On a paper in Marjorie Mulanax's office are words that were written by members of Hospice Austin's leadership team during an exercise in which they had to pass around sheets with a different person's name on each one. The task was to anonymously write a word that describes that person.
For Mulanax, they wrote words like "dedicated," "thoughtful," "gracious" and "compassionate." And another that's particularly fitting for Mulanax, who this year celebrates her 25th year as executive director at Hospice Austin, a nonprofit end-of-care provider that last year helped more than 2,200 people in five counties in Central Texas: "perseverance."
"I've always said that the volunteers and paid staff at Hospice Austin are this community's angels," says Earl Maxwell, chief executive officer of St. David's Foundation. "The work they do is so precious. Not everybody can do that; not everybody wants to be around dying people. Marjorie has been the leading angel."
Mulanax, 59, never would have imagined she would be working in a field that is about dying. As a kid, she was always fascinated with medicine, but, she says, was "afraid of being responsible for someone else's life."
Mulanax grew up in a suburb of Cleveland with two sisters and a brother.
"All four of us still get a long," she says.
She remembers her mom would take the kids to the park a lot. Of course, her mom would be dressed in heels and a dress for the park. Her father worked as a carpenter.
"We never went hungry, " she says. "Money was tight, but we always had a roof over our heads."
She had a wealthy aunt who made sure Mulanax could go to a private Catholic high school.
"That was life changing for me," she says.
Her high school then connected her to a scholarship at John Carroll University in Ohio, where she studied business. She later earned an master's degree in business at Northwestern University in Illinois.
The summer before she went to Northwestern, she had an internship at General Electric and learned she didn't want "to worry about light bulbs for the rest of my life."
Mulanax knew that whatever she would do, "It had to be meaningful for me," she says.
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Her goal was to be a hospital administrator. Her first hospital job was in Harvey, Ill., and, she says, while it was a good hospital, "it was extremely political."
At that hospital, she says, "It was so hard to get anything done."
She began to question if this was what she wanted to do, but life stepped in and took her to Australia.
She and her husband, Craig Fulthorpe, met by "a happy accident," she says, through mutual friends. He was at Northwestern, getting a doctorate in geology.
When he got a chance to go to Australia to study marine geology, they went.
In Australia, she says, she "fell into her dream job" at a hospital there, where she could get something done.
She loved it. She was young and didn't know a whole lot about the Australian health care system, but they trusted her and her ideas.
After three years, she says, Fulthorpe needed to get back to the U.S. to advance his career. He got an offer to do research at the University of Texas Institute for Geophysics.
They set off for Austin. It was 1990 at a time when Austin and its health care systems were much smaller and going through a transition period.
Mulanax applied for hospital administrator jobs in Austin, but nothing was happening. "It was not meant to be," she says.
She decided to expand her search and found out about Hospice Austin from an article in the Austin American-Statesman. She connected with Peg McCuistion, who was executive director at the organization that had formed in 1979 and began serving patients in 1980.
"She was willing to talk to me," Mulanax says.
McCuistion hired Mulanax as a contractor to do a strategic plan for the organization. At the time, Hospice Austin had about 75 employees and served about 300 people a year, Mulanax estimates. Today, it has 280 employees.
McCuistion was looking to retire in a couple of years and was quietly finding her replacement. After that contract ended, McCuistion hired Mulanax to be the assistant director.
McCuistion, Mulanax says, "did this really smart transition plan, not just because it was me. It meant very little stress on the organization."
Mulanax still had to apply to be executive director when the time came and go through the process. By the time she was chosen for the job in July 1994, she had been there three years and everyone was already reporting to her.
"They knew what they were getting," she says. "They were all OK. I was the one who wasn't confident."
It was very different than what she knew previously. "I was just trying to get the lay of the land," she says.
She liked the idea of it, though, especially after her experience in Illinois. "It's a smaller environment where you can make a difference."
Plus, she didn't see people trying to undercut one another.
"People are called to do this work," she says. "My philosophy is don't mess it up for them."
What she knew about the people who worked at Hospice Austin is "they are kind of different," she says, but "they were so passionate about the care."
To be executive director of a nonprofit hospice, you have to be compassionate, but you also have to have the business side, too, Mulanax says.
When she took over, Hospice Austin was digging out of a financial hole. Now, Mulanax says, "We're a much more stable organization."
"We had to learn what our role would be," she says. "Over time, we grew up."
Hospice Austin has two streams of funding: Insurance such as Medicare, Medicaid and private insurance, and philanthropy.
The philanthropy is what it uses to make sure that it doesn't turn anyone away from care no matter how complex or how expensive the treatment might be.
Nannette Overbeck, former board chair, first worked with Mulanax as the owner of a specialized pharmacy. Hospice Austin would come to her with a need and she would give them the price at a reduced rate, but it was often thousands of dollars a month. They never said no, Overbeck says. They would find a donor.
"Austin has always been a generous town because they know we will say yes," Mulanax says. "We do the right thing."
That right thing gets done on the limited budget of a nonprofit organization. "You want to do everything you can, and do everything on the littlest budget," she says. "It has made it very challenging."
As Mulanax and Hospice Austin were trying to figuring out what they would be together, they were also having to educate the community about what hospice care is and when to access it.
People often wait too long to call for hospice care, she says. About 40% of hospice patients get seven days of care or less, Mulanax says.
Her parents didn't have the opportunity for hospice. Her mom died suddenly of a brain aneurysm. Her father had emphysema, but had so many close calls before that it was hard to believe that it was really happening when he did die. "He never wanted to talk about hospice," she says.
Hospice Austin meets with senior care facilities and hospitals to try to spread information about what it can offer.
As Mulanax watched the desire for hospice care grow, so did the regulations.
She spends a lot of her day working on paperwork and keeping up with the regulatory aspects of health care. "There are multiple sets of rules we have to follow," she says.
"She has her steadiness and commitment to stay the course," says Nancy McCranie, the director of volunteer and bereavement services. "She asks for advice and help from really smart people. She's so humble. Because of that, we've been able to navigate the turbulent waters of health care through lean times and good times. A different kind of leader might have had a different result; we might not be here or look different than we do."
Mulanax would like to spend more of her time seeing Hospice Austin at work and less on paperwork.
The hard part is "do I go to this meeting or get this thing I need to get done? There's always more than enough work that I should be doing."
An ideal day for Mulanax would be to spend time riding along with the nursing staff to visit patients, she says. "They remember every single patient every day."
She remembers one ride along with nurse Carol Kiehl. "She was so well organized," Mulanax says. "She had her whole day mapped out ... she was dazzling to watch."
And she remembers one memorable patient, who had been a Hospice Austin employee. "She felt like a kid in a candy store," Mulanax says. She told Mulanax, "All the people I love are coming back to me."
Mulanax is not known to micromanage. She empowers her team, but "she knows everything that's going on in the organization," Overbeck says. "It's just amazing the hours that she puts in. She's not only at the office, there's so many meetings after work with board members or going to a charity event for people to learn about Hospice Austin."
"I feel very free that if there's something that's a concern to me that is happening in the office, her door is open," McCranie says.
"It's the respect; the family aspect," says Susan Franzen, chair of the board of directors at Hospice Austin. "They care about the people that work there ... She really does set the tone, and it engages and coaches and empowers her leadership team."
Hospice Austin has had smart growth of new programs and adding capacity for helping more people. It started a palliative care program that might become bigger than the hospice program. It offers bereavement programs, including webinars and support groups, and Camp Brave Heart for children who have had a loss. Mulanax says Hospice Austin is now starting to do more community-based care as well.
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Hospice Austin has now outgrown Christopher House, its hospice hospital, and is looking for a new location.
Christopher House was a different nonprofit that was dedicated to taking care of people with AIDS, but as better drug therapies were developed people no longer had to go to a hospital for care. They were surviving and thriving at home. In 1997, it became clear that Christopher House no longer had the number of patients to support it, and it closed.
Hospice Austin took a leap to buy it and add a new component to its care spectrum, a dedicated space to die outside of a home or typical hospital setting. Hospice Austin, which at the time was raising about $300,000 a year in philanthropy, had to raise $1 million in a short period of time to buy the building. They raised $1.5 million in 10 months and reopened Christopher House in early 1998 to serve anyone dying.
"Now it's time to do it again," Mulanax says of a new campaign to create the next Christopher House. "We're growing so much," she says. "We need it."
Just like Hospice Austin grew, Mulanax's family grew. She began the job with no children, but quickly added daughters Sarah, now 22, who works at Texas Instruments in Dallas, and Rebecca, 19, who is a sophomore in neuroscience at the University of Texas.
"I think I'm a very good mom," Mulanax says. "I think I've tried to always be there for them."
She knows she's a bit of a workaholic, but she does carve out time for an almost daily cup of coffee with Fulthorpe.
"It's been a very good thing," she says.
When she's away from work, she likes to walk her black Lab mix, Ella, and swim at the Jewish Community Center near her house. She likes to read, "and I almost never do."
She loves to travel. Some of the most fun she and her family have had was white water rafting in the Grand Canyon. All they had to do was hang on and watch the scenery. No phones, just a connection with the people they were with.
It would be that kind of peace that might one day come with retirement, but Mulanax isn't there yet.
"It's not going to be another 25 years," she says, but "if I feel like I am making a positive difference and I'm excited about the things we are doing, then it's good."
She also can't imagine doing anything else.
"Where else would I go? Where else would I find as meaningful work?" she says.
"I have never felt that I've gotten on top of the job," she says.
She thinks of the future for Hospice Austin; of course she does, "but if you go too far out, it can be overwhelming." "It really is one day at a time."
She does see exciting things on the horizon like a new Christopher House.
"She's always striving to do better," says Overbeck. "If there's something new out there, she's just all in."
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