Not Just an “Old Folks’ Home”

Illustration: “The Bus,” by Frida Kahlo, 1929

Zinn: Can you give me a breakdown of the number of younger residents-defined as those less than 65 years of age-who currently reside in your facility?

Fridkin: First I’ll give a little background on our overall population. We are a not-for-profit facility that opened at the end of October 2001. We are affiliated with the John T. Mather Memorial Hospital, in Port Jefferson, Long Island. Island Nursing and Rehab Center has 104 residents and patients, with a capacity to accommodate a total of 120.

We are seeing a larger population of younger residents admitted to our facility, a trend that is becoming more notable in the long-term care field. Of our current residents and patients, 7% were born between 1948 and 1982 (ages 21 to 55), and 6% were born between 1938 and 1947 (ages 56 to 65). The remainder of our residents range from 66 to 107 years of age. Of the younger people here, six are short-term patients (average stay, 25 to 30 days) who are here to receive rehabilitation services, and seven are long-term residents.

Fridkin: We really haven’t tried to attract them. I believe our facility appeals to this population for several reasons: our focus on rehabilitation medicine, our special unit for ventilator-dependent individuals, and the appearance of our building. It does not look like a typical nursing home; it looks more like an assisted living residence or a hotel. There is abundant space, and the rooms are airy and sunny, not dreary.

Zinn: It must be difficult for younger residents to come to grips with the fact that they will probably live in a long-term care facility for many years-perhaps several decades. What do you do to help them make the adjustment from their former independent lifestyle, and how do you help keep their spirits up day by day?

Awan: Some of the younger residents are extremely depressed from the time they’re admitted. Initially, many of them are hoping only to be here for short-term rehabilitation, but we know at their admission that they’ll be here for the long term. These residents need help adjusting. Because the signs and symptoms of depression are so common in this population, we provide psychological and psychiatric services for them.

Fridkin: Some other psychological and behavioral issues are also rather typical of this population and need to be addressed. For example, some of these residents resist standards we have for their safety. Naturally, they want to try to retain the independence they’ve enjoyed in the outside community. So they want to smoke alone, go outside without assistance, and go outside more frequently than older residents. Therefore, we have to provide more nursing assistance and more surveillance so that they don’t hurt themselves.

Awan: Staff members from our social services department also meet with these residents on a regular basis, and there is a great deal of interaction with their families. We work as a team to accommodate the younger residents’ needs.

Zinn: I’m guessing you can’t keep your younger residents happy merely with bingo games and sing-alongs. How do you gear activities to suit them?

Fridkin: We have a computer on the unit, because these younger residents are computer-knowledgeable and want computer access as a means of communicating with their families and friends. We also have a Web cam, so that the residents can participate in “visits” with their out-of-town loved ones or those who can’t visit in person. This allows the participants to see each other in real time. Video games are also very popular with this group, and we have painting classes and other activities that are appropriate for their ages and functioning levels.

We also try to hold group discussions for the younger residents. Frankly, few of them are interested in associating with the older population, so we have to provide different activity programs to meet their needs.

Awan: While the older residents en-joy movies from the 1930s and 1940s, younger residents want up-to-date action movies. They also enjoy some of the same activities the older residents do, such as outings to the mall or to restaurants, but they like going separately. We also choose different restaurants to suit their tastes and preferences.

Fridkin: No, we only have one, but she makes every effort to individualize activities for all our residents.

Zinn: It sounds like the younger population is somewhat more demanding than older residents. What sorts of adjustments have you had to make to accommodate their needs?

Fridkin: For one thing, it’s not unusual for the younger people to have visitors until midnight. We permit that, as long as they’re not disturbing anyone. One resident, a 21-year-old man, has five or six visitors at a time. At first we were concerned that he wasn’t getting enough rest, but he’s doing fine and he enjoys it. Again, we don’t have a problem with it as long as he and his visitors aren’t bothering other residents. It’s also typical for these residents to want daily bathing, which is not something our older residents demand or require.

Zinn: Given their preference not to interact much with the older residents, do you have younger residents housed in a separate unit or area of your facility?

Fridkin: Ninety percent of our younger residents live in a separate unit, on the first floor. Only a couple of them live on the second floor, which is our geriatric long-term care floor. We’ve given them the option of moving to the first floor, but they’ve adjusted to where they are and feel at home there.

Zinn: I would think that both the older and younger populations could benefit from interacting with each other. Do you try to encourage this interaction?

Awan: We do have programs in which the younger residents can interact with the older ones. Announcements of events and activities are made each morning. If younger residents want to participate they may, but they rarely do, except for one younger woman who participates in both sets of activities and who is constantly on the computer, e-mailing and listening to music. At the other end of the spectrum, we have one male resident who doesn’t want to participate in any activities, whether for younger or older residents.

Zinn: What is the most challenging aspect of providing care to this younger population?

Fridkin: It’s a challenge to keep them occupied, keep them from getting bored. Also, when they call, they want and expect instant service. They also need more one-on-one attention than the other residents. Social services helps with this, working closely with them to help them adjust and to foster linkages with outside community contacts. For example, they encouraged two residents with multiple sclerosis (MS) to participate in an online MS chatroom group.

Zinn: What advice would you give to other facilities that would like to dedicate a special unit to the care of younger residents?

Fridkin: They need to have their social workers, nursing staff, psychologists, and activities staff all involved. You definitely need a team approach-not only to deal with this population, but also to get the whole staff to buy into it and work together.

Awan: Dietary needs to be involved, too, for these residents’ special nutritional needs and desires. The foodservice director should be flexible, to meet the needs of all residents. We ask at resident council meetings what residents would like to eat and add to the menu accordingly. The younger ones want lots of pizza.

Fridkin: A program like this also affects the staff ratio. We have more nurses on the first-floor unit than on the other floors. Keep in mind that in addition to their psychological needs and their preferences and demands, this population is generally sicker than the general population and needs more nursing attention.

Zinn: How else has having this many younger residents affected your staffing levels?

Fridkin: Because many of these people are rehab patients, we obviously needed to have a good rehab program in place. We have an occupational therapist and a physical therapist on staff, and a speech therapist who provides consultant services. We also have a psychiatrist available once a week and a psychologist who is here almost daily. Nursing is closely intertwined with these residents, because they require a great deal of handholding.

There is a team of three social workers on staff (totaling 2.6 FTEs). In addition to the increased needs of these residents compared to our older residents, their families also need more time and attention, because they’re affected by their loved ones’ difficulties in adjusting to their new environment. We hold care-planning meetings with families regularly and as needed to help with that adjustment.

Awan: Even after they’ve been here a full year, it takes a great deal of time to meet with residents and their families. We are their whole support system for providing good-quality care. And then if you encounter a difficult family, they can make the resident uncomfortable; dealing with that requires a team approach.

Zinn: Have you had to change any aspects of your programs or policies for younger residents because you found they weren’t working?

Awan: We had to make changes in what activities we initially offered them. Because we were new to managing this population, it took a bit of trial and error to adapt to their needs, such as the types of music they wanted to listen to. We also had a challenge getting them to eat in the dining room with the rest of the residents instead of staying in their rooms to eat. We worked with them, reminding each of them that there were other younger residents like themselves with whom they could eat. This was important, because some of these people need eating assistance and need to be monitored while eating, to make sure they don’t have swallowing problems. Having them eat with everyone else in the dining room is simply better for them and saves nursing time, as well.

Zinn: I’m sure that, despite the challenges, you realize a great deal of satisfaction and benefits from working with the younger residents. What have some of the benefits and rewards been?

Fridkin: When younger people adjust to the facility, there is great joy in seeing their overall health improve. Even if their health does not improve, seeing their general demeanor improve is rewarding and serves to motivate the staff. Staff members take on mentoring roles, and there is very little social distance between them and these younger residents. We also hope to see signs that the younger residents are finding social roles within the facility that help other residents and/or families.

Another benefit is that the younger patients/residents bring in younger visitors, who get to see that a nursing facility can be a vital place and that it is a dynamic community that provides quality care-caring and supporting people who live in an environment in a home away from home. NH