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Erica Pahua

Journey of Compassion: Erica Pahua's Path to Culturally Competent Hospice Care

The beginning and end of life have always fascinated me. As a Midwife, I found the parallels between helping someone enter the world and aiding their exit profound.



Reflecting on what I loved, Hospice felt like a natural progression from my experience in birth. I started my career working with seniors and it felt natural for me to explore ways that I could serve both stages of life. I began researching how to open a Hospice in Tennessee and quickly found how complex the process is due to Tennessee being a Certificate of Need (CON) state.


Discouraged but not defeated, I spent over a year researching the CON process and found that one of the criteria for obtaining a CON was demonstrating that there would be a consumer advantage to bringing competition into the industry.

With this new information, I decided to take a leap of faith.


For our first application, I chose to focus on what made us different, including being female-run, minority-owned, currently serving rural communities, complex pediatric clients, and minorities, as well as how great Interim Healthcare’s continuity of care model is and the fact that we already served many families who would benefit tremendously from having a continuity of care model.


I felt that the consumer advantage was obvious. However, come the day of our hearing, we were opposed by three Hospice agencies who felt expanding our service lines would infringe on their service area and that we would not be of any benefit to the community.


We sought to explain our differences to the Health Facilities Commission. We felt strongly that the other agencies lacked many features we had and that we could, in fact, be of consumer benefit. Unfortunately, the Health Facilities Board felt that we needed a stronger argument and denied our first Hospice application.


I was left feeling discouraged but in my heart, I knew that the other agencies were wrong. I knew that we could offer something different and that ultimately the consumer should have a choice.


I began to focus on what I knew we could offer that other agencies could not and I found a renewed sense of purpose after my research led me to discover a significant gap in culturally competent healthcare in Tennessee.



My only challenge would be demonstrating that there was, in fact, a need for culturally competent end-of-life care.


My research began to go more in-depth.


I started by calling all the Hospices in our area to inquire about services for Spanish-speaking clients. Shockingly, none had a Spanish-speaking nurse. How could it be that these Hospice agencies were paying lawyers to oppose a minority-owned home care company when they did not offer culturally competent care to the fastest-growing population in Tennessee. This spurred me into action.


 I drove to local hospitals to speak with case managers and social workers who serve minority communities. As the front lines, I knew they would know best. Interview after interview, they all unanimously reported struggling to find culturally competent care due to language and cultural barriers.


As I left the hospital, I bumped into a Spanish brochure from a local Hospice; I called the number and once again confirmed that they lacked Spanish-speaking staff despite advertising to the Hispanic community. This further highlighted a significant gap in care for the Hispanic community. Determined to address this, I sought insights from local doctors.


I interviewed doctors who serve the Hispanic community and they all unanimously attested that the growing Hispanic population lacked providers to serve them.


A local doctor recommended I contact the Hispanic Nurses Association (NAHN). To my excitement, they were having a local meeting in the upcoming week. I made an effort to be there and as I walked through the Health Fair, I got lost and asked a nurse who was aiding in the Health Fair if she had seen any members of the Hispanic Nursing Association.


She promptly responded that she had not but that she would be very interested in learning more about them. She stated, “I’m a Hispanic Nurse. I’m a Palliative and Hospice Nurse”. At that moment, I truly felt like it was God telling me that I was in the right place and moving in the right direction.


With my heart fully motivated, I found Zacnite, President of the Hispanic Nurses Association. She was amazing. An advocate for the Hispanic community. We shared each other’s projects and found that we had a lot in common. She was eager to be of support to our project because she was very involved in the Hispanic community and knew firsthand their needs.



She quickly put me in contact with a NAHN member and Hispanic Home Health Nurse who shared her story about bridging knowledge gaps and misconceptions regarding Hospice, further reinforcing the need for trusted relationships between providers and the Hispanic community. Additionally, she put me in contact with a family who shared their experience and feelings of isolation due to a healthcare system that did not understand their culture nor their cultural needs. The fact that they never felt heard or understood never allowed for them to trust the motives behind end-of-life care.


Their story was incredibly heartbreaking because it highlighted the way the healthcare system has failed many families. The consequences of a lack of cultural representation became more evident after hearing this family’s story.


Furthermore, candid discussions with local Healthcare liaisons confirmed the difficulty in converting Hospice referrals due to language and cultural differences. After interviewing Hispanic families who had refused Hospice services, it made sense. These families never felt connected to these providers. They mistrusted the system and the motives behind end-of-life care.


This solidified my belief that there was a market for culturally competent care and further pushed my drive to obtain a Certificate of Need.


Through a mutual friend, I met a funeral homeowner who serves the Hispanic community. He shared his experience of how a lack of cultural sensitivity impacts the end of life. He advised contacting the Hispanic Chamber of Commerce in hopes that they could provide much-needed local support.


I reached out to the Hispanic Chamber of Commerce and explained my project and my desire to find local leaders who could share their point of view when it comes to culturally sensitive end-of-life care. Through a networking event, I had the opportunity to meet a Latina doctor with public health expertise who was working on a Latino Health Coalition, this perfectly aligned with our mission and she was eager to learn more and contribute. She had just completed her degree in public health so she had a very clear understanding of what this project meant and why it was so important. She was ready and willing to put all hands on deck to help with our project.



After speaking to Yuri and Lorraine from the Chamber of Commerce, they suggested that I speak to David Plazas from The Tennessean. David had a clear understanding of population growth and the way in which our Hispanic numbers are growing in middle Tennessee.

All the puzzle pieces were coming together.


We had a lot of support going. One thing that kept coming to my mind was the importance of religious leadership. My hope was to meet a religious leader that could provide me with their perspective on the project.



The Hispanic Chamber of Commerce was having a Christmas event. I had another event scheduled that day but I kept getting the feeling that I needed to go to this event. I ended up attending the Chamber’s event and met a lot of great people. Towards the end of the night, there was one table at the far back that I had not had the pleasure of meeting. I approached them to say goodnight. As I was leaving, I had the opportunity to meet Pastor Gerardo.


A few days later, I reached out to Pastor Gerardo. We met for breakfast and had a great conversation. He told me about his experience with Hospice. He explained that his experience with Hospice included a 21-year-old who was terminally diagnosed. He explained that in the beginning the family was incredibly hesitant to receive services. They feared the system, they feared the cost and they were hesitant to receive services due to a significant language barrier. He acknowledged that very little was known of Hospice in the Latino community and acknowledged that Hospice was a much-needed service but it was very poorly understood.



He recognized that Hospice was a benefit that could have tremendous benefits to the Hispanic community. He shared that the Pastor’s Association was preparing to start meeting again and looking to find ways to bring information about community services into their network. He suggested that I join him at the next Pastor’s association because he felt that we could create a large impact in the community. I truly felt like it was divine intervention. He then voiced what I was feeling. He said that Nashville was on God’s timing and that he felt the tide shifting for the Latino community in Nashville and I truly felt the same way.


With newfound inspiration and connections, I focused on demonstrating the importance of representation in Healthcare to the Health Facilities Commission. I gathered data on population growth, gathered letters of support, and gathered information on the importance of equity of healthcare from the perspective of the community. With this information, we completed our second application with a focused emphasis on minority needs in Hospice.


On the day of the hearing, I felt nervous but also empowered by a greater purpose. I knew that we were the voice of a community. A community that deserves representation and choice.


As we got ready to present our case, I noticed Pastor Gerardo walked in. I asked him to pray and at that moment, I truly felt the magnitude of our project. I truly felt like God was behind our project. The way our community united to tell their story was beautiful. We presented our case to the Health Facilities Commission. We had opposition from Alive Hospice. Ultimately, we were denied the opportunity to serve Davidson and Rutherford County but we were granted the opportunity to serve Montgomery, Robertson, and Cheatham county. This was a significant victory against the odds. We had been told by many that it would be impossible to obtain a Certificate of Need. We had moved the needle forward.


We have been able to show the impact that we can have when our community unites with a greater purpose in mind. The serendipity of connections and the unwavering support from the community was proof that we can move mountains when we unite. We have the opportunity to be a part of a larger impact by serving and representing a community in need. I know the journey is just beginning and I am excited for what is to come.



















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