A new development in senior care
Geriatric care managers become family substitutes
As the general life expectancy increases and the population ages, the need for geriatric health care services is becoming a nationwide problem - particularly for ethics committees grappling with elder care issues.
In situations with elderly patients in close-knit families, there is no question who takes on the role of the legal guardian should they become mentally and or physically impaired. Difficulties arise, however, when geriatric patients, who executed no wills and left no advance directives, have no relatives, or have been estranged from their families for years.
In rare cases, a close friend may take on the legal responsibilities, or it could be a spiritual counsel or even a medical professional. Frequently, care managers from government agencies step in, or those employed by hospitals or nursing homes. More recently, independent entrepreneurs called "geriatric care managers" are assuming the task of caring for lonely, aging patients, often as their legal guardians.
Considered by some as "fee-charging family substitutes," independent geriatric care managers appear to be a growing phenomenon. According to the National Association of Professional Geriatric Care Managers, membership has risen from approximately 600 in 1995 to over 1,100 by recent count. (See related story, p. 104.)
Generally trained as social workers specializing in geriatrics, some have nursing degrees, many also are certified financial planners. Most are in private practice and the vast majority are women.
Geriatric care managers will provide a variety of services, most of which are necessitated by emergency situations, such as sudden illness or an accident. After an initial assessment, a care manager may recommend relocating from a private home to an assisted living facility, a nursing home, or even a hospital. In cases of far-away families, care managers will act as a long-distance facilitator.
Should clients require extensive medical care or become incapacitated or comatose, geriatric care managers become their advocates. They arrange care plan conferences, oversee medical claims filing, counsel on end-of-life decisions, help with the execution of advance directives, and manage financial affairs. Occasionally, they step in as legal guardians; at times, they act as health care proxies.
In the majority of cases, legal guardianship has been transferred by a written agreement to the geriatric care manager, either by the patient or the family. If no relatives can be found and the geriatric patient is incapacitated but has been cared for by a private care manager, the court may appoint the care manager as the legal guardian. In the case of an indigent patient without next of kin, the state generally gives guardianship to a case manager employed by a social agency in the local community employed by the city or county.
When executing advance directives, patients often transfer the power of attorney for health care to a trusted adult they designate as their agent. Without a close family member, aging patients often assign this power of attorney to a geriatric care manager, especially if they entrust him or her with other issues or fear that their own families may not respect their wishes.
Depending on the area, the service, and the financial circumstances of the patient, fees charged by independent care managers range from $25 an hour to $150 or more. Aging patients, who are cared for in assisted living facilities and need only a competent person to make a few calls or keep up some business correspondence, may pay no more than $50 per month. Others who have transferred legal guardianship to an independent geriatric care manager who is in charge of their finances and negotiates with doctors, hospitals, and nursing facilities on their behalf - often on a 24-hour basis - may have to pay several thousands dollars a month.
To help aging clients lead active, happy, and safe lives requires gaining their trust first, says Erica Karp, LCSW, RG-NGA, principal of Eldercare Guardianship, a not-for-profit organization in Chicago. Karp also serves as director of the for-profit facility Northshore Eldercare Management, also in Chicago.
Karp has worked with the mentally ill and the elderly since 1972 and has specialized in geriatric work since 1975. Opening a business in geriatric care management in 1984, she has been acting as guardian for some of her patients since 1995.
"Most seniors are reluctant to give up their independence, even when living on their own is perilous to their health and safety," says Karp. Case in point: the 1995 Chicago heat wave that contributed to the loss of more than 500 elderly people's lives living alone. The fine line between competence and incompetence to make a decision can often be drawn only after a tragedy occurs, observes Karp.
Yet, if an aging father is besieged by worried family members to give up his independence, the typical response is, "Don't worry about me; I can take care of myself." In a case like this, a skilled geriatric care manger is generally more successful convincing the determined - some say "stubborn" - senior to give up that cherished independence than the most loving relative.
However, until a geriatric care manager reaches the point where she can discuss the dangers of living alone with the aging person directly, she may have to bring treats for the dog, buy freshly baked bread, or spend hours looking through family albums, says Karp.
The work of geriatric care managers presents an inherent conflict, however, especially if they work for large health care organizations and take on the guardianship of their clients, says Ray Moseley, PhD, director of the program in medical ethics, law, and the humanities at the University of Florida College of Medicine in Gainesville.
"Basically, geriatric care managers face the same ethical conflict as physicians do who work for HMOs," says Moseley, "because their function is to keep costs down by providing as little inservices as possible."
Additionally, he sees two significant problems that complicate the ethical issues of geriatric care: the increase of Alzheimer cases among the elderly and a social bias against aging individuals. Unfortunately, the former reinforces the latter.
In Moseley's view, guardianship over a geriatric patient should be granted only to those who know him well, generally a family member or long-time friend. Conceding that this is not always possible, he would like to see ethical guidelines established that prevent abuse or exploitation.
Similar to members in other helping professions, Moseley believes that geriatric care managers should adhere to basic standards that are defined and observed nationally, follow a code of ethics, and require certification and state regulations.
Above all, geriatric care managers should receive a great deal of ethical training to make them aware of the primary reason for their work - caring for the elderly who are physically and often mentally impaired.
An independent geriatric care manager agrees with Moseley. Steven Barlam, MSW, LCSW, CMC, director of Senior Care Management in Beverly Hills, CA, says he believes that the issue of conflict of interest applies only to care managers employed by large organizations, such as HMOs, insurance companies, or Medicare-contracted caregivers.
"We are not their gatekeepers," says Barlam. "An independent geriatric care manager is an advocate for the client. My job is to figure out what is best for my client and how the client and the family can get the biggest bang for the buck."
Barlam believes that independent geriatric caregivers have no incentive to keep care costs down - or keep their clients in the dark about other plans or objectives - precisely because they are not paid by the source or provider of the care plan.
Barlam, whose company has adopted the slogan "Aging is a family affair," has a personal commitment to the care of the elderly that is rooted in his close relationship to his grandparents. He agrees with Dr. Moseley about the need to raise the level of education of geriatric care managers and the importance of giving them extensive training in ethics.
Barlam also believes in certification but expresses doubts about state regulations. As to the issue of assuming guardianship for a client, Barlam is in complete agreement with Moseley. Barlam, while hesitant to criticize colleagues who have assumed legal guardianship over their clients, says categorically, "I've made the decision to be as objective as possible and would see in that [legal guardianship] a conflict of interest."
Sally Gold, CMC, MSW, of Geriatric Resource Services Inc., based in Greenville, SC, agrees. Gold sees no conflict of interest for independent geriatric care managers as long as they leave the legal matter of guardianship to others. Her interest lies in doing things for her clients that will enhance their quality of life, she says. This may involve a detailed discussion on medical treatments with doctors, or simply purchasing items for the client.
Considering herself to be her own boss if she were to assume legal guardianship and make financial decisions for her clients, Gold says, "I have my own ethical standards. I've made the decision not to serve as a guardian to any of my clients."
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