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Geriatric Care Management: A Practitioner’s Overview

 Fred Moskovitz, Psy.D.

Healthcare in America at the dawn of the 21st century continues to evolve as a fragmented, outdated, and overwhelmingly complex system. The emergence of Medicare, Medicaid, and more recently HMO's and HIPPA guidelines, makes it increasingly difficult, if not impossible, to stay abreast of them. Their rules and regulations can change monthly, and the subscriber to their services requires great expertise in successfully navigating the system. Physicians, too, are inadvertently becoming bureaucrats; occupied daily with the tedious but necessary routine of completing medical forms for insurance reimbursement. Many providers are being forced to hire additional employees, medical billing experts familiar with insurance codes and regulations. In fact, many non-medical providers such as psychologists and social workers are increasingly declining to accept insurance assignment for their services, and choose instead to practice strictly on a fee for service basis. They are refusing to accept substandard reimbursement for their professional services, while spending as much time filling out insurance forms as they do providing actual therapy. Additionally, there are literally dozens of Federal, State, and City programs that provide services of one sort or the other for the elderly and those with little or no income. Physicians and those in the helping professions are often hard-pressed for time, and lacking expertise in identifying, locating, and acquiring readily  available community resources for their patients and clients. Physicians, in particular, have enough difficulty keeping up to date with recent medical advances, and are mostly unable or unwilling to become social service and policy experts as well.

The medical sub- specialties have also proliferated. There are literally dozens of specialties and sub-specialties.  In the past, it was common practice to see a specialist physician who, for example, practiced orthopedic medicine and  would treat the entire range of skeletally related conditions. Today, however, the patient must first inquire whether a particular specialist's practice is limited strictly to one aspect of orthopedic medicine such as the hand or the knee, and whether, or not, the said physician is altogether competent in the diagnosis and treatment of the common back-ache. The medical profession has become so specialized that most doctors lack a holistic picture of their patient, and are limited to specialty practices e.g., gastroenterology, orthopedics, or cardiology. Furthermore, patients who suffer from numerous co-morbidities can expect to be treated by as many as three or four different specialists whom they see regularly. Each of these specialists will at some point prescribe medications for their patient without being sufficiently cognizant of what is being prescribed for them by a colleague from a different specialty. Many of the elderly who suffer from numerous chronic conditions can be taking as many as ten to fifteen different pills each day, often resulting in life threatening drug-interactions, contraindications, or  overmedication. In many cases, there is little oversight with regard to the dangers associated with polypharmacy; ultimately, it becomes the responsibility of the patient and/or their families to be knowledgeable and attentive to the possibility of deleterious side-effects of various medications; caveat emptor. Many studies indicate that in families where both spouses work full-time there is often no one available at home either during the day or the evenings as well, to administer and/ or monitor the medication regimens for the elderly patient. Who will know whether the patient is properly complying with their doctor’s orders, or if they are in fact skipping doses and subsequently doubling up on them when they remember, in order to get back on track again. It is, in all truth, very difficult to remember the proper dosages, frequencies, and schedules for many medications, as some of them require being taken in the morning, some in evening or at bedtime; not to mention before meals or after. The potential for serious complications and deleterious side-effects secondary to non-compliance is an ever present threat to the health and well-being of the elderly. In fact, statistics indicate that most admissions to nursing homes after the age of 85 years of age are primarily due to non -compliance with prescribed medications.

 Physicians spend very little time with their patients; office visits rarely last longer than ten to fifteen minutes. HMO's pay on a capitation basis; as a result, many physicians tend to be less motivated to treat the very sick. Sadly, and perhaps even adding insult to the injury, Medicare, Medicaid, and HMO's are notorious for  not paying providers fairly or adequately for many procedures and conditions; physicians are forced to see additional patients to make up for this loss of income. Physicians, pressed for time, often limit their examination to  the presenting problem and skip an expanded assessment; often resulting in undesired outcomes. Rarely does a doctor have enough time to adequately address important issues such as mental health problems, loneliness, pain, or poor nutritional habits. According to many reports, the elderly patient may feel rushed, and confused by what the doctor has said and is embarrassed to take up more of the busy doctor’s time. Many office visits made by the elderly are entirely rooted in issues dealing with the need for human attention, or emotional distress. Frequently, there is no pathological finding during such examinations, and the patient may be told that the various aches and pains that they are experiencing are "in their heads"  or to be expected for someone of their advancing age. This mantra is often used, and is a very poor substitute for simple compassion and empathy.

 Most physicians are very poorly prepared to deal with mental health issues and the problems arising from depression, loneliness and social isolation. Having received little or no training in medical school on how to recognize and treat  such ubiquitous conditions, the average physician is at risk for missing the signs of depression and existential isolation. The physician is trained with a bias towards objective data, and towards the gathering of information which can be clearly seen, felt, or measured. Little time or effort is invested in collecting data of a psychological or emotional nature; the "door" for the patient who needs desperately to communicate emotional or psychological distress is hardly cracked opened. Male patients, in particular, suffer from a tendency not to volunteer information or feelings of an emotional nature; from early childhood on, they are  socialized to be tough, macho, and to "take it like a man" when it comes to emotional distress. It is often perceived as a sign of  core weakness to admit that one is sad, or depressed. Detecting emotional and/or psychological pathology requires time, patience, and active listening; nearly impossible to identify during the fifteen minute time slot  allotted to the average patient. Furthermore, most medical practitioners see and treat their patients in an office or hospital environment, and rarely if ever do they make house calls; effectively resulting in the elderly patient being assessed and diagnosed in a relative vacuum. The doctor is unaware of how the patient is living at home. Is the home clean, and well maintained? Is the apartment “elderized” so that an older person will not trip on frayed carpets, cluttered floors, or slip in a tub or shower? Are there grab-bars present where they are most needed? Is the  frail patient capable of cooking a nutritious meal or is he/she eating junk food, or worse? Is the home lacking smoke detectors, hot water, adequate ventilation for the warmer months, and heating during the cold season? Is the elderly individual spending an entire day cooped-up in an apartment, staring at the four walls, without so much as stepping outdoors for fresh-air or exercise? Often, the simple but extremely important act of interacting with one's peers at the local senior center, church, synagogue, library, coffee-shop etc. is not being adequately taken advantage of. When doctors examines their patients, rarely ever do they inquire about these important and potential, life-style based, health hazards. A plan of care recommended by a physician without ever having investigated the wide range of external factors potentially causing or exacerbating the presenting problem is often ineffective. Very little time, if any, is ever spent discussing social or financial issues with t he patient which may in fact contribute to their poor health habits and undesirable life-style. Patients, who for example, are losing weight can often be treated simply and cheaply by having someone cook a tasty, warm, and nutritious meal while providing  companionship while they eat it. Physicians need not treat all their findings among the elderly with medication and an endless battery of medical tests and procedures; some of the most efficacious remedies recorded throughout history include nothing more complicated than a healthy dose of TLC (tender, loving, care), and are relatively cheap as well.

A recent article in The Gerontologist contends that as many as seventy five percent (75%) of moderate to severe cases of dementia go undetected by primary care physicians, while up to ninety- five percent (95%) of early stage cases are overlooked by them. Dementia can prove very difficult to detect when the physician is under pressure to clear a busy waiting room full of sick, and impatient people. Additionally, the physician must rule out a differential diagnosis for dementia, excluding other diseases which might exhibit similar symptoms to dementia i.e., brain tumors, delirium, depression, and stroke. The Folstein Mini-Mental Exam, a tool commonly used to screen for dementia, requires  anywhere from 20 minutes to a 1/2  hour to administer, and should be scored by an experienced clinician. A normal patient having a “bad day”, as we are all prone to on occasion, might not achieve a "passing" score on this test, and may be under suspicion of having dementia; while the patient who is, in fact, actively suffering from dementia might  be having a “very good” day, will score much higher than they usually would, and be told that "there is nothing the matter with you."   In such cases,  follow-up and retesting are required at a future point in time to validate or negate the initial findings. Many individuals suffering from dementia retain their "social graces" until very late in the disease process and when  engaged in conversation are often able to provide responses similar to those found in a cognitively intact person, and thus “fooling” the untrained physician. Unless the physician is experienced in recognizing dementia and engages the  person suspected of having dementia with a more detailed set of questions, it is very difficult to diagnose in its very earliest early stages. Often, the concerned child will be told by the physician that there is nothing wrong with their parent and will subsequently leave the doctor's office feeling like a fool. As a result,  dementia frequently goes undetected until it is well advanced, i.e.,  moderate and severe stages, while critical interventions to assist patients and their families are not forthcoming. Moreover, most physicians are inadequately prepared to provide the patient and their family with an adequate explanation of what to expect as the disease progresses, and how to cope; and very often the diagnosis of dementia is presented with little compassion or empathy. Family members are often distraught, angry, and at a loss for where to seek practical advice and empathy.

Americans are a society on the move. Many adult children no longer live in proximity to their aging parents. Years ago, families tended to live in the same city or neighborhood; in fact, many homes were occupied entirely by members of the same family. Daughters and daughter in-laws were readily available to provide care or companionship for their aging parents or in- laws, and adult children would spend time in their parent’s home practically on a daily basis. They would run errands for their parents, take them to their doctor for checkups, and maintenance of the elder's home would be provided during weekends. Additionally, families would attend services at the local church or synagogue as a unit; and the weekly social gatherings were a family affair providing the elderly parents with a built-in social life . Today, however, many adult children live at great distances from their parents; some live in the next state, many live across the country, all at distances requiring a minimum of a few hours of travel. Jobs require that they relocate, and elderly parents are left back home without a major source of social support. Often, adult children left home immediately after school while their parents were still relatively young and capable of  functioning independently. As time passes, however, these children become increasingly concerned about their aging parents’ health and well-being. They find themselves ill at ease when they communicate with their parents by phone, and detect subtle signs of cognitive impairment such as forgetfulness or confusion. Moreover, they become frightened when they discover that their parents are attempting to conceal the extent of their inability to cope in order not to burden their children. Often, when children come home for the holidays they are shocked to see a drastic change in their parents, which were not evident during their last visit. To whom can these children turn to for information and advice; how can they accurately assess the extent of their parent's problem? Are their parents, in fact, living safely, or are they at danger for accidents, illness, and worse?  How does the adult child concerned for the safety and well-being of an aging parent monitor  their progress, or lack of it, from a distance? What do children do if parents are hospitalized, require daily assistance at home, or can no longer live at home by themselves?

In most families today both husband and wife have jobs or careers. For many dual working couples, a job it is not a luxury or a matter of choice but rather a necessity for financial survival; they work full time jobs, with very little time for anything else. The daughter or daughter-in law who is usually the “primary caregiver” for the aging parent is often simultaneously raising children and running a household; it's been said that this is the sandwich generation”. The adult child’s time is divided between a job, career, wife, children, and elderly parents. Often there are grandchildren as well,  taking up the scarce  free time of  an adult child at the expense of an infirm parent, or vice versa. Caregiving, according to many studies, requires upwards of twenty -five hours per week, at the average. Many adult children are forced to sacrifice full time jobs in favor of part time work in order to be available for their parents when necessary. Often, the only time available to help Dad or Mom is in the evening or on a weekend, at the expense of one’s own family. The level of stress rises precipitously when children are required to tend to the needs of their elderly parents. The incidence of caregiver stress is well documented in medical and psychosocial literature. Even when an adult child is willing to expend the time on his parents, the time allotted is often insufficient as full time care is often required. To whom does the adult child turn to for guidance when overwhelming needs have to be addressed? The cost in time and money is often more than many adult children have to spend. The pressures of caregiving are overwhelming and often manifest themselves as high blood pressure, heart disease, shortness of breath, or gastrointestinal ailments; depression, as well, is becoming a common condition among primary caregivers whose work never seems to cease.

 Siblings are often at cross purposes when it comes to making decisions regarding an elderly parent. There is frequent interfamily conflict regarding how best to  spend available money, time, or other resources, and whether to opt for relocation,  placement in a nursing home, or bringing care into the home. In many cases, the aging parent has not signed a Durable Power of Attorney or Advance Directives, and thus leaving ample room for family disagreement. Many children need advice that is inter-disciplinary in regard to caring for their aging elders; they need the advice of an attorney, and would benefit from individual or family counseling. Some adult children need help in communicating with the family physician or pharmacist. Many children are desperate for financial entitlements to defray the costs of caregiving, and most need help in hiring and monitoring qualified home health aides. The greatest problem, it seems, is that in order to address all these many issues it would require the services of many different professionals with widely varying backgrounds, training, and education. It would require the assistance of elderlawyers, physicians, social workers, psychologists, pharmacists, and a gerontologist. It would also require that these diverse professionals work in unison with the caregiver in providing their services in both a timely and sensitive manner. In addition it would also necessitate that these professional providers communicate with one another in order to facilitate the best plan of care for the elderly client and his/her family. In most cases, it is hardly realistic to expect cooperation and coordination between an assortment of professionals, particularly when it is required immediately,  on a long-term basis, and cannot be postponed for another day or week. That is, unless, one has retained the services of a Geriatric Care Manager (GCM).

Geriatric Care Management is both a comprehensive and multi -disciplinary field. The professional care manager is usually a highly qualified individual who has been educated in the field of human services. He/she, at the minimum, has Masters level training in Social Work, Psychology, Nursing, or Gerontology. At present there are approximately 1,700 geriatric care managers in the United State; the umbrella group, The National Association of Professional Geriatric Care Managers (NAPGCM) was founded in 1985 and is based in Tucson, AZ. The Geriatric Care Manager (GCM) is trained to assess, plan, coordinate, monitor, and provide a wide range of  services for the elderly and their families; primary among them is advocacy for the client. Services provided by GCM's include the following:

  • Consultation

  • Assessment

  • Advocacy

  • Education

  • Arrangements for Home Care

  • On- Going Care Management and Long- Term Monitoring

  • Counseling

  • Information and Referral

  • Crisis Intervention

  • Placement

  • Entitlements

  • Financial Management

  • Psychotherapy, including Family Therapy

  • Arranging for Services Throughout  the U.S.A.

 The initial consultation is usually the first step in retaining the services of a GCM. In most cases, the "primary caregiver" will contact the GCM after having been referred by a friend or searching the internet for available eldercare services. Often, the referral is made by a social worker, hospital discharge planner, attorney, or through an organization such as the Alzheimer's Association. Many families  will procrastinate for weeks and even months before finally calling for assistance; usually provided in the form of a consultation. The initial consultation may last anywhere from an hour to three hours, and is usually attended by adult children, their spouses, and any other willing family member involved in caring for the elderly person. The consultation is an opportunity to discuss a variety of issues and concerns in an environment which is private, safe, and free of judgment; it is usually suggested that adult children come unaccompanied by parent(s), in order that they might speak freely and without constraint.  A common issue of concern among many adult children is the physical deterioration of a parent with regard to their Activities of Daily Living (ADL’S) i.e., ambulation, transferring, grooming, toileting, and the ability to feed oneself or take medication. Additionally, there might be a noticeable decline in cognitive abilities i.e.,  memory loss, wandering or getting lost, repetitive speech,  inability to make decisions, calculations, remembering the name of objects, and poor judgment. The person might also behave in a manner that is odd or inappropriate; improper dress and/or sexual behavior. Caregivers usually want to know the best way in dealing with a parent when they are confronted with such confusing and frequently frightening behaviors. Additionally, questions regarding the accessing of home health care are usually discussed at length, as well as the means to finance it should it become necessary. End of life issues such as DNR’S (Do Not Resuscitate), Advance Directives (Health Care Proxy, and Living Wills), Durable Power of Attorney of Attorney (DPOA), artificial nutrition and  hydration, are common topics as well. Families often need referrals to a wide range of professionals, including an "elderlawyer," geriatrician, internist, or psychiatrist; additionally, they might also be at odds as how best to proceed with Dad and Mom's care. In a nutshell, the consultation generally addresses a broad range of issues and concerns which requires time, cooperation, and a multi-disciplinary approach to problem solving. Once the initial consultation has been completed the GCM has a clearer picture of the major issues of concern as seen through the eyes of the adult child. Usually, at this point, the family will decide whether the information they have acquired during the initial consultation is sufficient for their  present purposes, or whether they choose to continue the evaluation process with a  more thorough in-home assessment  of their elderly parent(s). In reality, only after such in-depth evaluations taking place in a face-to-face venue with the elderly person can the GCM have a truly objective picture of a family's situation. Once the assessment phase has been completed the GCM can furnish the family with a "plan of care" and a set of recommendations specifically tailored to the needs of the elderly client.

In referring to the "client", it is always the elderly individual that is intended; regardless of who pays the GCM’s fees. The by-laws of the NAPGCM are clear in stating that the client is always the individual who is being cared for, and it is for their needs and rights that the GCM must advocate. In fact, should the wishes of an adult child or primary caregiver (payer) run contrary to what is in the best interest of a client, it is unethical for the GCM (payee) to abide by such guidelines regardless of the fact that is this person who is hiring and paying the GCM's fees. In such cases, where irresolvable conflicts arise between the GCM and the persons paying their fees, potentially resulting in harm to the elderly client, the GCM is ethically bound to recuse him/herself from providing further services in the current case, after having provided the family with a list of suitable GCM's to act as replacements.

The assessment phase is generally performed in the home of the elderly client; occasionally, it may have to be administered in a hospital, rehabilitation center, or a skilled nursing facility (SNF), depending on where the client is currently located. Adult children or appropriate family members may be present during the assessment so that the elderly person does not feel intimidated or confused by the presence of a total stranger asking personal questions in the privacy of their home. In certain cases, e.g., moderate dementia, the presence of an adult child can prove to be beneficial because they might be able to provide the GCM with important information that would otherwise be omitted or forgotten. The amount of time necessary to complete the assessment can vary anywhere from two to four hours, depending on how many persons are being assessed (couples?), as well as the complexity of the case. The assessment covers a wide range of issues, and provides the GCM as well as the family with a better understanding of the client and their circumstances. Once the assessment has been concluded, the GCM reports on their findings to the appropriate person , submits a plan of care, and  offers a list of constructive recommendations for use by the family. Additionally, the information collected during the assessment, physical and/or cognitive, provides valuable baseline data of potentially great value when used at a future date to determine the client's current status; stability, improvement or deterioration. A copy of the GCM's report  can also be sent to the primary care physician if the family wishes.

Once the assessment has been completed, the GCM together with the primary caregiver are better prepared to discuss the implementation of the plan of care for the client. Each plan of care is tailored to the specific needs of  the individual client based upon the data gathered during the initial consultation as well as from the assessment. The GCM will usually draw up a “contract’ or “letter of agreement” in which the services to be implemented are outlined and their fees agreed upon. Fees might be in the form of an hourly rate, which is  most common, or the caregiver and GCM may choose to negotiate a single flat rate which will include all the services to be provided during the course of a single month. Once the adult child and the GCM have reached an agreement about the services to be provided as well as their fees, the first order of business, in most cases, will be to access home health care for the client.

The GCM is frequently asked by the family to locate, interview, and hire a Home Health Aide (HHA) or companion; either through a licensed health care agency or from an employment agency in the private sector. The process of hiring an HHA or companion often begins as  a process  of trial and error, and is commonly referred to as "matchmaking." The GCM networks with numerous health care agencies and employment services to be assured of a steady supply of experienced aides, who have been pre-screened by the agency and are  reliable as well as honest. The client’s needs and personality must be compatible with that of the aide, and often the GCM will interview three to four different aides before a final choice is decided upon. Gross incompatibility between a client and their new aide might appear within a few weeks, and the GCM must begin the entire process of hiring a new aide all over again. The GCM will usually suggest a minimum amount of hours which they believe, in their opinion, to be necessary to ensure the safety of the elderly client. At times, this might call for 24- hour live-in help, while in others, an 8- hour daily shift, or less, will suffice for the client. Once the aide has been retained, the GCM must properly instruct the aide with regard to their new role, duties, and associated responsibilities and to monitor them as well.  

Many families choose to subscribe to a plan of "ongoing care management" and monitoring services for their loved ones. In such cases, the family retains the GCM to provide a wide range of services. In many instances, adult children and their spouses have full time careers or jobs and cannot minister to their parent's needs consistently. Frequently, the caregiver has been "there" for an elderly parent or an ailing spouse for months, perhaps even years, and is now experiencing burnout” on both a physical as well as on an emotional level. Under such circumstances, there is an urgent need for someone else to immediately assume the day -to -day responsibilities previously provided by the caregiver in order to provide them with much needed respite. The GCM, in such cases, can coordinate necessary services, and monitor the aide who will be instructed to report to any problems directly to the GCM, and not to the adult child as was the protocol in the past. The GCM, using their best judgment, will decide whether to notify the caregiver about a new problem, or might choose instead to solve said problem without involving an already overstressed caregiver. In doing so, the GCM is effectively providing a buffer between a client, their aide, and the burned out child or spouse thus sparing them from needless calls and petty problems. Physicians’ appointments can easily be scheduled by the GCM, and transportation will be arranged as well; the care manager, under certain circumstances, might even accompany the client to the doctors’ office and discuss necessary treatments and medications with the physician; relaying such information to the child or spouse at the appropriate time. The GCM is often familiar with medical issues, and is thus capable of intelligently discussing matters with the practitioner. In many cases,  the family finds itself frustrated when trying to communicate with their parent's physician who is not returning their calls in a timely fashion; leaving no choice but to sit and wait near a phone. The GCM, on the other hand, is a healthcare professional and is usually more successful in communicating with the physician and their office staff.  The family will usually sign an authorization allowing the GCM to communicate directly with the physician on their behalf. In providing ongoing care management services, the care manager is performing many of the duties that the primary caregiver would provide on their own, thus reducing the level of stress in a situation that is already fraught with intense pressure.

 Counseling, too, is a significant component of geriatric care management. Often, families need information about issues such as Medicare, Medicaid, Assisted Living Facilities or Nursing Homes. They may want to learn about Alzheimer’s disease and how it manifests itself behaviorally over time. In many cases, the family may be split over how a parent should be cared for. Is home care better, or would a Nursing Home be more appropriate? Should a parent's estate be conserved for the next generation even if they will ultimately receive a lesser quality of care, or should their savings be spent entirely on their care as this is what they worked for all their lives? Family members are often consumed with guilt when they cannot provide more time for an elderly parent, and are forced to split their time between jobs and their own families.  In such cases, the GCM can offer individual or family counseling, and act as a mediator between feuding siblings and/or family members. A major part of the GCM's counseling services deals with issues related to caregiver “burnout”, often a sad but inevitable part  of eldercare. The GCM is a major source of information and referrals to elderlawyers, geriatric physicians, psychiatrists, senior centers, and adult health day care programs. The GCM is also familiar with community resources and programs; an important service for families in crisis having neither the time nor the patience to spend on research. GCM's are also a major source of empathy and compassion for an overburdened adult child, and refrain from being opinionated or judgmental .  

 The GCM is adept at dealing with crisis; crises, as we are all aware, can arise without a moment's notice. For example, when a parent is scheduled for discharge from a hospital in two or three days and there is no home health care plan in place. Similarly, if an immediate decision has to be made in the hospital about which rehabilitation center or nursing home to choose for Dad, lest  the hospital will make a placement to a facility of their own choosing, which ultimately might not be the family's first  or best choice. Many families do not plan for such emergencies; they wait until the last moment to act. In such cases, the GCM can be called upon to develop an immediate plan of action that will tide the family over the emergency, and will buy additional time to solidify a well thought out strategy.

 Another major concern for many families is, often, a financial one. Home health care can cost as much as $15-20 per hour while medications may run into   many hundreds of dollars per month; and clients suffering from Alzheimer’s disease frequently require 24- hour live-in care. The GCM, in such cases, can offer guidance with regard to entitlements. Very often, a client may be eligible for Community Medicaid, as opposed to Nursing Home Medicaid, and is unaware of this information; the GCM will advise the client and help complete their application forms or make a referral to the appropriate professional. Many elderlawyers will ask a GCM to complete parts of the clients Medicaid application because GCM’s are experts in describing the functional needs (ADL’s) of clients. Physicians, often, will fill in the medications prescribed and a diagnosis, but may not show a compelling reason for home health care services. Many clients are also entitled to governmental or pharmaceutical sponsored prescription plans; rent increases may need to be frozen, and Food Stamps may be urgently needed. The GCM is well versed with the various entitlements that are available or who to turn to when needed; thus, the financial burdens for home health care services might be alleviated, if not completely absorbed, by the appropriate entitlement agency.  

Many GCM’S offer Financial Management Services through an affiliate. When a client is unable to assume the responsibility of monthly bill paying, and the family is unavailable or unwilling to provide this chore, the GCM will provide cash management services. Essential service bills such as gas, electric, and rent will not be jeopardized by late, double paid, or unpaid bills.

When living at home is no longer a viable option or choice, the GCM can help with placement. If the client deteriorates to the point that he/she requires skilled nursing, or if the family is unable or uncomfortable with the idea of leaving a loved one at home by themselves or in the care of an aide, placement may be the best option. The process of selecting a Nursing Home or Assisted Living Facility is time intensive. Families are often pressed for time and have little or no criteria by which to judge a facility; often, when private pay is not an option the family must chose between two or three facilities that have beds available; the process of selecting the “best” facility is always a frightening decision for caregivers. The GCM is capable of researching a particular facility or, for that matter, might have prior experience with said facility; GCM's are, for the most part, usually knowledgeable of the various facilities in their community. The GCM could visit the prospective facilities together with a family member, or simply recommend the best three or four facilities from previous experience. The GCM is also available to advocate for the client once the placement has been made to assure that the adjustment period and subsequent stay will be successful for the new resident and his family.

Dychtcwald, in Age Power (Putnam, 1999) notes (p. 71) that there will be a need for “Eldercare coordination firms that support older adults and their families as they navigate the services necessary to maintain health and independence at home.” Bass and Noelker in an article titled Family Caregiving: A Focus for Aging Research and Intervention (Gerontology, Perspectives and Issues; Springer, 1997) review research that indicates (p. 258) “that caregivers who use services, compared to equivalent controls, have reduced levels of depression and strain, lower rates of nursing home placement, improved relationships with care receivers, and higher morale.” Malone, J., Greenberg, J., Olson, G, in  “Towards a Chronic Care Model: The Potential Roles of Geriatric Care Managers in Long Term Care InsuranceGCM Journal, Summer, 8 (3): (1998); (pp.14-21) state that “GCM’s bridge our fragmented system of care.” Nickel, et al., (1996) in “Quality of Life in Nurse Case Management of Persons with AIDS Receiving Home CareResearch in Nursing & Health, 19 (1996); (pp.91-99) maintains “ GCM’s use holistic approaches to meet the needs of the frail elderly. They collaborate with other professionals to identify and prioritize long term/chronic care services for clients and families. They aid in early detection of care needs and promote access to services to maximize client functioning, thus reducing the use of higher cost services.” Joseph Matthews in “Beat the Nursing Home Trap(Nolo Press, 1997) states that (p. 2/13) “Geriatric Care Manager are most helpful in guiding you through the maze of home health care and other support services needed for long-term care in the home. They can be particularly useful when family members live in a different city from the person who needs the care. Care managers may know of difficult-to find services; they can evaluate agencies and individual care givers; they can set up a coordinated program of care among several providers; and they can follow-up with ongoing management and changes in care.”  

Healthcare in America has evolved into an extremely complex and fragmented system. Many of our elderly will require a  “safety net” to care for them as they succumb to the various frailties associated with aging. America does not have a national healthcare program that will successfully provide for all senior citizens who require healthcare beyond what Medicare has to offer. Medicare will provide a limited amount of services at a time of life when a great deal more care is necessary. When the elderly require additional medical or custodial services, they must pay out of pocket for services that Medicare will not reimburse. In the event that adequate financing is unavailable for these crucial services, the elderly are forced into being cared for by family or friends. The alternative option is to  impoverish oneself by "spending down" and to apply for Medicaid or other forms of governmental assistance. The GCM is an expert at navigating the entitlements arena with all its inherent complexities; they find affordable solutions for homecare or institutional care, and, if necessary, will  assist in applying the appropriate entitlements.

America, in the 21st century, needs desperately to provide comprehensive and universal healthcare coverage for all its senior at affordable prices. The demographics point to a crisis of great proportions unless the Medicare, Medicaid, and Social Security systems can guarantee adequate services for seniors as they reach retirement. The elderly should not have to impoverish themselves in order to receive the care that they require, after having spent an entire working career paying taxes into the system. Until such time as America can guarantee its elderly citizens with complete medical and custodial healthcare services for its aging population, there will be an increasing need to locate services wherever they may be found in a timely, caring, and economical fashion. Demographics point to adult children living at greater distances from elderly parents than they have in the past; while dual working couples have also become a fact of life in America, creating a huge void in the pool from which eldercare services were traditionally found. A need exists for  reliable experts who can monitor the elderly parent's circumstances, and be the “eyes and ears” for concerned children wherever they might be. The GCM is a professional whose time has come; someone capable of managing, coordinating, facilitating, and advocating for the elderly and their families. The author contends that in the future, just as one requires the services of an M.D., CPA, Attorney, and Financial Planner in order to feel adequately secure in one's daily life, so too will they need to add GCM services to complete this list. As a healthcare professional, the GCM's multi-focused services will become increasingly essential  to navigate the complexities of the American healthcare system. The GCM is one of  that unique breed of healthcare professionals who will provide the family with a multi-faceted picture of the elderly client and their needs, and is ready to advocate for them on all medical, legal, financial, and psycho-social fronts and issues.