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Before the Fall

Early in Kate Clayton-Jones’s nursing career, she was struck by the cost — both financial and personal — of neglecting preventive care.

Specifically, of the feet.

“I kept seeing a whole bunch of people getting their feet amputated or having surgeries for having fallen,” she said, “and I thought, ‘my God, this is just so preventable.’”

That thought eventually (after plenty of planning, training, and persistence) became FootCare by Nurses, a model for preventive foot care that meets clients — mostly older people — where they are, especially in their homes.

“This isn’t nursing care like, ‘let me come in every day and feed you, clothe you, whatever else,’ but nursing care that could come episodically, once a month, or once every other month, and do this much-needed work, which is taking care of the feet of older adults.”

She explained that her nurses sit on the floor and look for circulation problems, sores, and calluses, and release tension in the toes that can limit flexibility and lead to falls. They also check the fit and lacing of shoes and make recommendations about socks. “All our work is designed to improve quality of life. This is an alternative pathway for foot care from typical podiatry or nail salons that most people know.”

For those who would prefer a clinic to a home visit, FootCare by Nurses also has offices in Greenfield, Lenox, and Fitchburg.

“It can be as simple as showing someone how to lace their shoes. We have an opportunity to spend time with people to help them understand simple changes like the way their shoes and socks fit, and skin care. We do a lot with balance and trip hazards,” Clayton-Jones explained.

“Elders are getting touched, and they’re having meaningful conversations. The work we do restores dignity and quality of life. Because we come in as nurses, we can talk about other things as well, and we see them on a regular basis, not just when they have an acute incident.”

While podiatrists are medical doctors whose responsibility is to diagnose and fix problems — recommending treatments and performing procedures — she and her team are licensed nurses with extensive training in foot care, whose responsibility is to prevent problems from happening in the first place. And there is some overlap.

“We have many podiatrists who support this work, though podiatry is a medical intervention, and a lot of this is not medical; it’s basic activities of daily living, and nursing is ideally suited to take care of people in that way,” she said. “There was this gap, and a huge opportunity to do something that is so meaningful, and it’s just a delight.”

The work is important, Clayton-Jones said, because people can become embarrassed by neglected feet and neglect them further — often with dangerous and even tragic results. She was thanked recently by a man whose edema was diagnosed by FootCare by Nurses, and he got the treatment he needed before the situation grew dire.

But even beyond such critical interventions, she said, people are happy when they can simply find pain relief and be able to leave their house or walk with their loved ones.

“We support quality of life in so many ways,” she said. “We not only make a difference when we walk in, but we give them peace of mind. It’s the only type of nursing I’ve done where I’ve heard someone say, ‘I can’t wait for that nurse to come back.’ It’s just such a nice intervention.”


Finding Her Footing

Clayton-Jones didn’t start off as a nurse; in fact, she earned a business degree and was working in aviation before shifting her flight plan to nursing school.

About a decade ago, while working on various floors of Berkshire Medical Center, she encountered patients with inflamed, infected feet, or — even worse — who had broken a hip in a fall, where poor foot care had been a factor. So she asked herself, “why can’t we, as nurses, take care of feet? I can learn to do it.”

So she sought further education through the Wound, Ostomy, and Continence Nurses Society. During that time, she recalls watching a toe amputation of a Korean War veteran who had developed an infection due to ill-fitting shoes a doctor had recommended.

Kate Clayton-Jones

Kate Clayton-Jones at the American Foot Care Nurses Assoc. 2023 National Conference.

“The surgeon did a beautiful job. He was very nice and kind and connected to this man. But the man was very angry because he was losing a part of his body.”

It occurred to her that no one had checked on him and his new shoes — a simple intervention perfect for a nurse’s assessment skills. And she wondered how many other serious infections, debilitating falls, and amputations could be avoided altogether with simple, home-based foot care … by nurses.

After becoming a certified foot-care nurse, Clayton-Jones started treating people’s feet in various setttings. When met with skepticism by people who suggested clients just visit a nail salon, she had a ready answer.

“I said, ‘you don’t understand this population. They’re not able to go out. You’ll never see these people; they’ll never be on your radar, but they are costing the healthcare system an inordinate amount of money when they fall.’”

More importantly, “it gave me great joy to bring dignity and function to these humans who have put so much back into the community,” she added. “These are really incredible people. It doesn’t matter how wealthy or poor you are or where you live — your feet still need to be taken care of.”

By 2016, she had become very busy and realized she couldn’t provide all the care on her own.

“I knew, if I’m going to take on the responsibility of taking care of all these people, this needs to be a real business, with people who want to do this work,” she told BusinessWest. “I will train these nurses, but it needs to be a business that solidly sits on its own foundation.”

In doing so — the business has expanded from three employees in 2016 to 42 today — Clayton-Jones said she’s not only taking care of the community, but providing good jobs for nurses on schedules that work for them, which is especially important if they have families.

“They can start a quarter after nine, after they drop off the kids, see six or seven people, and pick the kid up by three o’clock,” she said, adding that “foot care is not an emergency — it’s prevention.” So if a snowstorm strikes, appointments can be easily moved to a different day. In short, she’s providing nursing jobs with predictable, and not burdensome, schedules.

nurse at FootCare

At right, a nurse at FootCare by Nurses teaches three new nurses how to touch and treat feet.

“I wanted to give them autonomy and responsibility and quality of life while also a joyful, meaningful job that’s not just about trimming toenails, but restoring the best function to an older foot.

“It turns out feet are really, really important,” she added, noting that 40% of cardiac flow is related to foot and leg movement, and toes are part of the body’s ‘seeing’ system for positioning itself in space, so the healthier the feet and toes are, the less likely an older person will fall.

“It’s just preventable with good foot care, good foot function, knowledge about how shoes fit. I started pulling the pieces together — what was behind everything we were doing. And we keep evolving the science.”

And as age demographics in the U.S. keep trending older, it’s a growing problem, especially among the Baby Boom generation.

“They need help — not just care at a podiatry office or a nail salon; they’re going to need this help at home because many can’t drive, or they’re cognitively impaired, or frail. They need to stay home and have care come to them,” she explained. “So the business model was not working with one visiting nurse association or one long-term-care facility — we would work with many, and I would work regionally.”


Next Steps

And the practice is still growing. Clayton-Jones — who regularly speaks on foot-care issues nationally and around the world — recently announced that three new contracts will allow FootCare by Nurses to expand its services in Central Mass., the city of Springfield, and some towns in Connecticut.

A contract with the Program of All-Inclusive Care (PACE) in Springfield will allow Serenity Care case workers to refer clients to FootCare by Nurses. The PACE program is centered on the core belief that, given a choice, most elders, the disabled, and their families would choose to receive care in their homes and communities rather than in a nursing home — so it meshes well with Clayton-Jones’s own mission.

Meanwhile, a contract with Tri Valley Elder Services will expand FootCare by Nurses’ services into the area south of Worcester. Additionally, FootCare by Nurses will take on former clients of Connecticut-based Pedi-care.

“This expansion and continued growth means adding close to 1,000 new clients and $300,000 in new revenue, which will trickle in slowly as referrals for foot care come in,” she said, adding that she plans to add two administrative positions and 10 nursing positions — and is actively hiring for them.

“At the end of the day, if you want a meaningful nursing career, this is just an excellent place. If you’re community-minded, if you like one-on-one conversations where you can make a huge difference, this is really a good career,” she said. “My nurses speak of it as the most joyous job they’ve ever had. They thank me for the autonomy and responsibility, and they get to use all their nursing skills. And they feel connected to the community that they live in, supporting other people.”

As the company grows, its mission — to redefine elder care by making evidence-based foot care central to general health — will not change, she added.

“Our mission is prevention, and our passion is caring. Feet are literally the foundation for our body; they allow us to be mobile, they pump blood back to our hearts, and they connect us to the world. Any fault in feet affects the whole body, just like faults in a foundation affect the entire structure. Yet, feet are too often ignored or neglected, while their care and well-being are essential.”

In short, Clayton-Jones stressed, FootCare by Nurses is not an aesthetic service that simply makes feet and toes more presentable.

“These people need nursing care; it’s a nationwide problem. I can’t tell you how many times I’ve seen nail polish glossing over toenail fungus or a callus or corn, and it continues to perpetuate because no one’s done preventive education,” she said.

“Nurses are educators. We teach people how to take their medications, what the side effects are … a lot of people recognize we’re the healthcare teachers out there. Our mission is prevention. Yes, we’re great at taking care of toenails, but we’re also there to prevent falls or wounds from happening — and we save lives.”

Business of Aging

No Time Like the Present

By Mark Morris

The senior-living industry is preparing for a “gray tsunami.”

According to the U.S. Census Bureau, nearly 10,000 Baby Boomers will turn 65 every day for the next 10 years, while the oldest Boomers will start turning 80 in 2025.

Robert Kelley, in-house counsel for Everbrook Senior Living, predicts that, once Boomers start reaching that age, the demand for senior-living communities will increase significantly. That’s one of the many reasons he’s excited about his company’s newest community, Cedarbrook Village in Ware.

From its corporate office in Southampton, Everbrook already manages three senior-living communities in Windsor Locks, Hebron, and Bozrah, Conn., and Cedarbrook is its first community in Massachusetts.

Originally planned for a July opening, various delays postponed the ribbon-cutting ceremony until Sept. 14. Kelly Russell, executive director of Cedarbrook Village, has worked in the industry for more than 20 years and has overseen plenty of community openings, but this one was different.

“For this grand opening, we made sure to have plenty of PPE on site for anyone who needed it,” Russell said. Moving people into their apartments safely during COVID-19 also required a new approach.

“We set up different times and arranged for people to use different doors, so they would not run into each other,” she said, adding that social distancing and cleaning between move-ins was all part of the extra planning and organization necessitated by the pandemic.

When families help their parents move into senior living, it’s often a stressful time, she said, and the added stress of COVID-19 has only intensified the anxiety and guilt family caregivers feel. With all the restrictions imposed by COVID-19, families now worry they won’t be able to see their loved ones.

“We reassure family members that we are taking all the necessary precautions so they can schedule visits in a safe environment and stay in touch with their loved ones,” Russell said.

For example, scheduled visits are a departure from pre-COVID times when families could drop in anytime.

Kelly Russell

Kelly Russell says senior living is an attractive option during a pandemic because the safety measures in place give families peace of mind.

“We would tell families this is their home, too. If they wanted to come spend the night with their loved ones and eat in the dining room with them, they were welcome to do all that,” Russell said.

Unfortunately, that wide-open policy is on pause — one of many ways life is different right now in the senior-living sector. But the fact that Cedarbrook opened at all during such a year is a reflection of the growing demand for such facilities, and how this multi-site company intends to continue meeting that need.


Safety First

Keeping an aging loved one safe at home during the pandemic can mean a great deal of work for a family. That’s why senior living is a good option, Russell said, noting that Cedarbrook has extensive COVID-19 safety measures in place which can ease the burden for families and give them peace of mind.

“We saw this location as a good fit, and the town of Ware was very accommodating to work with.”

“Even if families don’t see them as much, they know their loved ones are getting all the care they need and still being able to socialize with the residents,” she noted, adding that she also reassures families through social-media postings.

“Whether we’re using FaceTime or sending videos, I post a lot online,” she said. “This way, the families who can’t visit their loved ones often enough can see them smiling and engaged in activities with other people. It lets the family know their loved one is OK.”

Among its 119 units, Cedarbrook offers independent living, assisted living, and a memory-care center. Russell explained there are many reasons why people choose to move in.

“Folks usually move in to our independent-living apartments because they are tired of taking care of a house and a yard, or their laundry is in the basement and stairs have become too difficult, things like that,” she said, adding that independent residents can either make meals for themselves or join others in the dining room.

“Those who move into assisted living usually need some help with everyday tasks such as eating, dressing, and grooming,” she continued. Instead of sitting home alone watching TV, they can be part of a community and engage in activities and exercise programs, and socialize with other people.

Independent-living residents

Independent-living residents can either make meals for themselves or join others in the dining room.

Everbrook chose Ware as the site for Cedarbrook because the Quaboag region, encompassing Ware, Brimfield, and surrounding towns, had no senior-living facilities; the closest options were located in the Wilbraham/Ludlow area to the west and Greater Worcester to the east.

“We saw this location as a good fit, and the town of Ware was very accommodating to work with,” Kelley said, adding that the building design incorporated local influences.

“Several design details of the building are reminiscent of the South Street School that once occupied this site,” he noted, while another example is the large-screen movie room at Cedarbrook, called the Casino Theatre, inspired by the iconic movie house once located on Main Street in Ware.

Trends in senior living have changed over the years. Twenty years ago, such communities tended to attract people in their mid- to late 70s. As longevity has increased, the average move-in age these days has risen closer to the 80s and even 90s.

In the past, inquiries from families focused on services and amenities offered, as well as activities and the level of care. Since COVID-19, Russell said, the questions have changed. “Now, we’re asked, ‘do you have a generator?’ ‘how do you respond to emergencies?’ and ‘what supplies do you have on hand?’”

As a new building that has only recently opened, Russell is able to market the community as having plenty of space for socially distanced meals in two large dining rooms. “Everyone can eat together because we can space them far enough apart.”

Cedarbrook also works with a primary-care physician whom residents can access through telehealth for routine inquiries, rather than going out to a doctor’s office. Meanwhile, an exercise physiologist runs the fitness programs for residents. At one time, exercise programs and other activities filled the calendar, but the number of activities has been reduced to allow for disinfecting equipment and rooms in between sessions. Russell described it as emphasizing quality and safety over quantity.

“If you’re smart about it,” she said, “you can still offer activities and keep everyone safe.”


Shifting Tides

By following that same approach, Russell continues to assure families that senior-living communities such as Cedarbrook are the right choice for their loved ones during this crisis.

“We want families to feel secure in knowing that there will always be support here for their loved ones,” Russell said, adding that, while no one can guarantee COVID-19 won’t find a way to infect people, Cedarbrook has measures and equipment in place in the event of an outbreak.

“If our residents have to quarantine, they will still get the care they need and still have their meals,” she said. “We will also help residents stay in touch with their families.”

Keeping safety as the main priority, Russell believes the key is to make adjustments as things change. “I don’t really feel like there is a ‘new normal’ because every day brings new and different challenges we have to face.”

And, like everyone, she looks forward to a time when COVID-19 restrictions are a thing of the past. “We can’t wait until we can fully open the community and share with families everything we have to offer here.”

Prior to Cedarbrook’s opening, Russell had another big event on her calendar this year — she was married on Aug. 28, a date she intentionally chose before the September opening.

“The wedding was much easier to plan than opening the building,” she said with a laugh — but is happy to have accomplished both during a year no one will forget.

Business of Aging

Shifting the Balance

Visiting Angels Director Michele Anstett

When Michele Anstett opened a Visiting Angels franchise with her husband in 1999, it was only the ninth branch of a home-care company that now boasts more than 500 locations in the U.S. and overseas. Home care in general had yet to proliferate; maybe a dozen agencies were offering such services in the Pioneer Valley.

The law of supply and demand meant there were more caregivers than jobs, which was great for companies, she noted.

“We had more control, and they were more willing to do what we said. Because there were fewer agencies for these caregivers to go to, they had less choice. They were easier to hire back then — you could find a well-trained one easily because there was a deeper pool, and they were more experienced. The pay was lower — like $7.50 an hour when we started. And more of them were willing to work full-time. They were more likely to take whatever you could give them.”

These days, that balance has shifted, to say the least. Home-care services, both small independents and national chains, now dot the region, and workers are in demand.

“Now, it’s not us with the control,” Anstett said. “They have the control. They can pick where they want to go. They can choose how many hours they want to work. They’re less willing to take whatever you want to give them.”

It helps, she said, that her Visiting Angels franchise, now celebrating its 21st year, is a known name with deep roots in the community.

“You don’t have someone down the hall where you can yell, ‘hey, can you help me?’ This can be a challenge for some nurses, but the nurses we have appreciate meeting with a patient exclusively, being able to develop relationships they often don’t have time for in an acute-care setting.”

“When we first started, there were only a few businesses like this. It was just emerging, and it was something that was really needed,” she told BusinessWest. “Our model was based on what people wanted. We matched the caregiver to the client. We weren’t telling people, ‘we’ll come here at this time.’ We made it all about the client. But we also matched them with a caregiver, and they could meet their caregiver and say, ‘yes, this works,’ or ‘no, this isn’t a good fit.’ There’s a lot of work in matching a personality, skill level, schedule — it’s really challenging.”

That philosophy hasn’t changed over the years, but the challenge has become more intense with increased competition for certified nursing assistants, home health aides, and personal-care assistants.

Also more challenging is the level of care many patients require, in an era when hospital stays are shorter and Americans are living longer than ever before.

“I was a home-care nurse fresh out of nursing school in the early ’90s, and compared to the patients we saw then — even compared to five years ago, really — the patients are much higher acuity, much more complex, and they really need a lot of care coordination and are on so many medications,” said Priscilla Ross, executive director of Cooley Dickinson VNA & Hospice.

“One of the biggest roles of the home-care nurse is reconciling those medications, because medication errors are one of the most common reasons for rehospitalization,” she went on — for example, people often don’t follow instructions, or aren’t aware of certain drug interactions, or are mixing pharmacy prescriptions with mail-order drugs. “Things are so much more complex than years ago, with hospitals focused on shorter stays, and there’s pressure on skilled-nursing and rehab facilities for shorter stays as well, so people are coming home with more needs.”

Michele Anstett (second from left) with some of her team at Visiting Angels, from left, Julie Dewberry, Helen Gobeil, and Natali Pilecki.

For this issue’s focus on the business of aging, BusinessWest spoke with several home-care professionals about what’s appealing about this critical work, what’s challenging, and why those challenges are only increasing as the senior population in the U.S. continues to swell.

Return to Form

The VNA has a sizable clinical staff, as many of its clients have been in and out of hospitals or acute rehab settings. But the focus isn’t on the illness itself, Ross said, but returning people to functional status in the short term. “They want to get back to making dinner, doing the laundry, taking care of grandchildren. With nursing and rehab, that process can happen much more quickly.”

She noted that the national shortage of non-medical home health aides may be more pronounced than the shortage of nurses, but it’s a struggle for organizations to recruit both. For nurses, not only is the pay scale less than in, say, a hospital setting, but some nurses don’t like the autonomy and independence that home care requires; they’d rather work in a team setting. Of course, other nurses desire the opposite, and relish the idea of focusing on one patient instead of several at a time.

“You don’t have someone down the hall where you can yell, ‘hey, can you help me?’ This can be a challenge for some nurses, but the nurses we have appreciate meeting with a patient exclusively, being able to develop relationships they often don’t have time for in an acute-care setting.”

Julie Dewberry, marketing and recruitment specialist for Visiting Angels, agreed. “They like the one on one,” she said. “They don’t have the pressure of one person with five different patients. Some come from nursing homes and say they don’t want to do that.”

Helen Gobeil, staffing supervisor for Visiting Angels, said determining who will be a good care worker is as much art as science.

“It’s a mother’s instinct — you’ve got to feel it,” she said about sitting with prospective staff. “You see they’re caring, they want to work, they really enjoy elders. They don’t call them old people; they respect them. I have to feel it.”

That ‘feel’ can be as simple as whether the interviewee makes eye contact, Anstett said. “What’s their demeanor? Are they a warm and caring person? If they’re warm, caring, and compassionate, that’s the basis, and we can move on to skill.”

That skill can be reflected in many ways — their degree, their experience, perhaps a referral. Sometimes, the agency will bring on someone whose only experience was taking care of their grandmother. “If they have good character, we’ll put them on a companion case, with a mentor, and help them get more education. We didn’t do that before. Now that the pool is lower, we’re trying to find ways to bring in more people.”

One way is to offer more training to staff. In addition, Visiting Angels has done well bringing on nursing students from area colleges, who are able to supplement their income while gaining on-the-job experience. “They’re very good workers,” she said.

The shallower pool of talent is only one growing challenge; a tougher financial climate is another. Wages are higher — Anstett said her goal is to keep what she pays workers above Massachusetts’ minimum wage as it creeps toward $15 over the next few years — as well as higher recruiting costs and expanded paid medical and family leave in the Bay State.

Finally, as noted earlier, workers increasingly eschew full-time work and often make home care one of two jobs, and they increasingly resist set shifts in favor of flexible schedules.

“We are a known name with deep roots, but it is a challenge,” she said. “We do well, though — we’re finding people of quality. Because of our experience, we understand what makes a good caregiver and who wouldn’t make a good caregiver, and how to screen them properly.”

Constant Mission

Roseann Martoccia, executive director of WestMass ElderCare, says her 45-year-old organization’s goal has long been in line with the goals of the home-care industry.

“From the beginning, our mission has been constant: to help people remain at home with the supports they need,” she said, noting that most people, as they age, want to remain in their homes, with some measure of independence.

To help them achieve that goal, WestMass ElderCare offers a broad range of supports, not just home care, aimed at helping seniors live independently. These range from nutrition services — it delivers about 1,400 hot meals daily in seven communities — to adult foster care; from housing support to personal-care management, helping people with chronic conditions or disabilities direct their own care by hiring and supervising personal-care attendants.

In the realm of home care, the goal is similar to other agencies: to help transition people from rehab settings into the home, and to maintain their function there.

“Our goal is to provide compassionate care and guidance so people can live in their homes and communities,” Martoccia said. “When we visit the home, we’re setting up a plan of care. What is your family doing? What do you need help with? What do you want help with? What’s most important?”

“Generally, people have chronic conditions, and their family may be at a distance, or they may not have a lot of family supports,” she continued. “In that case, we might be providing more services to them, helping them with many things they may not be able to accomplish on their own.”

WestMass focuses on the needs of family caregivers as well as patients, she added — people who have to work or raise families, but still want to make sure their parents or grandparents are OK.

“A lot of times, we hear caregiver stories about how what we do helps them and gives them peace of mind,” she said. “They may be checking in daily or weekly, but they know services will be coming.”

Cooley Dickinson VNA & Hospice has a different model than home-care agencies that focus on non-clinical assistance, often over the long term. Instead, it hires nurses and physical, occupational, and speech therapists, among other team members, to help clients transition from an acute or rehab setting to home life over a shorter term. Involving family caregivers in the process is often critical.

“We offer things your average person can’t provide without some training — wound care, IV therapy, or teaching about disease processes and how to manage an illness and manage medications,” Ross explained. “We’re teaching family members how to do wound care, how to provide care at home.”

The other side of the company is hospice care, which can be a longer-term engagement for people who are grappling with terminal illness and the decisions that come with it.

“What matters to you? What are your goals? How do you want your care to play out? It’s really hard to have that conversation, introducing that sense of taking away hope from people,” Ross said.

“But often, when you open those conversations, you’re relieving a burden for the patient and their family, and giving them an opportunity to actually talk about the elephant in the room — and that can lead to earlier access to care,” she went on. “Studies show that the earlier patients get on hospice, the better they do in the course of their terminal illness and the better the family does in the bereavement process.”

Giving Back

There’s a large, framed photograph at Visiting Angels of an aide with Anstett’s mother-in-law, who required home care due to Alzheimer’s disease around the time she and her husband opened the franchise; she passed away a few years ago. It’s a reminder that these services hit close to home for many people, and they’re important.

And not just for the clients, said Natalie Pilecki, the company’s administrative specialist. For workers in this field — at least the good ones — it’s more than a job.

“Spending time with the elderly is always nice,” she told BusinessWest. “The hours are good, the flexibility is always good, and they enjoy socializing with the elderly. Every day is different — it’s different every time you walk into their house.”

A good work experience starts with the employer, though, Anstett said. “I think we all have to value our workforce. We did a survey of our caregivers, about what’s most important to them. They put the highest value on how they’re treated. Pay was second, and benefits third. We listen to our caregivers, and those are the things we work on.”

She noted that one client has been with the company for 13 years, just one of many long-term connections being made.

“You develop a relationship with clients and their families. It’s about giving, and when you give, people respond. The job gives back.”

Joseph Bednar can be reached at [email protected]