What does it really take to care for our elders?

Until my last year of college, I thought I wanted to be a medical doctor. My grandfather was a physician who operated a surgery out of his home in London. He was a deeply caring man. I looked up to him. I wanted to be like him.?

Although I later realized that practicing medicine wasn’t for me, I pursued the field with fervor up to my early twenties.

I decided to go to Columbia to study biology because of their reputation in the natural sciences.? I researched pathogens and disease through amazing fellowships at places like The Rockefeller University, UT Southwestern, and Amgen – and even got certified and worked as a nurse aid to help the elderly. For several months, I would drive to a skilled nursing facility early in the morning. I helped older adults with activities of daily living before attending my classes. The work was a rewarding but hard job.

While all these experiences were invaluable, I find myself turning back to my time as a nurse aid most often these days. As I research the complexity of long-term care (LTC) in the US, my time at a nursing home helped me understand the unique challenges of caring for the elderly population.

Here are three reasons why LTC is so hard:

Taking care of the elderly requires a large and active workforce.

There are a lot of patients in nursing facilities. Residents in nursing homes outnumber their aides ten-to-one. In bottom quartile facilities, that ratio of patients to caregivers is almost double. Each of these residents requires attention and support, often for even the most routine activities. As you’d imagine, caregivers are often overworked given shortages in the supply of labor.

Here’s what my day-to-day as a nurse aid looked like: because of how many residents lived in our facility, we got in early at 5am to individually wake each resident and help them start their day. Each patient needs something different. Some residents could get out of bed independently while others required help going to the bathroom or brushing their teeth. Others couldn’t get out of bed at all and needed their basic necessities like food and bathing brought to them.?

Many residents in nursing home facilities complain about being woken up early and the lack of independence they feel. Given how understaffed nursing homes are in the US, it’s hard to get the work done without starting early and being very systematic about how you deliver care to a large number of people.?

The emotional labor was the hardest part of the job.

A lot of residents in nursing homes are not happy.

Many residents are lonely. Because the location I worked in was such a high-skill facility, residents were not just lonely because they missed their families, but because so many of their neighbors were not mentally or physically able to be social.

In fact, a resident could get sick with an illness that would effectively put them in quarantine – isolation from the rest of the people in the nursing home. If, as a resident, you had shingles, a painful reemergence of chickenpox in late adulthood, my facility would take strong precautions to protect other residents from you. That kind of isolation is emotionally very hard on residents. With COVID-19 impacting the elder population so strongly, isolation is more of an issue than ever before.

It broke my heart to see residents so lonely or unhappy.

Residents would see, hear, and smell things that they didn’t love – about themselves and their neighbors. It is a sad part of the reality of living in a nursing home. Many people are unwell. That environment impacted me, and impacted the residents around me.

As a result, residents can be agitated and sometimes angry. I was called names and insulted. I knew that many of the comments I received weren’t about me, they were a way for some of the residents to express themselves and feel a sense of control in a world where so much was out of their hands.

While I never witnessed this at the facility I worked at, through my research, I’ve learned about elder abuse occurring at nursing homes. This can range from aides keeping the call button too far away to reach to stealing residents’ belongings to purposefully hurting or insulting them. Some residents fear negligence such as not being bathed regularly or turned over in their beds (to prevent bedsores) as often as they should.?

Even though this kind of mistreatment in nursing homes is rare, it happens at some locations. That’s devastating.

The cost of elder care is taxing to residents and their families.

The most common concern I hear from families who have considered long-term care is cost. Elder care, and nursing homes in particular, is expensive.

62% of nursing home residents are on Medicaid; however, this program often covers the bare? minimum of care. Depending on the US state you live in, the quality of care that Medicaid pays for varies dramatically. Still, I’ve never spoken to someone who said they were satisfied with the quality of care that Medicaid affords.

I spoke with young professionals who unexpectedly needed to help parents who became disabled and needed LTC. One went bankrupt trying to support a family member. Their parent didn’t qualify for state and federal programs. Even though the parent needed regular nursing support and help with several activities of daily living, they could not afford a nursing home on the family’s income. The family’s savings were wiped out as they tried to care for a loved one.

Someone else whose parent did qualify for government aid found that many of the Medicaid eligible facilities they spoke to tried to illegally charge them above and beyond Medicaid’s set rate.?

Planning helps prepare families for the exorbitant costs of LTC. But people are still surprised by how expensive LTC is. Families that don’t prepare enough for their LTC needs may be shocked to find out that the typical LTC insurance plan only covers half the cost of living in a nursing home - $108,000 a year for a private bedroom in 2021, according to Genwroth.

Beyond the direct costs of long-term care, families are overwhelmed by the time it takes to secure care for their loved ones. People I’ve spoken to lost over a month of work trying to identify care solutions and transition parents into LTC. Even with the help of a social worker and an attorney who specializes in elder law, one person I spoke with said he struggled to navigate the decisions he would need to make for his parent’s care. “Between the attorney, the social worker, and [my spouse and I], this was still an opaque process. If it was hard for us to figure out, I can’t imagine what it’s like for others.”

What you can do: make a plan.?

Whether you have a loved one who will need support, or you may need it yourself, nearly all of us will come in contact with the long-term care system, which is already buckling under these pressures.?

While there is much room for improvement, there are steps we can take to make elder care a better experience. It starts with making a plan.

A common theme I’ve heard throughout my conversations with caregivers and those supporting family members is feeling surprised and underprepared. The multiple decisions, unexpected costs, and shifting priorities, you can experience all while feeling concerned for someone you love, can be a lot to bear – and yet, these can be meaningfully addressed.?

While none of us can predict the future or anticipate all of the challenges that will come our way, having candid conversations with your loved ones can help you learn what kind of care is feasible and ideal for them. These conversations might be scary, but having them now can remove layers of anxiety for when you need to put that plan in place.

About the author:?Ben Goldwater invests and consults across the capital structure with particular interest in distress, special situations, insurance, and financial services. He recently received his MBA from Stanford. Before that, Ben was the youngest director at Apollo Global Management and consulted at McKinsey & Company and Mercer. Ben received his bachelor's degree in biology from Columbia University and was licensed as a certified nurse aide (CNA) in the state of Texas.