Hospice Nurse Executive: Leaders’ ‘Tough Balance’on Improving Health Equity, Sustainability

Today’s hospice leaders are balancing several competing demands in the battle of sustainability, according to Altonia Garrett, a registered nurse. Executives are facing complex decisions around financial and labor pressures, technology innovations and improved access amid rising demand.

Hospice News recently sat down with Garrett to discuss the most significant challenges at both clinical and business leadership levels.

She has spent roughly two decades in the hospice, home health and palliative care space. Garrett is certified in health equity research and became a registered nurse in 2008 after receiving a master’s degree in healthcare and business administration.

She currently serves as founder and principal of Garrett Innovations LLC. Founded in 2026, the consulting company provides services to healthcare organizations related to workforce and leadership development, strategic growth, health equity and access, technology innovation and operational and clinical improvement.

Garrett previously served as COO of Virginia-based Blue Ridge Care since 2023, leading the organization’s clinical services, operations, partnership development and growth.

She began her career in 2005 as a home healthcare consultant and marketing manager at the nonprofit health system MedStar Health. Two years later, Garrett stepped into a similar role at The Washington Home and Community Hospice.

Garrett also has served in several business development, executive and clinical leadership positions at Hospice of the Chesapeake, MedStar Health and AccentCare. She also served in various roles at Capital Caring Health for more than 12 years. Garrett began as a clinical supervisor at the nonprofit health system, moving through its ranks to become the executive director of Capital Caring Health’s Center for Equity, Inclusion and Diversity.

She was also a senior advisor in innovation and health equity at the National Partnership for Healthcare and Hospice Innovation (NPHI).

What are you most proud of in your hospice and palliative care work during the past two decades?

My proudest moments are really about the good people that I’ve helped bring into the space over the years, from clinicians to marketers, volunteer coordinators, pediatric leaders and business development people. It’s making more people aware of hospice and its benefits and sharing that access and information.

I’ve also been able to bring more innovations to different organizations, including community programs and building energy in the health equity space.

What were some of the most challenging experiences you’ve seen, both at the bedside and in your leadership roles?

Leaders have to strike a tough balance. It’s remaining true to the people who are doing the work — helping and caring for them. We also have to know the goals, standards and margins of running the business of hospice.

Many of the challenges we face today will continue into the foreseeable future, and they are interconnected. These include workforce sustainability, financial and regulatory pressures, access to care to high-quality care, public understanding of hospice, technology and the need to adapt to an ever-changing healthcare environment.

Hospice professionals do emotionally demanding work, and organizations need to think seriously about how they support their teams. Compensation matters, but so do manageable workloads, strong managers, professional development and a culture where people feel valued.

Organizations must manage rising costs, reimbursement pressures, regulatory requirements and increasing expectations for quality. Leaders must make thoughtful decisions about resources and growth while ensuring that financial pressures do not compromise patient care. That requires strong operational discipline and a clear understanding of the organization’s priorities.

We need stronger relationships with referral partners and more effective ways of educating communities about the support hospice can provide. Some patients are referred to hospice later than they could benefit from it, while others and their families may not fully understand what hospice offers. Misconceptions, cultural concerns, limited provider education and gaps in communication can all affect access.

Leaders will have to be more comfortable navigating change, particularly as technology evolves. Artificial intelligence and other digital tools may create opportunities to improve workflows and decision-making, but leaders must understand how to use them responsibly.

The challenge is balancing all these competing demands while staying connected to the mission. The leaders who will be most effective are those who can make complex decisions, adapt their organizations and maintain a clear focus on quality, compassion and the needs of their communities.

What is important when it comes to building the next generation of hospice leaders?

Developing the next generation of hospice leaders requires us to be deliberate about both whom we prepare to lead and how we prepare them, as well as when we begin.

As we select and develop those future leaders, it’s important to note that hospice leadership is about much more than managing operations or understanding regulations. It requires clinical understanding, business acumen, emotional intelligence, ethical decision-making and the ability to lead people through complexity and change.

We need to consider a few things:

– Creating meaningful pathways to leadership and recognizing that some of our strongest future leaders may be working at the bedside supporting families, coordinating services or building relationships in the community.

– Mentorship with sponsorship and real opportunities to lead. It’s important to share knowledge, but it’s also equally important to open doors and invite emerging leaders into strategic conversations.

– We must prepare leaders to understand hospice as both a deeply personal service and a complex healthcare business. Quality, compliance, technology, financial stewardship and other operational responsibilities are interconnected. Decisions in one area can directly affect the experience of patients, families, and team members.

– We need to develop leaders who can balance accountability with compassion. This includes building healthy organizational cultures in which employees feel supported, expectations are clear and the mission remains central to decision-making.

What do you think is needed to improve diversity and inclusion in hospice leadership And how could having more diverse representation among leaders impact end-of-life health equity?

Improving diversity and inclusion in hospice leadership requires more than acknowledging the problem or making a commitment to representation.

We must start by looking at how people get into leadership in the first place. It is not enough to say we want more diversity. We must examine how we recruit, develop, mentor, sponsor and promote people, and whether everyone has a fair opportunity to advance.

That means investing in people who may not have access to traditional professional networks and giving emerging leaders meaningful opportunities to demonstrate what they can do.

Representation matters because leadership influences how organizations think, what they prioritize, and how they respond to the communities they serve. Diverse leaders bring different lived experiences and perspectives that can help organizations recognize needs or barriers they might otherwise overlook.

This is particularly important in hospice and end-of-life care. People approach serious illness, caregiving, death and grief in different ways, shaped by their experiences, cultural backgrounds, family structures, faith and trust in the healthcare system.  

Having more diverse representation in leadership can help organizations ask better questions, build stronger community relationships and develop services and communication approaches that are more responsive to the people they serve. Organizations must also be willing to examine their practices, listen to communities and address the barriers that prevent people from accessing appropriate services.

It is important to recognize that the responsibility for advancing diversity and inclusion cannot fall solely on leaders from underrepresented backgrounds. It must be a commitment shared by executive teams, boards and organizations as a whole.

What’s next in your professional journey? What are some of the ways you’ll remain connected to healthcare delivery and equity?

As a registered nurse, healthcare executive, patient, and caregiver, I have had the opportunity to see the healthcare system from various perspectives. Those experiences have reinforced my belief that strong organizations, effective leadership and meaningful community partnerships are essential to delivering the care people deserve.

As I move into this next chapter, I want to use that experience in new ways, while remaining firmly rooted in healthcare through strategic advising, consulting and opportunities to support organizations that are committed to improving care and strengthening the communities they serve.

I’m also interested in expanding my work at the intersection of health equity, organizational strategy and emerging technologies, including artificial intelligence. I believe there are opportunities to help organizations think differently about how they operate and strengthen their infrastructure, how they expand access and reach underserved communities, and how they prepare for the future of healthcare without losing the human connection that is so important in the care we provide.

Garrett Innovations LLC is a business I’m developing to bring together my experience in healthcare leadership, organizational strategy and mission-driven and community-focused work. At its core, the idea is to help mission-driven organizations translate their mission and vision into practical strategies, stronger operations, sustainable growth and meaningful community impact. I am also exploring how health equity and emerging technologies, including artificial intelligence, can inform organizational strategy.

Healthcare and community-based organizations will be a natural focus, particularly those working in hospice, palliative care, PACE, aging services, and other areas where access, quality, and community partnerships are essential.

I am building Garrett Innovations intentionally and continuing to shape how these areas will come together. I want to be responsive to the needs of the organizations I work with rather than offer a one-size-fits-all solution. Ultimately, my goal is to help organizations become stronger, more effective and better positioned to serve their communities. I am especially interested in helping organizations think strategically about growth, leadership development, operational effectiveness and sustainability.