we're comfortable, but also kind of learn where our boundaries are.

[12:03]  And the only way that we can do that is by getting out of our comfort zone and leaning into our potential genius, which I think is so beautiful. What did it feel like? I want to kind of hop in a time machine really quick. when you received that job on the northwest side of Chicago and somebody says, "I don't know what it is about you, Karen, but I believe in you and I want to give you this opportunity." How did you feel in that moment? Did you feel seen? Did you feel validated for like what you knew your capability was or what was that internal conversation with yourself?

[12:30]  Well, I was really um excited and I was surprised because that's not how the interview ended, right? It wasn't like, oh, you know, we're really excited that, you know, we'll call you and, you know, kind of the normal things when you're interested in a candidate. But I remember also thinking, oh, wow, now I've got to really prove myself, right?

[12:51]  So, he saw something in me that was, you know, something that he wanted to bring onto his team and now I really have to, you know, step up and and this will be a stretch assignment, you know, and so there's all that doubt that you have to like, you know, can I really do it and and that sort of thing. But um yeah, it was really exciting. I uh I recently heard a phrase. So my girlfriend, as you know, um she is a physician's assistant, right? And she was talking to me something about uh the process of like growth the other day, and she introduced me to something. I'm going to butcher this, so I just want you to stick with me. Okay? I talked about Wolf's law, right? Wol's law is if you create tension and friction against a um a tendant or a bone, it will grow stronger, right? But the only way it

[13:38]  does that is by experiencing tension. And it's like I think that we need to reform our relationship with tension and that flexing process of growing outside of our comfort zone because the only way we get stronger, just like in the gym, if you want to build muscles, you have to lift heavier weight and you have to go through that tension. But it seems like so many people don't have that perspective where we kind of expect our career path to be easy and that things shouldn't be kind of frictionless and we shouldn't overcome the challenges. How what is your kind of relationship with challenges? Do you believe in healthy challenges or what's your kind of perspective? You know I I like challenges because I think they make us better. Um I think that uh one of the things that I have kind of adopted as a philosophy is that it's okay to make a mistake. Right?

[14:23]  So, you should embrace the mistakes that you make and make sure that they're big mistakes, right? Make it worth it, right? Don't do something little, like do something really big. Um, and I think that, you know, people get so afraid, right, of making a mistake or what is that going to mean? Or, you know, if I if I do this and it doesn't work out, what's what's going to happen? Um, and so you get in your comfort zone and you just kind of keep going. And um I think it's you if you are really wanting to explore that, you have to find people who are going to really push you and challenge you and you have to be able to you have to be able to take the feedback and listen to them. Hey, real quick. If you enjoying the podcast, we first want to say thank you and we also just want to give you a little insight of what

[15:09]  we're up to at Francis. Some they'll even realize that we're working with organizations to help them use AI to create that real human communication experiences where that's actually supporting your your families, those patients or the entire community. We're actually creating tech that connects. Check it out. Francis.ai. That's a scary process for a lot of people though, hearing feedback honestly about us as a person, right?

[15:36]  Being able to, I would say, separate ourselves from the feedback, but just look at us as kind of like an evolving masterpiece, one stroke at a time of a painting is really tough. A lot of people struggle with that. Yeah, for sure. Yep. So, here's my question. We spent a lot of time, right, fundraising, education, teacher, working at UNLV.

[15:56]  Now, we come to Nathan Add. I want to get your honest opinion about what was your perspective about hospice before you actually started working within the organization getting more assignments. Did you have any type of beliefs maybe that were broken when you kind of got into the space? Yeah. I I I had not had a hospice experience. So my perception was when when my former boss called me and said I think you need to interview for this role. I said hospice. Are you kidding me? who is gonna give money to a hospice that is one of the most depressing things I've ever heard.

[16:31]  Like that that I'm not interested in that at all. Right. So I had that perception that it was you know um a very sad very uh you know who's going to give money to that? It's just so sad. Um, but then I got into it, right, and learned about what we do and it was almost immediate that I felt like, boy, you really can re see the return on investment if you're a donor. Like, you can really see how you impact someone's life. Um, and especially at the end of their life when, you know, they're just, you know, it they just you just want it to be as peaceful and painfree as possible. and um you know it really is a a really beautiful thing. So got hooked right away. I mean I think about the

[17:19]  role of you know a hospice organization to play in somebody's life when they're challenged with one of the most scary experiences they're ever going to come across. Right? We grow up in our entire lives when we're younger. We're like hey I'm going to be alive forever. My my parents are going to be here. My grandmother, everybody's going to be here. But then life's head turns the corner and says hey this isn't forever.

[17:38]  And when we get thrust into the hospice experience, often it's the first time we're ever challenged with this. I shared my personal experience recently when I was talking with you and your team about when my dad got a call in 2008 about hospice, right? He was the only person in our family that had the ability to go be with his mother before she passed away, right? And what that meant for him and how he navigated that.

[17:58]  He had a hospice organization of caregivers and people who truly care to navigate through that experience. And I want to use this as kind of a segue into kind of the proliferation of hospice organizations. I want you to share some of the stats here because you guys are the gold standard right in Southern Nevada for services when it comes to hospice. But we've seen so many different types of organizations that are popping up. And for somebody who's on the outside looking in, they would say, I mean, obviously more people equals me need more organizations for more support. But why could that be wrong? Yeah. So, um, you know, hospice, uh, has been around since 1983. It's a Medicare benefit. Uh, the the population of people that are usually in hospice are people that are Medicare beneficiaries over 65. Um, people that

[18:47]  are kind of coming naturally the progression to the end of their life. And, um, hospice really started out as a nonprofit business. That was the business model. like you weren't supposed to be making money off of people who were in hospice. And um you know it became kind of this you know way for people to you know make a lot of margin um on you know Medicare dollars.

[19:14]  And so um we've seen this explosion probably in the last 10 years of forprofit companies starting hospicees. So they might have a home health, they'll start a hospice. They might have, you know, own a facility of some sort and they they they start a hospice. Um, and in Clark County when California put a moratorium on hospice business licenses in 2021, we just saw this influx of people from California coming in and starting a hospice just in Clar County, not the state, just Clark County. um where where you see some of the proliferation in states that's statewide like California from you know San Diego all the way up to San Francisco you've got you know thousands of hospices but this is just happening in Clark County and we have over 280 hospices so we have probably

[20:04]  nine hospices for every 100,000 uh Medicare eligible recipient right and so that is a huge number of hospices not all the we don't have enough people that are hospice eligible to have for the business. Um, but hospice is paid on a perdm rate. So for every day you have that patient on your care, you get paid a perdm rate. So a daily rate and you can do with that daily rate whatever it is that you want to do. You can pay a nurse, you can pay a doctor, you can pay a social worker. Um, and so if you have a uh model that doesn't have a lot of care at the bedside where with your with your more expensive staff, that's your margin. You know, you can pocket that money, you can make money off of and

[20:52]  we've seen um, you know, some hospice companies across the United States making like 30% margin. Now, an average forprofit or nonprofit hospice makes about a 5% margin, maybe 7%. If they're lucky. So, it's really a um it's like, you know, you we always say in the nonprofit space, we want to put people over profits. Like, you know, you need to any money that we make goes right back into supporting patients and families. We've got a families in need program. You know, sometimes people when they come to us, they have exhausted every resource that they have. on medical bills or whatever it is that they're dealing with, social determinance of health. And so our foundation raises money, you know, to help keep the lights on or help relieve some of that stress that you have

[21:40]  because you don't want to be worried about all that other stuff, even meals, right? We started a meal delivery program because we were, you know, finding that, you know, the caregiver, you have a 80-year-old caregiver that doesn't drive and their spouse is, you know, 80 years old and they're a hospice patient and they're not driving. So how how are they getting food, right? Except through their neighbors or something. So we started um a meal delivery program and and even pets, right? So a lot of for a lot of people their pet is their child, right? They might have children, but they don't like their children as much as they like their pets, right? So true. You know, your mom is I know.

[22:17]  Trust me. So what happens to the that that the stress of what happens to their pet at the end is is something that we identified as a stressor that people really worried about. So, we created a program called Pause for Paul, um, in memory of Brad Garrett's brother, uh, Paul, who loved loved animals, um, and had a lot a lot of animals or a lot, I think it was dogs, and he was really worried what was going to happen to his animals. And so, um, your mom actually helps us with that program to, and so what we try to do is, you know, you know, take the dog to the vet, cover vet bills if the dog is, you know, sick, and then, you know, try to place that animal when that loved one dies or before, so at least they know, the owner knows that

[23:05]  the the their pet went to a uh a good place. So there's all those kinds of things that we do that, you know, forprofits just don't do because it's just extra money away from the bottom line. When you change the incentives, right, you change the outcome. And if we're talking about making money, naturally, we are going to optimize for how do we get as much money out of this daily PDM as possible. And what that often turns into is cutting corners. But what you've described is not just the clinical delivery of services in the home and at the bedside, but one of my favorite terms that I love kind of leaning into is like this is a whole person care model, right? Emotional, spiritual, their pets. We're talking about protecting the entire person as they go through this transition, which is so important. So, now that we've

[23:52]  recognized kind of the problem that's out there, Karen, what can we do? What are you doing to combat against some of this? I would say misaligned incentive in the space because you guys are such a cornerstone that this often I could imagine has a negative interpretation or you know a negative effect on your guys' reputation as an industry. Oh yeah, for sure. Yeah. So, you know, um there's a couple of layers to this. So, starting at the national level, uh there is an organization called the National Partnership for Hospice and Healthcare Innovation. um that is a member um uh a member organization that is just nonprofit hospices. And so we really work to make sure at the federal level that people realize that there's a difference between uh for-profit and nonprofit. And and when I say that, I

[24:41]  would never say that all the for-profits are bad. There's some really good for-profit companies out there. And it and people will argue it shouldn't be about tax status, but today it's definitely about tax status and margin, right? And how much you're making off of off of these patients. So, we are a member of that group and and that group has about two over 200 members in it.

[25:02]  Um, and then and there's a whole uh legislative advocacy team that works uh with CMS. We have a close relationship with Medicare um and the Department of Health and Human Services just to kind of keep that conversation in front. And then uh statewide, we've got a piece of legislation that is in this uh Nevada legislative session that I think has got um some good teeth to it uh around some of this regulation. Right. It doesn't call for a full moratorum on hospice business licenses, but it does put up some guard rails for some of these bad players to have to report their quality scores. If you stay under a certain number of patients every day, you you have no requirement to report quality scores to the public. I have to report

[25:51]  mine because I'm a larger organization. So you get to see everything that I do and every everything that the patient wants or the family member gives us as feedback once that loved one dies. But if you're below a certain census level, we call it census. It's the number of people that you're taking care of each day, you have no responsibility to report that or you can take a fine like you can get dinged on a fine every day if you don't report the the information.

[26:16]  So you know there's what we're looking for is just some checks and balances, right? If you're going to allow 280 hospices in Clark County, what are you doing to make sure that you got those checks and balances? We've uncovered some data where there are 13 hospices that have a registered address at one address on Westlake. Okay. 13 hospices at one and they all have different names. They all have different owners. Uh, but sometimes it's a family that just spins off these hospices. And so, you know, you own a hospice, I own a hospice, your dad's got a hospice, your mom's got a hospice, right? It's just, it's crazy.

[26:58]  So, this is kind of mind-blowing to me. It's like, okay, so if you are an established organization that has the infrastructure to be able to support families at scale like you guys do, you are held to a higher standard. Yeah. Right. for quality scores and transparency of the outcomes that you're creating and the feedback from the families who you serve. But if you're small enough, you could strategically stay underneath the radar and the only impact is, hey, we have to just pay that fine. So like this seems like a system that is ripe for fraudulent activity very transparently. Yeah. Yeah. Not that I want to ever have a conversation with Elon Musk, but it seems like Doge could be looking Right. Exactly. I agree. I mean there are there are important areas where we can deploy resources to make sure that people are in alignment with what is really supposed to be happening

[27:44]  because if we change the incentives, we change the outcomes. Wow. Yeah. And you know for for big organizations like mine um that comes with a lot of regulatory burden too. We get audits all the time and an audit in our world means we owe money back. So Medicare comes in and does these audits and says, "Okay, we think we paid you too much for this patient." And so now we want to do this audit and we want to see all the records and um you know the the little the little guys, they don't get those kind of audits, you know, it's just people like me that because of our scale, right? Yeah.

[28:20]  All right. Well, this is you're really enlightening um the entire space, right? because there are checks and balances that need to be made but also you know thinking about how you as an organization have withtood this the tales of time right and been able to provide such impactful stories in the community I mean just the census that you guys have today and I think about the families that are impacted like you guys are reaching deep into the organization or into the community like you guys are a cornerstone of the end of life experience for Southern Nevada and Clark County um I would almost say that you guys are like an integrated part of the culture of our community as well because of how great work you do and how many people you impact. I want to use that word culture to kind of talk about um the organization and how you kind of look at the term culture. Now, I was on a podcast the other day and this leader

[29:08]  said to me, he said, "Remember Kenan, that culture eats strategy for breakfast every single day." Yeah. And if your leaders are not thinking about culture, especially in today's changing landscape of work, they've got it completely backwards. So, what is your prioritization on culture and what does it mean to you? Yeah, culture is everything, right? So, I absolutely agree. I've heard that phrase before that culture eats strategy for lunch and it's true, right? It is absolutely true.

[29:34]  Um, you have to take care of the people that are providing care to the people that you're caring for, right? And you have to make sure that um you provide them with the tools and the resources that they need to do their job every day and challenge them to do their job better tomorrow than they did their job today. So, how are they going to do that? How are we going to accomplish that? Um you know, at Nathan Hospice, we've always had a very transparent policy around communication. You know, we don't have any secrets, right? we share all all of the struggles, the good and the bad with the staff and and I think that that is what um is one of the things that that staff appreciate, right? Like with this pr proliferation of hospice companies, what are we going to do, right? What what is the solution?

[30:23]  And um you know, we've been very fortunate to uh be a best place to work, which is a national uh recognition for about 14 years. And that is an anonymous survey that our um our employees fill out and we have a 94% employee engagement rate which is huge. Now I always like to validate it. So we found another survey that we do at another time of the year just to make sure that like that survey data is good. Yeah. And it it it works out right. So we still have 94% um engagement and the same comments come back on both surveys. So that's good too. So we're validating that that employees feel engaged. But um I I do think that you know um providing education, providing leadership training and identify those leaders once they get here like who are who is that next

[31:12]  generation? What is going to be the succession plan for every one of those managers? If you left tomorrow, who's going to step in and making sure that we've got um people that are trained to do that and feel empowered to do it? Um and then you know the people that you know just show up every day. just making sure that you're rounding with them. We do thank you cards. I send a birthday card and a work anniversary card to every single employee that we have. Um we do a milestone lunch. So if you've been here 10 plus years, we take out to lunch as a group. Um and some of some people haven't ever met each other, right? Because we're a pretty big organization and most of what we're do is remote so people don't have to come to an office every day. Um and you know that makes people feel good. Um, we have a a um a email that I send out which is

[32:02]  like a little newsletter on Monday and we are always putting feedback in about that we get from families and calling out if they call out you know the names of our staff we make sure that we've got that um you know in there and Francis I mean Francis was a great way for us coming out of the um pandemic to make sure that you know our employees knew that we were engaged like we were really concerned about how everybody was doing, not only, you know, after the pandemic, but you know, in the throws of it because it was just so traumatic for people. Um, and so Francis has become this fun thing, right, for the staff and we've got a lot of people that don't even have, you know, a Nathan addospice issued cell phone that opt into Francis.

[32:49]  And now everybody's always comparing like, what did your Francis say today? Because that's exactly what I was thinking. Like, I needed to have that message. Um, and you know, when we first started, everybody was like, "What is this a text message every day? Like, come on." But now people are like, "Where's my text message? Where is Francis?" Right? Um, because it comes at different points of the day. And so, a lot of times that message will pop up and you'll think, "Oh, yeah. I needed to hear that today." Right? And and the the stuff that we're doing with you all on the grief support, I mean, those families that are um connected through uh Francis through grief support really love it. Um, I'm I'm just stunned at some of the feedback that we get when we get those feedback reports of what people say about it, which is wonderful because it's a it's just another way we can touch people, right? And make them

[33:37]  feel like um we're supporting them. So, I say all that back to culture, right? Because I think culture is is critical. One of my favorite leaders um is actually located I've never actually had the honor of actually spending a little bit of time with her, but she is a a 34 year old CEO of a company um that does about a hundred million a year, right?

[33:58]  They are a little family office, so they buy equity and companies, help them turn them around. And she's huge on people. She's like, if you think that some system is going to come into the organization and change what you guys have built, you're completely wrong. It is all about people. And guess what? People appreciate culture. So, how do you build culture? She said, Kenan, not to me, but personally, she's speaking to me says, you know, it's important to remember that culture is built in all the small things, the letters of recognition, the birthday cards, the little messages that you get, the slack acknowledgements, the little pats on the back, the hey, I see what you're doing out there. And I think that we need to really emphasize that more in this world of transactional business, right?

[34:37]  Especially in the world of isolation and loneliness that we live in, the work environment that we participate in every single day is a huge part of our life and a huge part of how we feel about ourselves and the community that we're a part of. And when that community is nurturing, when it's inspirational, when it's encouraging, that is a way in which we can impact our communities today, right? not looking for somebody to come save the day, but the leaders like you, Karen, are the ones who literally have an impact on all of our families because when mom or dad comes home and they feel encouraged, they're going to pass that message on to their family as well. And that is multiplicative. So, I want to congratulate you seriously for everything that you've created. It's a people business, right? You know, it's all about relationships from the the doctor that makes the referral to of their patient to hospice to the

[35:25]  relationship with the family. And so if we're not taking care of the people that have to build that relationship, um, you know, I I have no confidence that they're going to go and build that relationship in a positive way with the people that we're putting them in front of. So here's something that I want to talk about which is really important. So when I talked a little bit about my story, I referenced it, right? In 2008, my grandmother went on hospice for the first time, right? I had no idea what hospice was. And often the other members in my family of all ages had no idea what hospice was nor what to expect. So I want to use this as an opportunity to inform the audience about you know we have a perception right that hospice of end of life is scary but what are some of the ways in which we can get prepared to have those conversations with our family so when we do come across that

[36:12]  inevitable experience we aren't taken back but we have a plan on how to move forward and we've been here before and we're prepared for what this experience is going to mean. Yeah. You don't want to have those conversations in the emergency room, right? You don't want to have those conversations in a high stress situation. So, um, we always encourage people to have those conversations early, right? Like sit down for dinner, right, around a Sunday dinner table, if people even do that anymore. I don't know, but we used to do it. Um, or, you know, while you're on vacation, just carve out some time and just go around and say, "What's important at the end of life?" You know, we spend a a a lot of time, you know, celebrating life. We celebrate birthdays. We celebrate births. You know, they have baby showers, right? And when the when a new life is coming, but we don't talk about

[36:59]  what's important to us at the end, right? And you know, it it's inevitable. It's going to happen to all of us. So, I'm not sure why we're so afraid to talk about it, right? And it doesn't have to be a long drawn out conversation or anything that's sad, but you know, do you want extraordinary measures at the end or don't you? Do you want to be cremated or you want to be buried? Do you want to have your ashes spread in the ocean or whatever it might be?

[37:22]  Right? And those conversations are so important because you don't want to do that in that high stress time when you need to make a decision, right? And so, um, there's lots of tools out there. Um, we have tools on our website where you can download some questions that are kind of guides to help you, you know, have those conversations. Um, and some people don't want to have them, right?

[37:44]  Some people are like I I I don't want to talk about this. This is but you know eventually you just have to keep kind of peeling away that you know that layer to say it's really important for us as a family to know what we want right because as kids you know we're faced with our parents getting older and you know what if we have to make those decisions and in the moment you're like I don't know what I'm going to do right I but with my mom she was always saying that she didn't want you know anything uh that was artificially keeping her alive right So, she didn't want the tubes and all that.

[38:18]  Um, and I was very clear and and you have to be your own advocate because the people in the hospital are like, "Oh, yeah, we can keep her alive. We just shove a tube down her throat and get her all wired up." And I kept saying she doesn't want that, right? And I don't want her to come back and haunt me, right? So, I want to make sure I do what she wants. Um, but I knew that because she had been very, very clear about it.

[38:40]  We didn't talk about it all the time. We didn't talk about it except maybe once or twice in probably the last 15 years, but I was very clear that that's what, you know, she wanted to have happen. And then that led to a conversation with my sister and I and you know, then um her she had four sisters and so they all talked about it. So it just it doesn't it might not happen today, but it's important to really have those conversations. Also important to recognize that hospice is not just for elderly people as well, right? We can have events in our lives where we have to go on hospice at multiple different ages. And so being prepared at any stage in life is super important. Yeah. Well, Karen, this has been an amazing conversation with you today. I want to give you an opportunity to share with the audience how they can not only learn more about Nathan Add, but how they can

[39:27]  support the mission and the amazing work that you guys do for hundreds of families every single day across the valley and just in the southwest of the United States. How can we get involved? So, we've got a pretty comprehensive website. Um we there's all kinds of information there about hospice. Um we do have a foundation. Uh we do lots of events uh during the year. The other thing that um you know we do we have a lot of volunteers. So there's lots of volunteer opportunities um in hospice and you know if you don't want to spend time with a patient, we've got all kinds of things that you can do volunteering at our events or delivering meals or you know whatever it might be. Um and we have a camp for kids that's coming up.

[40:05]  We're always looking for volunteers for that. So, we take the um kids up to Mount Poty for a couple of days and it's a a way for them to uh process their grief and so there's all kinds of opportunities on our website for ways that people can support us. So, we're not always looking for that philanthropic dollar. If there's a way that people can give back their time and attention, um that's always a good way to do that, too. So, one of our traditions here on the podcast is our previous guest wants to ask you a blind question. Okay. Now, this is a little bit more of a contextual question. So imagine today we get a knock on the door and outside your door there's a time machine and there's a note that says if you press this button you're going to go back to speak with the 20year-old version of Karen and you have five uninterrupted moments with that person.

[40:54]  You can give them any advice to how on how they're going to navigate to the future to be right where we're at here today in this conversation. What advice would you give to that version of yourself as they navigate the future? I would say to that person, don't listen to the voices in your head, right? You're like your selft talk, right? And don't be afraid to try something new because it's all going to work out as it always does. Well, Karen Rubble, thank you so much for coming on the show. Seriously, this is an amazing episode. You are the definition of heart and hustle and I'm so glad that you know the audience was able to learn a little bit more about you today. Seriously, can't thank you enough. That's the episode, guys. We'll catch you in the next one. Okay. Bye.