Silver Linings: Communities, churches turn to 19th century nursing traditions for elder careBy GRETCHEN M. GROSKY
New Hampshire Union Leader
February 18. 2017 9:53PM
Susan Waddell Thrane grew up in a small family and "never had been around death before." But her 84-year-old husband, Bill, was suffering from vascular dementia, and his disease was progressing. She became his around-the-clock caregiver and needed help.
Friends told her about hospice, something she was unfamiliar with. She walked into a local facility, told them her story and found out the services didn't quite fit. She was handed a hotline number for the Alzheimer's Association and left.
"That's not what I wanted. That's not what I needed," she said.
Thrane turned to another resource in their small town of Thetford, Vt., one she had heard about but "was never really convinced" was needed in town.
She called Cindy Grigel, the community nurse of Thetford. Grigel is an independent contract nurse paid for by a nonprofit to provide 10 hours a week of service to the town's seniors in need.
The community nurse position was the effort of three nurses, a doctor and a pastor who live in Thetford. The group saw that Thetford, like so many other small and rural New England communities, had too many frail elders in need of care, too many living in isolation, and too many not getting the services they wanted to be able to live out their days at home.
Neighboring communities on both sides of the Connecticut River, a natural border slicing Vermont from New Hampshire, were grappling with the same issue, but some had come up with a solution - hire a nurse to help their aging population. Churches in Lyme, Hanover, and New London each hired parish nurses for their members. People in communities like Grantham, Lebanon, and Hartland, Vt. formed nonprofits and sought out donations and grants to hire their own community nurse. In some cases, town tax dollars were provided. In others, there was no public money.
Today, there are nine community and parish nurses helping frail elders in eight communities in the Upper Valley area of New Hampshire and Vermont. Most are paid about $30 an hour and provide anywhere from four to 25 hours a week to those in need.
These nurses can't provide much direct care beyond taking someone's blood pressure or administering a flu shot. They can help show a family member how to properly roll a bed-bound patient, help seniors manage their medication, and serve as an advocate to help them navigate the complexities of health care. They also survey the patient's wellness and make sure they have food to eat, heat to keep warm, and companionship to break their isolation.
These women describe their role as part social worker, part nurse, part advocate, and a friend.
For Susan Thrane, she needed Grigel to help her prepare for Bill's death.
"We were coming into the end-of-life thing and we didn't know about it, and that's where Cindy came in," Susan said.
Grigel was there when the hospice social worker first came to the home. Grigel helped Susan ensure that all of Bill's wishes and needs were being met. Grigel was there when a singing group came to visit Bill, and he came out of his altered state to join in with the melodies. She was there to tell Susan that Bill had only days to live. Susan continued to list the ways Grigel helped them get through Bill's end-of-life and grief.
"I realize now the perspective I give is so important to people," Grigel said.
A community tradition
The notion of parish nurses and community nurses is not uncommon in the Midwest, but is unique in the Northeast - a part of the country with the nation's oldest population. Maine, New Hampshire and Vermont round out the top three state populations with the highest median age, according to U.S. Census figures.
Bringing this nursing tradition of community care to the Upper Valley was spearheaded by the late Dr. Dennis McCullough, a geriatrician, and Laurie Harding, who now serves as co-director of the Upper Valley Community Nursing Project.
"The danger with medicine is now it's being done as a drive-by Walmart service," said Phil Langsdorf of Eastman Cares, a nonprofit that hired its own nurse a year ago to serve its private living community in Grantham and Enfield. "Doctors get 10 minutes with a patient - not because they want to, but they have to because of billing, insurance."
Rita Severinghaus is the parish nurse at The Church of Christ at Dartmouth Hanover Church. She makes many house calls on elders in need and says seeing them at home provides so much insight into the problems they face.
"When we go into a home, because of our experience and training, we're looking at the specifics. What are the smells? What are the sounds? What's the appearance of their home?" Severinghaus explained. "We're looking at the rugs, the bathroom, their clothes, their hygiene. We're looking at the whole picture."
Angelika Stedman, the Hartland, Vt., community nurse calls it "true holistic nursing." Severinghaus agreed and said the one-on-one time with the client in the home provides them a confidence in their care.
"This role is very much about trust and the establishment of trust," Severinghaus said.
"And hopefully we steer them in a better direction," Stedman said.
The Upper Valley Community Nursing Project serves as a resource for communities and churches looking to hire their own nurses by providing support, education and seed money to help get communities started. It also serves as a network for the nine parish and community nurses. They gather once a month to talk about their experiences, their clients, ask each other questions, and offer each other solutions. Many of the women work full time at other jobs in the medical field but take on the added responsibility to provide care for their neighbors.
On a snowy February morning, the group gathered at Severinghaus' church. They talked about clients leaving the hospital for nursing homes that are miles and miles away from their family support because of a shortage of beds. They talked about seeing more grandparents and great-grandparents taking care of youngsters because these children have lost parents to the opioid epidemic.
For many of these seniors with medical needs, the parish and community nurses step in after they have been released from a hospital or where the Visiting Nurse Association leaves off.
Harding explained that Medicare stops paying for a visiting nurse when the patient is considered "medically stable." She said the payments end when the patient's progress has "plateaued." It doesn't necessarily mean they are cured or ready to live without assistance.
"The VNA is limited by what they can offer because it has a beginning and an end," Harding said. "We work with the VNA and they see us as a resource."
But mostly, it's about the senior.
"It about being there to help them make decisions. It's about helping them be safe," Harding said.
Whom they serve
Sarah Jo Brown was one of the nurses who fought to bring a community nurse to Thetford. Initially the group sought town money to fund the position, but town leaders were unconvinced. The group turned to donors and grants to fund the position a year ago.
Brown is a nurse researcher and helped the group compile a profile of the people Grigel is helping. These figures show what's going on in Thetford; it is similar to what's being seen by all the community and parish nurses. She found that of Griger's 19 clients in 2016, the median age is 82, 42 percent live alone and 22 percent live in a two-member home where both clients have self-care, functional challenges, or self-care deficits. She estimates that 47 percent are either struggling financially or are on the edge. Fifty-two percent said they want to live at home but feel they are struggling to do so.
Most are frail with limited physical mobility, 58 percent have impaired cognitive ability and 84 percent have "ineffective self-management" of such things as taking medication.
Grigel's role is to help these people manage their medication, and prevent rehospitalization; much of what the nurse does has to do with reducing the elder's "social isolation."
She helps them get Meals on Wheels that provides food and some companionship, helps them get involved with activities, and she goes to their homes and listens to them.
Isolation is everywhere
"You read about social isolation and it doesn't really make an impact until you see it," Grigel said. "It really affects people's health."
Eastman is a 3,700-acre private living community spanning both Grantham and Enfield. It is a mix of higher-end condominiums and homes, offering a lake for fishing and boating, a golf course, a pool, its own restaurant and more. It seems like it has everything one would need to be connected, but it too has a share of people finding themselves homebound and isolated as they live longer, said Eastman community nurse Karen Johnston.
"The social aspect of keeping the elderly connected is so important to their health," Johnston said. "Keeping them in touch with the world and getting their needs met is much of what I do."
Johnston is seeing more baby boomers moving into their parents' homes - not because they need to. She said they are moving in because their parents need help and refuse to leave home.
"They may be retiring, but it might not have been their plan to live with their parents," she said.
It's another sign of an aging population that is only growing older, many of the nurses said. Severinghaus pointed to research by the New Hampshire Center for Public Policy Studies that estimated that by 2020, 20 percent of the state's population will be over the age of 65. Harding said by 2030, the Granite State will have the largest number of 85-plus year-olds per capita in the country.
Brown said the Thetford program has about two years of funding left and is hoping voters approve spending $3,500 this year to help keep it going. Griger plans to be at Town Meeting, wearing a traditional nurse's cape from the former Mary Hitchcock Memorial Hospital in Hanover. She asked her fellow nurses if anyone had a cap she could borrow. She is hoping the uniform will remind seniors and raise awareness about her program.
Silver Linings is a continuing Union Leader/Sunday News report focusing on the issues of New Hampshire’s aging population and seeking out solutions. Union Leader reporter Gretchen Grosky would like to hear from readers about issues related to aging. She can be reached at email@example.com or 206-7739. See more at www.unionleader.com/aging.
"For older people, nurses have always been very important people," Grigel said.