Lessons from long-term care life
When my Mom had to enter a rehabilitation facility for the first time, I had no idea what to expect. I didn’t understand that the rehab facilities she was referred to doubled as what I had considered nursing homes. I didn’t understand the time limits that would be enforced based on her recovery and “performance.” In short, I was completely unprepared.
I wish I had known Molly Gadd then. Gadd serves as the only nurse practitioner at a long-term care and rehabilitation facility in Northern Kentucky that houses a maximum of 140 patients at a time. She is kind, warm, funny and a thoughtful expert in how to work with patients and staff.
Gadd interviews every patient admitted to her facility, ostensibly to talk about their medical history and current needs. But she has found that some of the most important information she gathers has very little to do with patients’ health.
“I was surprised at how interested I was in older people’s stories,” says Gadd, who never set out to specialize in working with older adults. After enjoying work in acute care earlier in her career, though, she found that working with older patients allowed her the chance to use specialized skills and be part of an environment she enjoys. “I try to always learn from what they are telling me. They have a lot of wisdom that I don’t like to overlook.”
She also remembers from her medical training that older people are more likely to feel like the value of their lives has diminished. “They often feel neglected — like they don’t matter anymore,” Gadd says. Offering patients more of her time during intake interviews is, in part, a luxury that a long-term care facility can provide. But it’s also an important part of offering comfort and connection, she adds.
“I was surprised at how interested I was in older people’s stories.”
Her patients have shared advice about how they’ve managed to sustain long marriages (“my wife was always right” is a common theme) and told her gut-wrenching stories about how they survived combat and killed in the name of duty.
Getting to know patients as more than a collection of symptoms allows Gadd to check in with nurses, aides and assistants in more meaningful ways and also to make more comprehensive recommendations to her facility’s medical director.
Every day, Gadd checks in on patients who have developed fevers, had non-serious falls or otherwise gained the attention of an attending nurse overnight. Her areas of expertise — care of chronic wounds and other skin conditions — are in high demand. Bed sores, pressure ulcers and infections are both common (due to limited mobility) and particularly challenging (due to decreased circulation and complicating medical conditions) for older patients. “Always addressing those and really trying to prevent them is the biggest job in a long-term care setting,” she says.
Gadd says in a typical day she’ll see about 20 patients before she heads home. She’ll also consult with the facility’s medical director, and while he gives her welcome autonomy with patient care, she’s grateful for the extent of his dedication. “He is in the building seven days a week,” she explains, noting that he also makes hospital rounds and sees patients as part of a practice. “He is so committed to this place.”
She notes that her appreciation of patients’ stories isn’t the only unexpected lesson she carries with her at work. Coming from a hospital setting, she admits she heard a lot of nursing home horror stories of untrained staff and even dangerous incompetence. In reality, she’s found staff members who are caring and intuitive. “While some of them may not have the education you might find in a hospital, they just have good common sense and know when to report things to me,” she says. “I’ve been so impressed.”
Still, Gadd acknowledges her good fortune at finding a great facility. She also says it’s critically important to do as much research as possible about care alternatives before your loved one makes a move. But sometimes you have hours, not days, to make a decision. And sometimes you may be limited by insurance coverage or geography. No matter your situation, Gadd offers some important pointers to consider:
- Try to take a personal tour of the facility options and ask to talk to family members of long-term care residents. Phone calls can’t substitute for seeing, and smelling, the rooms, hallways and community spaces where your loved one will be living.
- Do whatever you can to visit your loved one regularly, or set up a system of visitors who can gauge changes in symptoms, behaviors, eating or sleeping patterns or anything else unusual. “I listen to family so much because they see changes first,” Gadd says. “I feel like I get my best information from them.”
- Look for underlying causes for topical or surface symptoms. A pressure ulcer or bed sore, for example, might develop because a typically mobile patient hasn’t been out of bed for a few days because of poor diet or a urinary tract infection or other illness. Staff, unused to having to assist in moving this patient, could easily overlook a subtle change.
- Barrier creams (aka diaper rash ointment) and comfortable adult diapers can make life in long-term care a lot more comfortable. Gadd is always on a quest to protect her patients’ skin from unnecessary irritations. She says that most facilities often only offer one type of underwear for incontinence and it’s typically not the soft and comfortable kind. Making your loved one feel good all under, then, can depend on providing an ample private stash and working with aides to make sure it’s being used.
- Find out where patients can exercise control and make the most of them. Take room décor, for example. Gadd recalls a patient with Parkinson’s who had loved playing guitar for much of his life. While he was no longer able to play, his family helped him hang three guitars on his room wall. “It makes him feel more at home,” Gadd says. Favorite books, a familiar pillow, a quilt or a warm lamp can begin to transform a sterile room into a cozy nook.
- Don’t forget treats. Unless there are dietary restrictions, you can bring in favorite snacks, or better yet, take road trips to favorite restaurants. Gadd’s facility allows patients to bring small, dorm-sized refrigerators where they can stock their favorite drinks, since the only options available on-site are coffee, tea, lemonade and water. “If they love soft drinks, then their families can provide them with weekly or monthly supplies — and we have an ice machine,” Gadd says. “Just little things seem to make the biggest difference.”
- Encourage your loved one to join group activities, even if at first they feel embarrassed. “A lot of people when they’re in that stage can’t see well or can’t hear well and it’s more of a stressor for them to be with people,” Gadd says. Staff can usually provide amplifiers, headphones or other assistance — it’s their job to engage and connect with patients and they should be used to making accommodations. “If you get to know the activities director, that’s probably going to help your loved one.”
- Lobby for continuity of (excellent) care. “We are like their family,” Gadd says of facility staff. “They know us, they recognize our faces — typically the same aides will be assigned to the same patient.” Ask about routines, schedules and make some drop-in visits to see the environment when you’re not expected.
- Don’t waste time feeling guilty. This is a big one, Gadd says. “I think there is still that generation that feels guilty if they were to consider a nursing home. It’s not an admission of failure or anything.” She notes that non-medically trained family members can become exhausted and burnt out after days, weeks and even years of gradually increasing caregiving. “It builds up. You get tired, and most likely challenges aren’t happening on a nine-to-five basis — it’s in the middle of the night. In the nursing home, we’re open 24 hours. The nurses are up and awake and if there’s someone really struggling, there’s a place for them to go. It’s a much safer situation.”
Find out more about the caregiving journey and sign up for updates on my new book, “Day By Day,” at elissayancey.com.
