These are excerpts from a book-in-progress, designed to be a training course for professionals in the practice of care consultation and care management. The book is in the editing phase.
Introduction to a Career
If you were anything like me, when you were a small child, you yearned to be a care consultant. You dressed in care consultant costumes on Halloween. You asked for care consultant outfits for birthday gifts, and you asked the multicultural gift-giver of your choice, sometime around the winter solstice, to deliver care consultant action figures. Your parents humored you, realizing that you’ll grow out of this fantasy because, when you were growing up, there was no such thing as a care consultant.
I began working with elders in 1984, but I didn’t start calling myself a care consultant until about a decade later. Even today, hardly anyone labels themselves as such, sticking with the more well-known term, care manager. Yet, there is a significant difference between their roles. In short, a care consultant guides the concerned parties — usually, family members of the client (who is the elder, or otherwise, infirm) — to appropriate services. This typically requires a thorough assessment of the situation that includes the needs and wishes of the client, and an agreement among those involved in the care decisions (usually, the family). If the family is unable or uninterested in managing the ongoing care, they often hire a care manager to do so. About one-third of the time that I’m hired for care consultation, I am retained in the role of care manager.
Schooling and Training
While you may have guessed that I didn’t really plan, let alone “yearn” to be a care consultant as I was growing up, I did plan to be a social worker for as long as I can remember. However, my work with elders came from an indirect route.
Before grad school, I did some work in an in‑patient hospital setting, and became determined to work with the severely mentally ill. Following getting my MSW, I took a position working in a residential treatment center for chronic schizophrenics. During my five years there, I rose to Program Director. Moving on from that program, I followed my husband-to-be to a small town, where the only opening in the counseling center was director of geriatric services. I was hired for my supervision experience, as I had no experience with elders.
My former grad school classmate and close friend had been working with elders since graduation. My agency agreed to pay for her long distance supervision, via phone calls. With her help, I managed my own work, supervised a nurse and clinician, and earned State recognition as a Geriatric Specialist.
The last decade, has seen care consultation/management programs spring up as a geriatric specialty, taught primary by academics, who probably have never done clinical work. As with any clinical profession, knowledge and theory can help you only so far. That’s why health-care professionals do internships and residencies.
Clinician-lead care consultation and care management training is still rare. This course book is an attempt to guide new practitioners into the profession, whether within a college training program or through self-education.
Principles for review
- A care consultant guides the concerned parties — usually, family members of the client (who is the elder, or otherwise, infirm) — to appropriate services.
- A care manager manages the services.
- Care consultation and care management are clinical, not academic, vocations.
- Though the demand for trained professionals is growing, rapidly, appropriate training is still rare.
- This course book is designed to be an aid to that training.
Getting Old isn’t for Wimps
Getting old isn’t for wimps
Joe Montana, one of the most accomplished professional athletes of all time, played into his late 30s. He was asked, with four Super Bowl victories to his credit, at the cost of accumulated injuries, why he kept playing. His answer: “What if someone told you that you will never get to do again what you love the most?”
Moving into old age brings a series of all the things you’ll never get to do again: loved ones you’ll never get to see again; ideas your mind will not be able to contemplate, no matter how smart you once were; places, such as your beloved home, that you’ll never live in again; memories you’ll never have again; social status you’ll never enjoy again; and, for many, the biggest insult of all, personal independence you’ll never have again. Getting old is an insult to your self-esteem, to your physical comfort, to your identify as an adult. No wonder the elderly yell at folks to get off their lawn.
It’s not, of course, all bad. Young grandchildren to spoil, then home to their parents to deal with the consequences. No dreary job to go to, or no worry about being laid off. Free or cheap health care. Discounts. For many, fewer financial worries. Less need for shopping, as you probably have enough clothes to last your lifetime, have bought your last car, your last home, and last pair of Nike Jordans. Failures, forgotten; successes, remembered (maybe, even enhanced). And finally, you’ll never be tempted to look like this:
If you think the elderly are cute, intolerant, dumb with technology, or any other condescending phrase often heard, think again. We find young children cute, because they’re innocent of most of life’s experiences. By definition, older people have more life experiences than younger people. Intolerant? Everyone is more comfortable with the world they grew up in, because they are experts in negotiating that social world. Same for technology. Familiar is easier, but don’t forget, older people dealt with less automated machines, less technology that (to borrow from the Apple motto) just worked. Telling Siri to place a phone call does not make you more clever than someone who dialed on rotary phones for much of their lives.
To say that old people don’t like change is silly. With decades behind them, most older people have survived many downs, and have a wide repertoire of adapting to change. They just don’t like turns for the worse any more than anyone else does, and they’ve had more of those than have most younger people. As I stated above, turns for the worse will continue. Let me state that in more detail. As you get older, you must adapt to numerous unpleasant changes:
- Loss of family
Loss of friends
Loss of vision
Loss of hearing
Loss of mobility
Loss of memory
Loss of independence as in ability to drive, care for self, etc.
A shrinking support system
That’s a lot of losses. Old age isn’t for wimps.
As a care manager/care consultant, you have an opportunity (and often, a responsibility) to be the most effective member of their non-familial support team. That team may include doctors, nurses, and other medical personnel; caregivers; a bill payer; one or more lawyers; a member of the clergy; a power of attorney (a relative, or not); a spouse or partner; an adult daughter or son; a brother or sister; and so on. These people may all agree on proper care. And lions may lay down with lambs.
As a care manager, you are the candidate to be the one who knows and coordinates how all these professionals will work with your client. As a care consultant, you may be charged with getting those lambs and lions to co-exist. Being a care manager/care consultant is not for wimps either but, as with most challenging professions, training, support, skill, and experience will make for a satisfying career.
Priniciples for review
- Your clients are experienced with life, more than those who care for them.
- While losing certain physical and cognitive facilities might make you dependent, it does not make you a child.
- Old age brings mourning for many kinds of loss.
- There are some good things about getting old.
- The care manager/care consultant profession is demanding and satisfying.
The Care Manager
Recently, I spent several unanticipated hours attending to the basic needs of my clien: was she fed, was her phone installed? She had just moved into a pricey assisted-living facility, and during her first day there, had not received the services for which she had contracted. I ended up subsidizing the services of this facility by attending to those things myself, which meant that my client was paying me for what should have been taken care of by the facility.
Returning home, I complained to my husband (a licensed marriage and family therapist, co-owner of our business, and co-author) with the statement that it was a good thing that I’m detail-oriented, because those at the facility don’t seem to be. After listening to my frustrated rant, he suggested that being detailed-oriented was an inadequate description. He pointed out that I am vigilant with my clients — alert to their needs, sensitive to their moods. What needed to be done for them, detailed or not, followed from that.
That discussion got me to reflect on the difference between being detailed-oriented versus being sensitive to the needs of your clients. A detail-oriented person (or efficiently-run facility) would make sure that dinner was always served at 5pm, sharp. An individual (or facility) that was sensitive to the needs of clients would make sure their clients are not hungry. Being detail-oriented means every necessary service has been put in place. Being sensitive to the needs of your clients means that you make sure those services are working for them. Being detailed-oriented means making sure meds are taken, as prescribed. Being sensitive to your clients’ needs means that you observe the effects of those meds: are they helping, are they causing problems, or are they helping in some manner, but causing discomforting side-effects?
There are countless examples of the difference between being detail-oriented and being sensitive to the needs of your clients but, in general, it boils down to this: being detail-oriented is about efficiency, while being sensitive to the needs of your clients is about service. Being detail-oriented often has more to do with serving the needs of the person or agency providing the service than serving the needs of the client.
The responsibilities of the care manager
I could attempt to describe the profession of care management by listing common services that we provide, but as with any complex profession, being a care manager is not service by rote, and it’s not a list of stuff we do, it’s service guided by expertise and concern. The concern part comes from what I expressed above, being sensitive to your clients’ needs. That’s necessary, the way fine-motor coordination for a surgeon, dentist, or mechanic is necessary. Expertise comes as always from experience and the training and education necessary to learn from experience.
A care manager is hired for several related reasons. Often, after a care consultant advises a family on the services that need to be put in place, the members of the family decide that they are too busy, too much in conflict, or lack the confidence or skills to follow through on the initial or ongoing advice from the care consultant. Along with having knowledge of a wide variety of services, and knowing which ones will best serve a particular client, a care manager’s main job is to get those services to work in harmony. Though the required services might be practiced by highly-skilled professionals — doctors, lawyers, nurses, accountants, physical therapists, social workers, counselors, power-of-attorneys, placement specialists, assisted-living agencies, and others — someone has to make sure these services work in harmony. And no matter how much family members, or otherwise concerned, care about the client, working with the various experts takes skill and experience. Let’s look at some of the services a care manager might have to facilitate and/or coordinate:
- Doctor, dental, physical therapy and other health-care appointments.
- Facility (long- or short-term) placement at an assisted-living facility, hospital, nursing home, hospice.
- In-home services for clients who want stay in their home.
- Non-health professionals, such as lawyers, accountants, bill payers, power-of-attorneys.
Along with the above services, the care manager will have to maintain agreed-upon communication with the client’s family or designated family liason.
A heavily organized and companionate person, for example, a professional nurse, might think that he or she has all the skills and experience necessary to pull off being a care manager. He or she might, but the training and experience necessary to communicate effectively with all the various people and agencies mentioned above (and there are more), is usually beyond the experience and expertise of a professional in another field. Care management is a challenging professional field that requires compassion, specific training, and specific clinical experience.
- Care management is not about efficiency, it’s about being alert and sensitive to the needs of your clients.
- The care manager has to facilitate and/or coordinate numerous professional services. The care manager’s main job is to make sure that the many services put in place, to assist the elder or infirm client, work in harmony.
- A major responsibility of the care manager is to maintain communication with the elder’s family or liaison.
- Care management requires specific training and experience.
How to have a career — Money, theirs
Care management is not yet recognized as a distinct professional heathcare service. It’s not covered by either Medicare or conventional health insurance, so as with lawyers, accountants, and palm readers, it must be paid fully by clients. As we know, those without some means can’t afford lawyers, accountants, and often, palm readers. And while many can’t afford care manager services, one of the advantages of hiring a care manager is that they can save many clients money.
One of the most ethical practices a professional can make is to refer to a lower-cost provider when appropriate. For example, physicians can refer to physical therapists, psychologists, or masters-level clinicians, accountants can refer to bookkeepers or an online service, and lawyers can refer to a number of less-costly (not to mention, more appropriate) professionals, including care managers.
I have established mutually beneficial professional relationships with a number of lawyers. We don’t compete in the services space, we complement the other’s work. Clients save money when their lawyers (and other professionals) decide that my services are more appropriate for them. In turn, clients save money when when I decide that a care provider, placement specialist, nutritionist, occupational therapist (because they can bill medical insurance) can provide a more appropriate, and often less expensive service than I can.
Ethical dilemmas that aren’t
When it comes to ethical dilemmas, the fun never stops. Another consideration for a care manager is their clients’ financial situation versus their quality of life. Clients with the means can have their lives enhanced in a variety of ways. Because they had more money than they could ever spend, my unnecessary concern sometimes kept me from recommending these life-enhancing services. This is just another example of making it clear in your mind whether your decisions with a client is for your personal needs rather than the that of the client.
The elephant in the assisted living facility
Nearly all of those who stood to inherit money from my clients have acted with love and caring rather than greed. Nearly. The concerns of loved ones responsible for making financial decisions on my clients’ behalf have usually been about making the money last as long as necessary. But, on occasion, it’s been about hoarding money they’d inherit. That’s one of the toughest issues a care manager will deal with, because it will always be left unsaid. Who’s going to say aloud, “We don’t want that for her because we want the money after she dies”?
While I’m a relentless advocate of my client, I’m not anyone’s family therapist, so I see no advantage in challenging anyone’s motives for their financial decisions. I work around things left unsaid as best I can, primarily, by emphasizing cost-saving approaches to getting my client appropriate services.
As I’ve said, I believe that I provide value, and often, money-saving expertise. And I try to make my services as cost-effective as possible, for example, by combining client visits in a way that minimizes travel-time billing. However, if you don’t value what you offer, then don’t expect anyone else to. Be fair, be efficient, and charge for your work.