Serving the Elderly Client and Family *
October 2004, Vol. 9, No. 2
ISSN 1540 5273
Margaret Matheis, Ph.D.
Older adults are the fastest growing segment of North Carolina’s population – projected to number 14.1 percent of the populace by 2010. North Carolina currently ranks tenth nationally in its number of elderly citizens. Regardless of practice area, attorneys will be increasingly confronted with the issues of elderly clients and their families. Firms with a large elderly clientele such as elder law, trusts, and estates are frequently called upon to address issues that are not strictly legal. Clients of elder law attorneys seeking guidance concerning estate planning, Medicare/Medicaid, guardianship, and probate are often experiencing stress. The attorney may be confronted with needs outside his/her expertise and time constraints, becoming involved with clients in ways never anticipated. Trained in tax planning, elder abuse law, and estate planning, the attorney may be suddenly struggling with questions about geriatric care, assisted living, or home safety. In attempts to meet client needs, good intentions may result in copious time spent researching answers. In addition, genuine intentions may result in less than optimal advice.
Class level has no impact on difficulties that develop throughout aging for the elderly and their families. At first glance, the affluent client might seem immune to the frustrations involved in long-term planning. After all, their assets allow for more creativity and access to care resources. Unlike lower income elderly who may qualify for community services, middle-class and higher socioeconomic groups do not have a natural entree into entitlement services. These individuals may be more demanding and less accepting of the loss of independence. As their personal network and spouses die, they can become isolated in their own homes. Their children are busy and may be geographically distanced. The family network is disbursed and unavailable to provide assistance if the elder declines. The bubble bursts – stable finances alone cannot manage and control the passages through age.
Cries for help in our state were noted in the political arena. In 1999 The General Assembly directed the North Carolina Department of Health and Human Services to design a long-term care system that addresses a continuum of care for the elderly. One significant finding of this task force was that North Carolina's long-term care system is fragmented. The sheer number of agencies and service providers makes it difficult for consumers to know where to obtain information and assistance. With little or no sharing of information among agencies, care coordination becomes difficult. The following introduces the role of the Geriatric Care Manager as a resource guide in negotiating the complex maze of the senior system.
Geriatric Care Management
The Geriatric Care Manager (GCM) specializes in assisting elderly clients, their families, and other professionals serving the elderly. During care management an assessment is conducted through which client needs are identified, a plan to address the needs is established, and the plan is implemented. The GCM is frequently brought into the case by attorneys, family members, or other health-care professionals facing tough decisions (e.g., concern about independence in the home). The family’s limited knowledge of available options necessitates a geriatric specialist who can help plan and organize care. The GCM proves a valuable adjunct to a legal practice by facilitating solutions through this process.
This is an evaluation of the older person's life taking into consideration physical and mental health, family relationships, and living conditions. The assessment may help the attorney in the determination of capacity. Consider the case of an older gentlemen who begins to forget things, misplaces documents, and is facing the onset of Alzheimer’s or another dementia. An attorney could find himself in the middle of a crisis in which he becomes counselor, educator, and family go- between. His client may need specialized geriatric care, or help managing daily living expenses. The spouse may require education in managing the family finances. These changes could represent financial and emotional turmoil, which would demand the attorney’s attention. A GCM would assess whether the appropriate levels of medical and home help are in place and offer family members support and counseling as their caretaking responsibilities increase. For example, what should the spouse do if the client refuses to eat, misuses medications, feels depressed or mismanages the finances? When home care is no longer possible, family members may need help with selecting assisted living accommodations or nursing homes. The GCM is invaluable when health-related and psychosocial issues are paramount.
After establishing a true picture of client needs, the GCM crafts a care plan. Client data is classified according to a number of categories such as identified problems, chronic or acute illnesses, functional deficits, environmental status, psychosocial health, and coping mechanisms. Intervention strategies are put in place to alleviate crises, ongoing concerns, and future changes. The plan will indicate whether family members, unskilled or skilled caregivers, community resources, or entitlements will be used. As the GCM discusses the plan with the elderly and their family, everyone is able to set more realistic expectations. When a client becomes part of a care management program, the burden of anxious and fearful calls transfers from the attorney to the care manager. The client benefits from a trusted source knowledgeable in gerontology whose goal is to enhance the quality of the client's life. The care plan speaks to short-term stabilization, ongoing maintenance, and potential long-term needs.
The GCM works with a number of sources including federal, state, local, and available community resources. Clients may be linked with programs such as adult day care, senior socialization, support groups, and Meals on Wheels. For those who can live at home with modifications, the GCM can step into a role often filled by a daughter or daughter-in-law, with the added feature of professional training. The care manager is responsible for ongoing support required to keep the older person and household stable and running smoothly. This might mean helping the elderly modify his or her environment with safety measures, and selection and hiring of home health-care or chore services. The GCM can coordinate medical management by accompaniment at medical appointments, arrangement for medical equipment, and as liaison to the physician regarding medication, treatment progress, and compliance. For those who require placement outside of the home, the GCM works with the elder and family to evaluate and choose an appropriate new residence. The options include continuing care retirement communities, assisted living, specialized skilled dementia care, and nursing homes. The care manager assists in facility selection and helps with an effective transition from the home to a long-term care facility.
Attorneys bear particular witness to their client’s loss of self-esteem associated with residency at a nursing facility. Having a health-care professional visible and advocating for the client is extremely valuable. The GCM monitors medical treatment, staff attentiveness, and makes certain benefits are not exhausted without consultation. Daily living activities are monitored to include incontinence status, nutrition, leisure pursuits, even laundry mishaps. The GCM attends the facility’s review meetings concerning the client and functions as a member of the team, by sharing insight and advocating for the client. Whether the client resides in his own home or not, ongoing personal visits and telephone calls establish a communicative, personal relationship between client and GCM. Elders in the home have tremendous needs that aren’t medical including feeding, bathing, dressing, toileting, shopping, phone calls, bill paying, and transportation. The GCM develops and coordinates a support system addressing client needs and helps maintain it for the client’s safety and comfort.
Geriatric Care Management As A Resource
In addition to assisting families and elder clients of the attorney, geriatric care management can support other legal circumstances as follows:
- guardianship cases requiring counseling and coordination of disability or senior services
- intervention through assessment and care management for elderly persons with no family or close support system
- trustee responsibilities that could be carried out with the assistance of a care manager for a disabled or elderly person
- vehicle to spend down assets to qualify for entitlements such as Medicaid by setting aside funds for care management services
- ongoing monitoring and updates for personal injury clients whose life care plans require those services
- special needs trusts that require development and implementation of a care plan.
Increasingly clients are expecting their attorneys to be responsive to many dimensions of their lives. The care manager assures that the attorney has the resources at his disposal to offer clients whatever assistance they require. The GCM is a significant collaborator with the attorney in helping the elderly and their families negotiate the senior care network to the elder’s best advantage.
Margaret Matheis, Ph.D., is principal of Matheis & Associates, a geriatric care management company in Chapel Hill, N.C. Dr. Matheis holds a doctorate in psychology, is an experienced Geriatric Care Manager, a Registered N.C. Guardian, and holds certifications as a Case Manager, Disability Management Specialist, and Rehabilitation Counselor. For information, call (919) 644-7308, or visit the firm’s Web site at www.eldercare-solutions.com.
* previously published in the North Carolina Lawyers Weekly