During one especially dicey period with my mother, then in an assisted living facility, my brother and I hired a geriatric care manager, first for a consultation and then for additional help at an hourly rate. It felt like such an extravagance, given that we weren’t rolling in money, but the care manager helped solve a series of complex problems that I doubt I’d have solved by myself, mostly involving brokering a compromise with the facility, whose management wouldn’t let me hire a private aide for my mom but could not provide what she needed.
Relations had soured to the point that all I could do was scream at them, which was making a bad situation worse, so having an advocate was a blessing. Also, the care manager, who visited regularly with my mother, often was privy to concerns she was keeping from me, and she was always there for me by telephone, which was a lifesaver.
Many of you have asked questions about geriatric care management and how it is performed. I posed some of them to Patricia Mulvey, a care manager who has worked in hospitals, nursing homes, home-care agencies, hospice and bereavement programs, and as an independent contractor. Currently she is the director of the private geriatric care management service at the Jewish Home Lifecare System, which runs several long-term care facilities in New York City and its suburbs. With some modest editing, here are her thoughts.
Would you explain what geriatric care managers do, how they are trained and certified, how much they cost, and how consumers can make wise decisions if they decide to hire one?
A professional geriatric care manager has been educated in various fields of human services — social work, psychology, nursing, gerontology — and trained to assess, plan, coordinate, monitor and provide services for the elderly and their families. Advocacy for older adults is a primary function of the care manager. We belong to the National Association of Professional Geriatric Care Managers and are certified by one of the three certification organizations for care management — the National Association of Social Workers, the National Academy of Certified Care Managers, or the Commission for Case Managers.
Our rates vary by region and firm. Some firms charge an initial assessment fee; others bill by the hour only. In New York, an initial assessment is in the range of $250 to $750 for a one-and-a-half-hour assessment visit. Hourly charges run from $150 to $200. Some firms also require a retainer to cover the last month’s bill.
To be a savvy consumer, check the credentials of the care manager you are considering hiring to be sure they are a member of the National Association of Professional Geriatric Care Managers, as well as a member in good standing of their basic professional organization — say, the National Association of Social Workers. They also should be certified by one of the certification boards. You should check references and interview candidates.
An important part of working with the client and their families is chemistry. Be sure you get along with and like the individual you are considering hiring. They should be available 24 hours a day, seven days a week, and you should have access to their cell phone number or answering service. You should also be aware of other members of their team — nurses they may work with or their support staff — in case you have a question and can’t wait for the care manager to return your call.
What circumstances are most suitable and valuable for using a geriatric care manager? To put it another way, if you were in a caregiving situation and had limited means, when would this extra expense be money well spent?
An example is when things are going well — the elder is managing on his or her own, with little help and oversight, but the family is noticing slight changes, or the physician has indicated a change in status or diagnosis. This would be the time where it would be very beneficial for the family to know what resources are available to them, how much they would cost, how to access these resources and what options are available. Some of the key points to cover would be these.
- What is day care? What types of rehab might be available? What does “short-term rehab” mean?
- What is “respite” and where might it be available? Who pays for it?
- Information about home care services. What kind of care and how much care can be provided at home?
- Who pays for what services? This is key because a common misconception is that Medicare pays for long-term care.
- What is the difference between Medicare and Medicaid?
- What does insurance, either medical or long-term care, actually pay for?
- What happens at the end of a hospitalization when discharge is imminent? Time is of the essence, because it is often Medicare or the insurance company’s determination as to how quickly things related to discharge must happen.
- Is the health care proxy in place, appropriately witnessed and current? Is there a power of attorney? Does your state recognize other documents, such as a living will?
- Has the conversation about the wishes stated in the health care proxy been discussed with the individual who has been nominated proxy? Does the physician have a copy of the document?
- With a long-term care insurance policy, what is required for the policy to begin coverage?
- What resources are available to pay for services? How much can the family afford? And who is going to pay for what?
A relationship with a professional geriatric care manager can allow the children of the elderly person to be children, while someone else manages the situation. When a son or daughter is providing the hands-on care to the parent, the quality time they have to be there emotionally for their parent is limited…. The care manager can handle the difficult interpersonal issues, address the immediate problem, remain connected once the crisis passes and get back involved as the situation requires it.
I’d imagine that long-distance caregiving and trying to keep someone in their own home with reliable help would be the two hardest things to navigate without professional assistance. Can you tell us some of the special challenges of having an elderly parent in Florida, or Chicago, or any place where you can’t go scope out the situation regularly and thus need eyes and ears on the ground?
As for home care, I know from friends how arduous it is to manage a staff of people working in a parent’s home. They quit. Or you have to fire them. They compete with one another for who’s top dog. The client, who is so dependent, becomes almost an emotional hostage, needing the aide so badly they may be afraid to complain or offend. How does a care manager guide families through this?
It is imperative to have eyes and ears available locally. This is not a process that can be managed long-distance, even as in-touch as we are with cell phones, text messaging and video conferences. We always work with another care manager in the other location to have an independent individual assess the facility and situation. I’ve frequently moved parents from the tri-state area to California, Florida or Arizona to be closer to their children, and moved the parents to the New York area from those very same states. Moving is one of the most stressful life events we can experience, and this applies at any age. The client needs as much support as possible, someone to help them pack, stop the newspaper, disconnect the cable, and much more.
Anyone with help in the home most definitely would benefit from help coordinating the aides and other staff going in and out of the home. Adding home care to the services delivered to an elder can be very traumatic — it’s saying that “you can’t take care of yourself anymore.” How would you feel if someone you didn’t know turned up one day and moved into your spare room, cooked meals in your kitchen, sat with you when you were watching TV or reading? It’s a huge transition for people to incorporate help into the home.
A care manager can closely monitor the situation, soothe over the hurt feelings and address the anger that comes from losing our independence. And yes, you are right, the elder may become an emotional hostage, afraid to say something for fear of retribution or recrimination. It’s best to let a professional address issues the elder is concerned with.
In an upcoming post, Ms. Mulvey will answer questions about how caregivers ought to look after themselves and why they often don’t, the differences between caregiving for a parent suffering from Alzheimer’s disease versus physical frailty, and how a lifetime of family baggage can cause strains between siblings and between adult children and parents during this role-reversing experience.
By New York Times, JANE GROSS, Founding Blogger