The Emergence of Private Sector Geriatric Care Management
Geriatric Care Management, a multidisciplinary profession made up primarily of nurses & social workers, first emerged as a professional field about 15 years ago when experienced clinical professionals, across the country began, to leave traditional third party settings. Disillusioned with the large caseloads typical in non-profit and publicly funded agencies, and the limitations of third party payors such as Medicare, a group of about 100 practitioners in 22 states had begun to set up private consulting practices to help family caregivers of frail elders. They met to share ideas and to discuss how they conducted their private clinical gerontology practices. The result of these early meetings led to the formation of the National Association of Professional Geriatric Care Managers (NAPGCM). NAPGCM currently consists of more than 1500 professional geriatric care managers nationwide with a vast majority in individual or group practices. The national association exists to foster the profession of GCM through marketing and public relations, legislative activism and professional development. NAPGCM facilitates a yearly national conference, publishes a practice journal and several other publications. Additionally, individual state and regional chapters host regular chapter meetings and some also hold chapter conferences.
-What is a Professional Geriatric Care Manager? –
A Professional Geriatric Care Manager (GCM) is a human service professional who specializes in assisting elders and their families with long term care issues.
Geriatric Care Managers:
1.) Conduct care planning assessments to identify problems, eligibility for assistance and need for services;
2.) Screen, arrange and monitor in-home help and additional health and mental health services;
3.) Review financial, legal and medical issues and offer referrals to other professionals for dealing with problems and conserving assets;
4.) Provide crisis intervention;
5.) Act as a liaison to families and long-distance care givers;
6.) Offer guidance in identifying alternative housing options and facilitating transitions;
7.) Provide counseling, psychosocial support, education and advocacy for elders and their families.
Case Example Part 1
It was 4:45 p.m. on a Friday afternoon and Dr. Jack Braun had just hung up the phone after speaking with Susan Moore, a nurse with the local Visiting Nurses Association (VNA). Dr. Braun said to himself, “Flo again!” Susan had informed Dr. Braun that his patient, Florence Clark, had been found in her home by an elder protective service worker confused, short of breath and with seriously edematous legs and acute cellulitis in her left leg. Susan explained that there was evidence that Florence had not been taking her lasix for up to two weeks and she had recently fallen. Dr. Braun recommended that Flo be taken to the Emergency Department at the medical center for evaluation.
Dr. Braun had just seen Flo the week before. She seemed to be improving. Flo, a 92-year-old widowed woman, living alone in her own home, had been hospitalized twice this year, five months apart for congestive heart failure (CHF) after failing to correctly take her medications. While Flo’s hospitalizations were relatively long, she had improved both times after transfer to the same skilled nursing facility (SNF), where she received rehabilitation and nursing care for about eight weeks. Dr. Braun expected the same course would be repeated. Flo was adamant about not giving up her home and moving to an assisted living community. She was still independent with self care and was actually able to drive herself around town. Flo had lived with and been helped by her son, until his death two years ago. Flo was estranged from her only other child, a daughter, who lived out of state.
Dr. Braun said to himself, “there has to be somebody who could help this lady on a regular basis, someone who could give her support and encouragement, help her to be organized and deal with her when she gets noncompliant with her medications.” While Flo did have involvement with VNA, this help was intermittent as the VNA would take her on each time that she was discharged from the SNF. However, due to a recently imposed capitated reimbursement system for Medicare payments, and Flo’s relative stability after post acute rehabilitation, the VNAs involvement never lasted more than a week or two. Flo also had a case manager from the Area Agency on Aging (AAA) who, due to funding cuts, could only respond when a crisis emerged. Flo’s income, from dividends and social security, far exceeded the public agency’s income guidelines for ongoing case management. Dr. Braun remembered that Flo had a trust officer at a local bank, who handled her finances. The trust department also served as Flo’s Power of Attorney.
Dr. Braun called the trust department toexpress his concern about Flo’s inability to live independently and his idea for some type of ongoing professional involvement. The trust officer assured Dr. Braun that he would check into this possibility and get back to him.
Flo was hospitalized for eight days and then transferred once again to a SNF for rehabilitation and nursing care. A week after her transfer to the SNF, Peter McClelland called Dr. Braun to say that he had retained the services of a professional geriatric care manager to work with Flo.
Over the years, the field of geriatric care management has has identified a range of effective methods for helping elderly clients. GCM’s have learned to stay abreast of the rapidly growing and changing array of long term care alternatives. GCMs typically identify problems that distinguish their clients such as: failing health and physical function, increasing problems with mental function and unmet need for care and assistance and often inadequate housing. Additionally, clients commonly have either no family or diminished family involvement, some times due to estrangement but more commonly because of geographic distance in our increasingly mobile society. GCMs are rarely hired by the person needing care. They are far more likley to be retained for the client by a family member or another professional such as the client ‘s attorney, trust officer or accountant.
The Growing Profile of Geriatric Care Managers
GCMs in well established practices are likely to be members of the National Association of Professional Geriatric Care Managers at the “Advanced Professional Level” of membership. Advanced Professional members of NAPGCM hold a masters or doctorate degree in nursing, gerontology, psychology, social work, or another health or human service field and have had two years of supervised experience in the field of gerontology (NAPGCM Directory of Members’00).
The Affluent Client-
For many of all class levels, aging is a difficult process that can generate stress for the older person as well as for family members and others. People involved in long term care often grow quickly frustrated with the overall lack of available resources. While elders with higher incomes and assets may be more likely to create resources for care, there are also aspects to affluence that can impact negatively on an elder who is experiencing an increasing need for care. For example, many lower income elderly remain relatively integrated in their community due to such factors as living in senior housing or having many involved local family members, particularly adult children. Lower income elderly also tend to qualify for means tested community elder services such as case management through a public or non-profit agency and may be more inclined to participate in community programs such as local senior center activities.
By contrast, economic mobility in the elderly, can often lead to a lack of community integration as upper middle class or affluent elders may not have had children or had fewer children whose educational and career pursuits moved them far from their parents. Frail elders who are affluent may have recently discontinued a retirement lifestyle involving living in more than one home throughout the year, causing them to be less rooted in their community. As spouses and friends who are peers die, long standing social networks disappear without replacement. Living in larger suburban homes, affluent frail elders may be less visible in the community and less active, as leisure interests such as vacations theater and restaurants become less viable given their failing health and little or no companionship.
While financially affluent elders may be less known in the community, they may be well known by their physician and his or her staff. As patients, affluent elders may be more educated, more demanding and less willing to accept advice they might disagree with. Economic mobility, at the very least, creates the illusion that much of life can be managed and controlled. An elder who may have had a successful career as a high-level problem solver may not be accepting of the advice from their physician that he or she is no longer capable of managing their medication independently or operating an automobile safely. The children of affluent elders, particularly those who live far away, may be demanding of the physicians time beyond the office visit as they may have a desire to be involved and have opinions about their parent’s medical care but are unable to physically attend medical appointments with their parent.
As geriatric care management services are generally not reimbursed by a third party payor, the patient or a family member, pays the GCM out of pocket. Fees for private care management typically range from $80.$150. per hour. As a result of being a privately paid service, commonly, the clients of GCMs are at a minimum, middle-class and often moderately affluent to wealthy; excepting lower income elders whose GCMs services are funded by a family member, often a son or daughter.
Case Example -Part 2
Dr. Braun looked at his schedule of patients for the day and noticed that Flo was scheduled for 2:00 pm. It had been 12 weeks since her episode of acute CHF with three plus edema and cellulitis necessitating hospitalization. Flo had now been home for three weeks since being discharged from the SNF. Dr. Braun then glanced at a fax regarding Flo from a private care manager.Dr. Braun remembered this GCM from years ago as a former clinical social worker at the medical center. The fax explained that he was now a GCM in private practice and that Flo’s trust officer had retained him to coordinate Flo’s multiple long term care needs.
The GCM explained that he had visited Flo at the nursing home. Prior to her discharge home, he arranged for Flo to receive weekly nursing assessments from a private duty RN. This nurse will also be maintaining Flo’s medication box according to Dr. Braun’s orders. The care manager also explained that he assisted Flo with the hiring of a homemaker/companion who will work with her in her home and in the community, four days per week. The homemaker/companion will be assisting Flo with preparing low sodium meals (a recommendation from Dr. Braun) verifying that Flo is taking her medication and reporting any concerns to the GCM as well as doing housekeeping and assistance with shopping. The last page the fax to Dr. Braun comprised an overall summary of Flo’s progress including daily weights since her discharge from the SNF. The GCM would be attending the next appointment with Dr. Braun, and would be in regular contact with the trust officer, and would monitor her ongoing care needs at home. The GCM would also be exploring alternative care options including assisted living facilities that might better meet her needs in the future.
Dr. Braun felt significantly more reassured about Flo and wished several of his other patients would use the services of a GCM.
The Geriatric Care Manager and Physician Collaboration
The preceding case of Dr. Braun and his patient Flo is based is one example of the increasing collaboration of physicians interaction with the growing profession of fee based geriatric care managers, who have emerged to fill the void left by underfunded, inexperienced and overburdened public and non-profit community care providers.
Typically GCM involvement enhances the elder’s ability to manage his or her overall health care while also fostering collegiality and more efficient communication with the physician and the increasingly complex long term care service network.
When considering GCM-physician collaboration, the following four salient features emerge that underscore a physician’s opportunity to optimize the relationship between the acute care system and the chronic care needs of a frail elder with minimal social support.
1. The GCM can enhance the interaction between the patient and the doctor..
As was referred to in the case example, GCMs often attend medical appointments with their clients. Particularly when a client has multiple medical issues and medications and/or when the patient may have some cognitive impairment. The involvement of the GCM can serve to assure that information is accurately exchanged between the physician the elder, the SNf and the home and community care providers. Additionally, the GCM can take on the task of assisting with communication in terms of status changes or making or canceling appointments between the physician’s office and the patient. This is often done with phone calls or faxes to the physician or his or her nurse.
2. Ongoing assessment of an otherwise isolated patient.
Through regular contact the GCM is able to provide monitoring of the client ‘s overall status. GCM can also arrange for more in-depth regular assessment or provide formal assessment in the areas of health/mental health depending on professional qualifications and certification. The GCM can relay patient concerns while they are at a, “pre-crisis state,” allowing the physician to intervene before a hospitalization or even an urgent, same day, appointment becomes necessary.
3. A GCM’s involvement can reduce an elder’s need for a “social’ physician visit.
The GCM is typically a well trained, experienced and caring professional. Through the process of care management, a supportive relationship between the GCM and the elderly client usually emerges. Due to this relationship with a prominent caring professional, the elder may become less inclined to make intermittent appointments with his or her physician when there is no real change in status. Additionally, given the psychosocial support and advocacy provided by the GCM, the elderly patient is less inclined to use wi a time limited appointment to meet social needs, allowing the physician to enjoy a positive and productive doctor-patient relationship within that boundary
4. The GCM serves as a conduit of information between the physician and other health care providers and the elder’s family and/or other involved parties.
While there are times when a private and personal conversation between a physician and a patient or a patient’s family is necessary, there are other times when communication is more routine and does not require direct contact with the physician. As a professional with health care knowledge, the GCM can synthesize information pertaining to patient health problems, treatment options, changes in medications, etc. and communicate these to the patient’s family. GCMs routinely follow-up with family members via phone or E-mail immediately following medical appointments. An established and ongoing arrangement for communication with the GCM and long distance care givers or involved professionals, can reduce the amount of communication a physician needs to engage in beyond the patient visit.
This article is intended to illustrate the opportunity that exists for collaboration between physicians and professional geriatric care managers with the overarching goal of better serving frail elders. In addition to collaboration on individual cases, physicians and GCMs can be excellent referral sources for each other. Physician referrals to GCMs for patients with a clear need for and the means to pay for the service, can clearly assist in a development of a positive, time efficient and productive relationship between the frail elderly patient with multiple medical and resource problems and his or her physician. Likewise GCM’s serve their clients well when they refer them to physicians who demonstrate a specific competence, for working with frail older adults.
Robert E. O’Toole, LICSW, is President of Informed Eldercare Decisions, Inc., a private company specializing in elder life planning . A founding member of the National Association of Professional Geriatric Care Managers, he is a former editor of the Geriatric Care Management Journal.
450 Washington St., Ste. 108, Dedham, MA 02027
Phone: (781)461-9637 Bob@elderlifeplanning.com
James L. Ferry MSW, LICSW is geriatric care manager based in Deerfield, Massachusetts. Jim is Ph.D. Candidate in Social Work at the State University of New York at Albany. His area of research is in the psychosocial aspects of geriatric care management. Jim would like to mention that his wife, Margaret A. Ferry MD provided him with some valuable insight for this article, from her vantage point as an internist and clinical endocrinologist.
James L. Ferry MSW, LICSW
Advantage Care Consultants
P.O. Box 307 ,Deerfield, MA 01342 (413) 775-4570 firstname.lastname@example.org