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September 2007
Professional Geriatric Care Managers: Who Are They?

Even though they handle an often-formidable number of tasks, professional geriatric care managers remain surprisingly unknown, even in their own arena. If you’re not familiar with them, you should be.

By Arn Bernstein

When one of her older patients showed up for an appointment accompanied by someone else, Daphne Goldberg, MD, ended up just a tiny bit embarrassed.

Goldberg, a family physician based in Bryn Mawr, Pa, automatically assumed the other person was a family member or a home health aide. She was wrong on both counts; the person turned out to be a professional geriatric care manager (GMC), a term she’d never heard before. “I have to admit, it was something completely unfamiliar to me,” she says. “I knew there were care-management people assigned to some of my elderly patients, but I didn’t know there was an entire organized profession of people who specialized in geriatric care at that particular level.”

Goldberg is far from being in the minority. “I’d estimate that about 90% of the time, the people I deal with have no clue we exist,” says Helene Feldman, president of Helene Feldman Inc. Elder Care Management, a Philadelphia GCM firm. “The only ones who know we’re out there are those who might have had some experience with us - geriatricians, medical directors at nursing homes, maybe some social workers.”

“It’s really true,” agrees Mike Kennedy, president of The Family Advocate LLC (a GCM firm in Cincinnati). “When I try to market myself, I find that most people have no idea what I am or what I do. I get that a lot. Sometimes, I think only other GCMs know what we’re about.”

Professional Services
Presently, based on membership information from the National Association of Professional Geriatric Care Managers (NAPGCM), there are approximately 2,054 GCMs nationwide -- not a huge number by most standards, but also not insignificant enough to be as unknown as they are.

What GCMs do is best described using a paraphrase: They’re jacks of all trades, but masters of all as well. In fact, it’s the diversity of what they do that makes it difficult to describe in just a few sentences. “The formal definition I give when people ask is that I help families navigate the complex legal/insurance systems to make sure people get the services they need,” Feldman says. “I act as the liaison between the family, the system, and the client. Basically, I’m an expeditor. I know how to get things done in 15 minutes that would take someone unfamiliar with things an hour or more. But it often goes further than that; I’ll usually provide almost whatever service is necessary. I do what the family would do if they had the time and resources.”

In many cases, that’s not an exaggeration. Depending on the parameters they place on their offerings, GCMs can and do provide the following:

· evaluations/consultations
· crisis intervention
· care management
· monitoring drug prescriptions
· arranging for home-care services
· evaluation, recommendation, and placement in adult daycare, retirement, assisted living, nursing, and hospice environments
· securing/recommending eldercare attorneys
· taking/accompanying clients to doctor/procedure appointments
· paying bills/handling banking/overseeing finances
· recommending a financial-services expert or accountant
· taking clients to hospital emergency departments
· coordinating/providing general transportation
· arranging for home modifications and/or repairs
· planning and arranging for moving/transition
· helping with funeral arrangements
· recommending durable equipment
· general support and counseling
· handling insurance matters
· getting help with Medicare/Medicaid applications
· arranging for cleaning/laundry services
· perhaps a dozen or so more duties that may be required on a client-by-client basis.

As one might expect, not every GCM provides the same range of services. Some, such as Feldman, for example, have actually served as power of attorney or guardian for some clients. Others, such as Sharon Miles, owner of Senior Care Options in Albuquerque, Nm, prefer not to get directly involved in finances or legal issues and stick to more traditional care services. Their limitations are determined by time, area of comfort, level of knowledge, or, sometimes, a combination of all three.

The other aspect of the job is that it’s not your typical nine-to-five. “Unless you make arrangements for coverage or have an understanding with some clients, you’re pretty much on call 24/7/365,” Kennedy says. “Personally, I haven’t had a vacation in four years.”

Why a GCM?
Obviously, GCMs serve what’s becoming an increasingly essential service -- they fill the gap a client’s family members cannot. As most of us are already aware, many times, family members live in different parts of the state or country from their older relatives. Those that do live closer, particularly children, are often juggling raising their own families, demanding full-time careers, and basic life-tasks such as shopping, cleaning, etc. They simply don’t have enough time to devote to properly caring for an aging parent and usually don’t know where to go for help. And frequently, parents who realize they can no longer be completely independent feel guilty and burdensome because they know they’re eating into their childrens’ limited free time.

“I give support and information to the families so they don¹t feel so alone and overwhelmed,” Miles says. “A GCM is a solution to that feeling because we’ll talk to doctors, get problems solved at living facilities, make sure clients are taking their meds properly, suggest lawyers and doctors, and handle whatever else they need. It¹s like having an extended family member onsite.”

The Numbers
While there are CGM companies with several managers available, the field is pretty much dominated by one-person operations. For this reason, the number of clients they maintain is understandably limited. “I have about 15 who I see, depending on what’s happening, weekly, several times a week, every other week, sometimes monthly. It’s really on an as-needed basis,” Feldman explains. “I could probably take on a few more, but I don’t want to grow to the point where I can no longer offer personal service.”

Miles’ number usually hovers around 10. It fluctuates, she says, because some clients’ needs are more short-term.

Kennedy’s situation is different. “I have six clients now, and truthfully, I’d like to have that many more,” he says. “I’d like to be busier, but it’s a matter of more people knowing about us and what we do.”

Cost
What GCMs charge their clients varies, but an hourly rate set-up appears to be most prevalent, with some exceptions. Miles, for example, charges a flat rate for an assessment/evaluation, then hourly after that. Feldman is straight hourly, with an extra fee for one-way travel or after-hours work. Kennedy’s charge is $75 an hour across the board. “There are no extra charges if I get called at 2 A.M.,” he says, adding that in another case, where his travel was between four and five hours each way, he dropped his rate 50% for travel time.

Even allowing a $10 to $20 variance on Kennedy’s rate, it’s apparent that hiring a GCM isn’t cheap, especially when one considers that their services are rarely, if ever, covered by Medicare/Medicaid or other health insurances. “It’s unfortunate, but in nearly all cases, you have to be more well-to-do to afford a GCM,” Feldman says. “Some long-term care policies will pay, but only if you meet their criteria, and that can be complex. Hopefully, that will change one day.”

“It’s really ironic that those people without means and access are often those who need us most, and usually, only people with the means have access to us,” Kennedy adds. “I’ve never been paid by an insurance company, ever. I’d love to be able to be able to get enough clients to feed my family, then give my services away to others who can’t afford them.”

Professional Requirements
As a relatively new occupational field, the criteria for becoming a GCM are uncomplicated. NAPGCM Communications Manager Ann Krauss explains that in 1993, as a result of care management becoming more prevalent in the area of geriatric care, the word ”professional” replaced “private” in the organization’s name. To help ensure continuity in its membership, it established the National Academy of Certified Care Managers in 1996, a credentialing program.

But not all members took advantage. A 2006 membership vote decided that as of January 1, 2010 (2008 for new applicants), all NAPCGM care manager members must hold at least one of four approved certifications – Care Manager Certified (CMC), Certified Advanced Social Work Case Manager (C-ASWCM), Certified Case Manager (CSM), or Certified Social Work Case Manager (C-SWCM). “We felt doing this helped elevate the profession as a whole,” she says. [Editor’s note: Requirements on achieving these four designations vary. For information on CMC certification, contact the National Academy of Certified Care Managers, www.naccm.net. For C-SWCM or C-ASWCM information, contact the National Association of Social Workers, www.socialworkers.org. For CSM certfication, contact the Commission for Case Manager Certification,

Motivation
Aside from the nuts and bolts, however, what drives a GCM? Many got into the arena as a result of personally caring for an aging parent. Kennedy was also an ICU nurse and saw being a GCM as a step forward. “There’s so much pain in the world the general public never sees,” he says. “Many of my clients have lost most or all of their friends, they’re lonely, and their families are involved in their own lives. I see this as a way of giving them help and hope.”

Inevitably mixed with the upside are dark moments; argumentative families, recalcitrant clients, and fluctuating emotions. One terminally ill client who was in severe pain asked Feldman to kill her with an overdose of pills. “The family was in complete denial she was dying,” she says. “I had to literally yell at them to tell them their mother really needed to be in hospice. It wasn’t easy.”

All of this touches on perhaps the most pivotal point of being a GCM: dedication. “You have to love what you’re doing; you absolutely have to,” Feldman notes. “It requires a lot of energy, and you always have to be ‘on’ with clients. There are a lot of stressful situations. Remember, many times you’re the rock for clients or their family members.”

Spreading The Word
Though many GCMs maintain Web sites and advertise in their local papers and Yellow Pages, the vast majority depend on referrals from physicians, eldercare lawyers, nursing homes, caregivers, financial-services firms and existing clients’ families -- the same people they work with. But it’s still not enough.

“We have small flurries of recognition,” Kennedy says. “A few months ago, we were mentioned on Dateline and in a New York Times article. But it didn’t do a lot. We still need to be marketed more.” In the same vein, Miles says that people not knowing who GCMs are is what she likes least about her career.

But things may be improving. Krauss notes that NAPGM is in the process of developing an informational brochure for GCMs to give to physicians as well as a GCM career Web site. “We think both will go a long way to helping get the word out,” she says.

Arn Bernstein is a Philadelphia-based writer and editor.