Navigating aging care with Back Nine Nurses

0:00 Welcome to Something More with Chris Boyd. Chris Boyd is a certified financial planner, practitioner, and senior vice president and financial advisor at Wealth Enhancement Group, one of the nation's largest registered investment advisors. We call it Something More because we'd like to talk not only about those important dollar and cents issues, but also the quality of life issues that make the money matters matter. Here he is, your fulfillment facilitator, your partner in prosperity, advising clients on Cape Cod and across the country. Here's your host, Jay Christopher Boyd. Hey, welcome. Thanks for being with us for another episode of Something More with Chris Boyd. I'm here with my co-host, Jeff Perry. We are both of the AMR team with Wealth Enhancement Group, and we have some great guests today.

0:46 We're talking about really important issues for people in the aging process. Joining us today is Kristin Hyde and Deborah O'Kelly. They are the founders of Back Nine Nurses. Thanks for being here. Thank you. Thanks so much for having us. So who's the golfer? I am. Okay. That's the name, huh? Yeah, I love the double meaning of the name. It's been so much fun to combine a couple of passions in life together, and we found that it kind of creates some fun curiosity when we wear our name tags that say Back Nine Nurses. It just creates some good conversation and some opening areas to talk about the business.

1:30 Yeah, definitely double meaning there. Tell us a little bit about, to start off with, your backgrounds and how that led to the creation of your business. Okay, sure. Yeah. So Kristin and I are both registered nurses. We are certified geriatric care managers, certified dementia practitioners, and we work together. We met together working at an assisted living and memory care community, although we've worked in many different areas of healthcare, including medical, surgical, short-term care, long-term care, assisted living, memory care, primary care, so many different areas.

2:14 But all along the way, and the reason that kind of prompted us to launch Back Nine Nurses was we heard so many times over and over again from families, we wish we had known this, we wish we had known that. And trying to navigate this world of healthcare that is so busy, confusing oftentimes, and trying to help, you know, we saw those families struggling to navigate all the decisions that need to be made. And sometimes within record speed, they're confronted with really life-changing decisions and needing to make decisions quickly. That's a great point about, seems as though too often families find themselves in crisis when trying to deal with aging in place or, you know, aging issues.

3:07 Tell us about what leads to the kind of instances that you work with people. Is it that kind of scenario where someone's visiting mom and dad and then says, gosh, things have changed, we need help, and there's a sense of urgency about it? Yeah, so often, like, especially around the holidays, like, especially being on the Cape, the parents are retired here, kids come to visit from out of state. And, you know, they notice, oh, you know, mom left the stove on last night. And they kind of, when they're gone, they don't really, they kind of put it on the back burner, per se.

3:47 And then these things they start noticing. And then, you know, it's great when people are like, you know what, this is kind of happening, we're seeing changes in mom. Can you help us now? That gives us a chance to actually, like, start the proper planning. What are some of the examples of the kind of changes in mom or dad that the family might be looking for as indications of aging, creating some challenges? Yeah, we see, you know, they notice cognition changes, the way that- What does that mean?

4:28 Not just the names, but- Expired food in the fridge is like- A big one. Not keeping their food, like, they're letting it sit there and they're not doing anything about it. Yeah, they're finding, you know, pill bottles that may have expired. Could be on the floor. Yeah, yeah. So there's so many signs where, you know, even just during a conversation, when they're working to have a conversation and they start kind of struggling to retrieve what word they're searching for in a conversation, maybe having some trouble remembering names, especially immediate recall.

5:09 Those are definitely signs. You know, people tend to remember their oldest memories the best when they have trouble with that immediate recall. So those are kind of signals to kind of say, hmm, what's going on here? Is it common that you find issues of hoarding and things like that come up as well? Or is that not so much a norm? Yeah, no, that's a sign too. And just the house being in general disarray, you know, not the best food in the fridge or- A weight loss, perhaps. Expired milk, things like that. So kind of, you know, somebody coming in and taking a look around the house and kind of identifying those factors that- The clothing, maybe certain signs as to how they're dressing or not, you know.

5:58 Dressed in animals, like some of our clients have had animals and maybe they're defecating in the house and they're not picking it up, which is normal behavior for this person, typically. Yeah. All right. So these are all examples of things to be on the lookout for, huh? Yeah. Just like you said, yeah, not dressing appropriately for the weather at hand, you know, it can overheat them. Yeah. All those things. I was going to say, it's so common that I've seen in not only my own family, but hear from friends and such is, mom's fine, mom's fine. And they're interacting maybe for 10 minutes here, or a phone call, or even maybe a half hour.

6:38 The elderly person really does a good job at- Mascotting. Yeah. Just their routines and how are you, I'm fine. There's no difficult conversations when you call mom, you know, it's like, what are you doing? But when you're there, you know, your example of visiting for the holidays or something, and you're there for a substantial period of time, hours or days, you can really start to see the signs. And what should you do? What's the first thing a family member should do when they have that- Aha moment. Like, oh, something's not right here. What should I do? Because sometimes it's too, you know, I've seen it, not in my family, but I saw it with a neighbor in that it was almost like an anger from the children towards the parents.

7:24 Like, you got to shape up here. You got to do something here. You know, you're not taking care of the house rather than maybe something a bit more compassionate or constructive. Right. Yeah, exactly. Do you see that in your experience where family members act in a- Scold them, you know, say, hey- Yeah, exactly. That's the word I was looking for. Yeah. Yeah. There's so many different emotions involved because, you know, their memories themselves of their parents are, oh, my dad was always an athlete and he's strong and he knows, you know, he does business finances and he's smart. And then, you know, they get frustrated about what's going on and they don't really understand it themselves quite as well as they may want to.

8:08 And so we strongly recommend reaching out to anyone in the healthcare world that can kind of advise them and give them a little guidance, whether it's a care manager like us. We belong to an association called the Aging Life Care Association, which is a wonderful network of well-certified people who are qualified to kind of guide people in that area. And there's also, you know, primary care, reaching out to their primary care doctor and just trying to start to get some guidance on what's going on. So what would you folks do if a family member called in the kind of scenario that we're painting here?

8:52 What would be some first steps that you might take? So we normally start with when the family member calls, we like to do a meet and greet and free consultation. And doing that starts because this whole relationship is based on trust. I mean, we're reading their medical records, we're finding out the whole family history, you know, this one, getting the family dynamics. So we'll go in person. And clear, not every instance someone is in crisis. Not every instance, but even we'll still go for a meet and greet, see if we're a good fit for them. And it almost takes a sense of relief when we're like, you know what, we'll meet you at the then how we can help them.

9:40 And then if they do decide to sign on with services with us, we start with an initial nursing assessment, which is a comprehensive whole assessment that looks at like home safety, the health, like all the whole, your whole life, basically. And then we make recommendations and give them options and implement a plan of care. I don't think a meeting goes by when we talk to clientele and because we work with retired people as well. And their plan is to age in place.

10:23 And, you know, Firmly, that's their plan. The discussion of anything else. We're not going to do that. Absolutely not. You know what I mean? Kind of mindset. Um, with all the extreme, uh, alternative as a way to deal with it. Oh, just, you know, smother we're with the pillow or, you know, the sort of silly stuff, you know? Well, that's the deflection though. Yeah. They don't want, they don't want to talk about it. Right. But there as a practical reality, that's not really what happens. And there's not always the option to age in place. Now, sometimes there are. So when you come in and do this comprehensive assessment, um, what are some of the instances that, you know, things can be done to help someone to be able to age in place, uh, certain renovations, maybe it's certain, uh, assistance that can be brought in with some regularity.

11:18 How do you help people identify what those things are? And maybe you can elaborate on what are some examples of, uh, you know, should someone who's starting to have a little bit of forgetfulness be managing their own medication as an example, or whatever it might be. Um, maybe you can elaborate on some of those kind of, let's start with that trying to age in place kind of scenario. Sure. And we agree. I mean, that that's pretty much the, the goal of most people is, is to age in place and stay at the home that they're used to and that they love and that they feel comfortable in. So. Wouldn't prefer that. Right. Yeah. Yeah. I mean, right. Exactly. It makes complete sense. Um, so, I mean, we really, that, that the assessment that we do, it talks about those goals and the, you know, we always want to align as best as we always can.

12:06 What are the goals and what are the preferences of that person and the family? Um, so we look at all those areas and then just for instance, if somebody has Parkinson's disease, um, and they've experienced a few falls at home, um, we can reach out to their primary care provider, um, set up a visit. Uh, there's a certain timeframe that you need a visit within to get a referral to say a home care agency to do an in-home PT OT referral so that they can come in and look, um, through the lens of a physical therapist. Um, what could be done as far as, you know, could we raise the height of the, the toilet seating to make it easier for this person when they're in the bathroom, the bathroom is one of the top areas in someone's house that falls occur.

12:57 Um, so we, we look at, you know, what does the environment look like? Um, how are the medications being taken? Are they taking them out of pill cases? Are they trying to take them out of their bottles? Um, how are they ambulating? Look at every kind of safety area, um, and, uh, take into account what the diagnoses are, you know, what their med list is. One of the huge things that we do is reconcile med lists. Um, you know, some people have so many different providers that they're going to. And so that's one of the top things we look at immediately is when people, um, engage in our services, we have a HIPAA, um, release and consent form that they fill out so that we then immediately send that out to all of their providers so that we can gather their information, look at their med list, look at their, um, visit notes and see, you know, what kind of supports can we put in place to keep this person at home and keep them at home safely to, to help them achieve that goal of staying at home.

14:07 You know, it's funny. I, I had a meeting, uh, in the last week or two with an octogenarian who, um, cognitively seems pretty sharp, um, but identified that she's been having falls and, uh, is, um, insistent. She wants to stay where she is and she's presently living on two levels, uh, probably could if she wanted to live on one level. Um, but, you know, just, uh, the thing that I was trying to impress upon her is that things don't stay stagnant. You know, it tends to be that things evolve and generally as we age, they progress for the worse, not for the better.

14:54 So how do you help someone find that path to maybe now while you have your cognitive and largely good health, uh, maybe, uh, that independent care living community would be a good choice for you sooner rather than later, or I don't know what, you know what I mean? How do you help someone figure out what's their next step, uh, to help them? And if it's at home, how do, how do they avoid problems where they're living alone, but having falls, you know, is there a lot of resist? And to add to Chris's question, is it, is the typical response resistance to these changes or is it acceptance?

15:36 I think we would both say there's resistance. I thought so, but that's what I was reading as well. We haven't encountered anybody that just says, oh my gosh. Yes. Let's go move to someplace else. Let's go exercise, right? The idea of a move, a lot of logistics in that. Yeah. I mean, really it's, you know, sometimes there is a crisis mode where maybe, maybe a move does need to happen fairly quickly, but you know, ideally it's something that they kind of ease into. And just as we were saying, you know, we get to know these families so well, we almost become surrogate family members with them, which leads, leads to trust in a lot of open conversations about, you know, the advantages that they might not even be aware of.

16:31 A lot of people go to assisted living who didn't want to go there. And then after they get there, we talked to them. Why didn't we do this sooner? This is so wonderful. That was my mom. Yeah, exactly. Yeah. I mean, there's, there's, you know, there's so many opportunities with socialization where at home, you know, they didn't even realize how isolated they were. They were. Not all the time, but yeah, that's about it. Right. And it was really affecting, honestly, you know, the isolation can lead to a little depression, which can lead to not showering as much, not, you know, which could lead to a urinary tract infection.

17:14 It can just really snowball. Yeah. Yeah. Good points. You know, I think one of the things I wanted to talk about with you as well is you mentioned becoming surrogate family members. I imagine a lot of times you're dealing with people where, you know, the, the, the actual family is not geographically local and you know, when it comes to like, are you helping people navigate going to doctor's appointments and who's going to take them? It's not, that's not something you guys do yourselves, is it?

17:55 You do that. You actually do that. Yeah. So there's the logistics of that. Then there's the aftermath of that, right? You know, what are the outcomes that a particular occasion might require doctor's appointments, logistics in and of itself could be an enormous task. I don't know how you guys would have time to do that for a lot of people and continue doing all the assessments and so forth. I mean, it is an important piece and not everybody needs that, but we find that the people who are requesting that are people who are, you know, their family doesn't live close by and they love their family member, but they're not able to manage their care from far away.

18:42 Even when somebody's already in assisted living, there's still a lot to manage because essentially assisted living is it's like living in a home, but with the extra supports of, you know, activities of daily living, bathing, dressing. But when that person goes off to the doctor, they're going by themselves. And you know, who's looking at the paperwork afterwards when they do that? Cognitive decline too, right? You know, are they going to remember everything that comes out of that appointment? Exactly. Exactly. So, you know, those, those appointments are really big, especially in addition, if there's unfortunately an ER visit followed by, you know, a discharge where there's all sorts of recommendations on that discharge list saying, you know, follow up with cardiology in the next week, visit primary care within, you know, and then they come back to assisted living and, you know, there's a lot of communication that needs to go on between the family, getting those appointments followed up.

19:48 So yeah, attending those appointments are big. And again, you know, medication reconciliation during those appointments, making sure the primary care physician is updated because sometimes it's not. So yeah, this is hugely valuable. You can just hearing you talk about it, you can get a sense of the importance of how this can really add value. Obviously it's not free and it's, you know, it presumes people need some resources to be able to get this kind of help. We are, point to ourselves as a fiduciary in the way we work with people. There are business models in your field where people are compensated through some kind of commission for connecting people with an assisted living or that kind of thing.

20:38 Would you talk about your business model a little bit that I think positions you maybe as the client's advocate, as opposed to trying to find where you get compensated directly, that kind of thing? Yeah, absolutely. And I'm glad you brought that up because we, as again, we mentioned we're members of the Aging Life Care Association that has a huge ethical standard that we always follow as well as our nursing ethics. So no, we don't take any commissions, there's no money, favors, anything being exchanged ever for the recommendations we make, whether it be for in-home care, a home healthcare agency, an assisted living community, a long-term care facility, there's nothing that we're getting back from them.

21:30 We simply are trying to find the absolute best situation for each individual person in their own individual unique circumstances. So tell us how it works after the initial consultation, which you said you kind of come in and do an initial consultation. Do people hire you on a contract? Is it hourly? Just how does it work? So it's a service agreement that we have that we can send them electronically for them to read over. We try to keep it as simple as possible. One of the things that we've been happy that we've done over the last year that kind of we feel sets us apart from maybe some other care managers out there is, you know, we're coming into families at a time when they are already stressed, making difficult decisions.

22:21 So within our service contract, you know, we do have an hourly rate, we are private pay, but we realize that, you know, that can be a scary thing. So if there's a really difficult month, families can be wondering, oh my gosh, what could this add up to? If mom's going to the hospital, she needs doctor's appointments. So we do have an hourly rate option on our service agreement, but we also do want to kind of taking the stress level down for people, we also have an option for them where they can set their own monthly budget cap rate where we will not go over that. So if they choose that option, once the assessment's done as nurses, one of the biggest things we do is prioritize.

23:08 So we can then take a look at the assessment, see what everything looks like. And if they choose that monthly budget cap, we can then say, here's what we feel are your biggest priorities. Do you agree? Do these line up with your goals and your preferences? And this is what we can do within your means to help you the best that we can. Yeah. Are you finding there's an abundance of need? Yes. That's my impression. How are you going to be able to keep up with that need? Are you guys growing? Are you expecting something? Yeah, we are actually just talking to some other nurses now because, and we want those nurses to be in line with us because everything is a representation of what we want to present and how we want families to feel when they work with us.

24:00 So we are in talks with other nurses now because it is such a huge need out there. Yeah. It sounds like you've got a good model and it just seems like there's a lot of need for help in this regard. Yes, there is. So this is an ongoing endeavor for most people, right? Because things change and evolve. Do you find that people hire you once initially and then come back? Or is it just something that is an ongoing thing and then periodically reassessed for what should our role be now kind of a thing? Yeah, that's a good question because what we found is people tend to keep us on, but it can taper down.

24:45 So say we, for instance, we've helped somebody when they were in the home and then we helped them transition to assisted living and then they flourished once they were in assisted living. And we still see that person, the one we're talking about, but cut it down to we see them quarterly now just to kind of keep that relationship in touch so that if she did have an emergency, she knows who we are and we can jump in if there was an emergency room visit or something happened. And then additionally, we have families that we may start working with a sibling and then all of a sudden something happens to the spouse.

25:31 So with multiple people within a family. Yeah, I can see how that could happen. Without violating any kind of privacy, could you share just a few examples of the kind of things you've been running into recently? What are some examples of the kind of stuff that comes about? Advocacy is a huge piece of what we do. So sometimes, just to give an example where advocacy can come in, we've had a situation where somebody was in the hospital, they were clearly declining.

26:15 Their ultimate wish was to spend their last days at home. This wasn't really an expected thing. This was kind of sped up. And when they were just playing in the hospital, the term hospice was not brought up. But Kristen and I have seen so many situations where sometimes you can recognize visibly when somebody- And you knew their preferences. ... would be appropriate for hospice. So even though they hadn't brought that up at the hospital, we did contact one of the specialists there to prompt the conversation and say, look, do you think a hospice evaluation would be appropriate here?

27:03 And the answer was absolutely yes. They had a diagnosis that would qualify them for hospice. And they got to get discharged with that, bringing those services on board, they got to be discharged, go home, have hospice in place, and have all of those supports that come with hospice to- But the comforts of home. ... have comfort, to have the emotional support for the family, and to be in the place that they wanted to be during that time. Advocacy is so important in healthcare, especially for all of us. I mean, we find ourselves at any age having to be our advocate sometimes and pushing back.

27:44 But especially with someone who's older and maybe diminished physically or cognitively, they're not really in a position to challenge the medical community. Oh, it's time for me to go home? Okay. Right, right, exactly. And we see that coming up in primary care too, where, I mean, no disservice to primary care, it's just very busy. And sometimes, especially older adults don't realize how much you need to push for something sometimes where we've been with someone who had had a few falls over the prior year, had been experiencing some balance issues, noticing on his own that there were some lapses in memory, cognitive changes.

28:32 So the primary care at that visit had put in an order for an MRI, and that person was good with that. But I actually asked for an additional referral to a neurologist to kind of take a deeper look at what could be going on. And lo and behold, they had a very thorough evaluation from the neurologist, and there was a diagnosis that came from that visit. So we can't say enough about advocacy. Good. Well, I mean, this just scratches the surface. I'm sure that you guys have numerous anecdotes of the kind of ways you've been able to help families in one form or another.

29:21 I think one of the things we've had similar conversations with people is the idea of sooner is better than later. When it comes to talking with professionals like your firm, don't wait till there's a crisis. Get some manner of a plan in place as to, this is what your needs are now, this is what it looks like we might need to be looking toward. Do you help people sort of navigate a plan of sorts of where we're at, where we might be headed, and what are the things to look out for as to when the timing might be coming, that kind of a process?

30:05 Yes. Yes. So even though one of our clients has Alzheimer's and the mind is still working fine right now, but we're already talking about, what are your goals for the future? You're going to need more care in the next few years. So do you have our funds allocated for this? Do you want to do an assisted living? Do you want to stay home? So we'd like to talk about all of that early. A game plan and then- And come up with the resources that they'll need.

30:45 Some people haven't updated their will. They may not have a durable power of attorney in place, health proxies, things to set up preserving their assets. So we look at every, we love it when people are planning, when they're planning because - It avoids strife as well. If the parent has, I'm thinking of the traditional setting, but if the parent has their wishes known, it will decrease the likelihood of siblings arguing about what's the best plan for mom when she maybe can't make those decisions. Oh my gosh. It's so important.

31:25 It's a gift, actually, to your family. Yeah. One will be like, mom would want to be on life support. And the other one's like, no, she wouldn't. If the wishes were already spoken by the parent, then that takes the burden off the kids. And we talk to them too and give them guidance on sometimes people, seniors have a tough time picking their healthcare proxy and they're like, they don't want to show one over the other. But one of the things we've gathered along the way as far as helping them guide that, it's almost like, hopefully they understand football because I think it's a great analogy. But if you think of it this way, who would you want to be your quarterback where there's a stressful situation and who is going to make the decisions that you would want made for yourself in a time of stress?

32:22 Who can stay level-headed and make the decision the way you would want it made for yourself? And try to go- Not impose their own priorities. Yeah. Yeah. Challenging stuff, right? Well, you guys come back again. This was really good. We could probably dig into some particular circumstances and elaborate on the kind of planning that could be benefited from. Found this really worthwhile. And let's tell everyone a little bit more about how to reach you if they have interest or need to do some planning of this sort, or to get an assessment for a family member or their own kind of assistance with their care planning.

33:06 Share a little bit about how you can be reached. Sure. You can always call us at 508-737 -4277, or you can go to our website at www.back9nurses.com. It's all spelled out B-A-C-K -N-I-N-E, nurses.com. Excellent. I'll put that website in the show notes. So if people are listening, they can just directly click the notes in the show. Wonderful. Thank you. All right. Thanks for being with us and hope everyone got something out of this. The bottom line is you've got to be planning for these kinds of challenges. Plan or not, they may occur.

33:48 And if you're not prepared, better to have some planning in place than to be in a moment of crisis that inevitably may arise for many people. So start early. All right. Thank you both for being here. Thank you so much for having us. Okay. Until next time, everybody keeps striving for something more.

34:54 Transcribed by https://otter.ai Any financial decisions.