Geriatric Care Managers: A Collaborative Resource to the Physician Practice

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 to $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 with 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.

Conclusion

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.


 

Authors Biographies

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 jim@coachingcaregivers.com

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 jim@coachingcaregivers.com

Leave a Reply

Your email address will not be published. Required fields are marked *