Editor: Theodore J. Sarenski, CPA/PFS
CPAs are trusted advisers. Their technical training makes them experts in navigating the many complexities of taxation and financial planning. However, they are also a witness to private aspects of their clients' lives that few others may see.
Messy and emotional life events like divorce, a terminal diagnosis in the family, or the declining capacity in a loved one share a common thread. They all have financial consequences. The CPA may not always feel well equipped to handle these conversations — and yet clients need help with critical money decisions in the midst of events they had hoped would never happen. That includes situations where a client might be on the verge of burnout, with a marriage falling apart or a job compromised, all because of having to shoulder care for an aging parent with dementia or chronic age-related issues.
A geriatric care manager (GCM) can become a valuable partner to the practitioner and his or her clients. GCMs are experts at navigating the medical system. They can serve as advocates inside and between care facilities. They can also step in to supervise care if adult children live elsewhere. By partnering with a GCM, the practitioner gains an ally in ensuring that care decisions align with financial goals and the family's resources.
Despite the many benefits that a GCM can deliver, the decision to hire one is often difficult. Some clients might feel it is an extravagance only the wealthy can afford. Others have never heard about geriatric care management as a specialty field and do not know where to begin.
This column's purpose is to de-mystify the emerging geriatric care management field and arm CPA financial planners to provide valuable guidance to their client families.Geriatric care management 101: What services does a GCM provide?
Geriatric care management is a new field, and many families do not even know that this service is available — until they need it. That puts them in the position of having to make quick decisions without sufficient background or the benefit of proper expectations. What does a GCM do, exactly?
Here is a quick overview of services that can be available through a GCM.
Coordinating health care across several agencies: A GCM can help the family choose the right balance of care locations depending on the circumstances, insurance, and financial resources that are available (e.g., in-home care, specialized facility, etc.)
Financial coordination services: Experienced GCMs have a deep knowledge of the medical and care systems. They can help the family plan for future care and estimate what it might cost. They can also recommend appropriate state and local relief programs.
Family assistance: A trained GCM can streamline conversations between care providers to avoid miscommunications. He or she can also help with conflict management and mediating tough conversations.
Advocacy within the health care system: A GCM can serve as the voice for the client and family inside facilities. This is particularly helpful if the patient's family does not live near the facility or has a strained relationship with service providers.
Legal coordination: GCMs are not attorneys, but they can connect client families with lawyers and other specialists if that becomes necessary.
Knowledge of local resources: A GCM can educate the client family about local resources that are available, make recommendations, and begin introductions.
Crisis intervention: GCMs can navigate hospital emergency departments, unexpected hospitalizations, etc. This is especially valuable for family members who live far away and would otherwise have to travel on short notice.
Making housing decisions: A GCM can help family members evaluate available options against the backdrop of the patient's health history and likely prognosis. Moving an elderly parent out of a home or from one facility to another requires awareness and expert balancing of facts and emotions. The right professional can make these tough transitions more manageable.Services to fit the circumstances
Keep in mind that the "right" range of services is always driven by patient circumstances. Ask clients to go through the above list and check off all points that apply. Encourage them to add any that may not be on the list. Not every GCM will provide the entire menu of services, so clients should first define their needs and then proceed to choosing the provider.
An important side note: In a case of dementia or an age-related health decline, the "service menu" must be handled by someone — regardless of whether the family chooses to hire a GCM. So, the services list is a helpful starting point for every family to ensure that an important decision is not missed.
If a client family is thinking about adding a GCM to the care team, encourage them to determine the specific services that are necessary (as noted above), as well as which time arrangement would work best. In some cases, an initial assessment plus one or two hours of work is all that is needed to get the family oriented. In other situations, an ongoing relationship would be beneficial.
For example, if someone in the family has been diagnosed with an early stage of Alzheimer's disease, a GCM might step in to develop a care plan, identify local resources, provide recommendations, and empower the family to take it from there. However, an ailing mother in a nursing home in Massachusetts and her daughter who lives in California may benefit from ongoing support by a GCM who will serve as the mother's advocate. This is especially true if the daughter's frustration with the care facility is straining relationships in a way that might compromise her mother's care.How do you choose the right GCM?
It is no easy feat to choose the right GCM for a client family. First, GCMs are not regulated by any governmental entity. Anyone can call themselves a "care manager" and not be sanctioned. So, how can the practitioner guide clients to make the right choice?
Here are five filters that will help.
The minimum education level required for certified GCMs is a bachelor's degree. Master's level education is recommended but is not required. The degree should be in a field related to elder care, such as social work, nursing, psychology, mental health, public health, counseling, psychology, rehabilitation, sociology, or gerontology.
Certifications and organizational membership
As mentioned previously, GCMs are not regulated. Someone could use the GCM label without any certifications at all. This is why those who choose to invest time and money into pursuing a certification and organizational membership will stand out as better-qualified candidates.
The National Academy of Certified Care Managers (naccm.net) offers a Care Manager Certification (CMC) program that sets requirements for education, paid supervised care experience, and/or direct patient contact experience. Membership in the Aging Life Care Association (ALCA) (aginglifecare.org) is another marker of the provider's commitment to the elder care profession. ALCA offers education, resources, and a professional community that spans nine regional chapters across the United States.
Below is a list of some of the other certifications, along with respective issuing bodies. Keep in mind that this is not a complete list. Research the requirements of unfamiliar certifications with an eye toward rigorous education, standards, and a commitment to a code of ethics:
- Certified Case Manager (CCM) through the Commission for Case Manager Certification (ccmcertification.org).
- Certified Advanced Social Work Case Manager (C-ASWCM) or Certified Social Work Case Manager (C-SWCM) through the National Association of Social Workers (socialworkers.org).
Taking on a new elder care case requires a considerable commitment of time and energy from the GCM. The provider must get to know the patient, the family, medical histories, interpersonal dynamics, and much more. He or she must be available to respond timely in the event of an emergency. A heavy case load can lead to delays, missed communications, and frustration for everyone involved. If the family needs a professional who will be on call 24/7, be clear about that requirement.
Experience in your local area
To be an effective advocate and adviser, a GCM must have hands-on experience and knowledge of local resources. While it is helpful to have assistance figuring out answers, the research process can take time. It is best to choose a GCM who already understands what is available and perhaps even knows program coordinators, nurses, managers, and other professionals within the system.
A GCM will have to work closely with the client family. Encourage clients to interview several providers and, all things being equal, to choose the one who offers the best natural personality fit. Interpersonal chemistry, communication habits, and personality will have a profound impact on each and every interaction — and can make or break the working relationship.Search tools and resources
Where can one get a list of GCMs? There are several ways to approach the search process.
One place to begin is the Eldercare Locator from the U.S. Administration on Aging (eldercare.acl.gov). The Alzheimer's Association lists local resources and professionals on its website (alz.org). ALCA has a tool for finding local aging life care experts (aginglifecare.org).
A word of warning: Even though general-purpose websites like care.com allow one to search for local senior care providers, use them with caution. Always validate credentials, certifications, organizational membership, and references before hiring a GCM.
No matter which resource the family uses to find care manager candidates, encourage them to invest some time and thought into each interview. Consider asking a prospective GCM the following questions before making a decision:
- What are your credentials, certifications, and experience in this local area?
- What services do you provide? What services do you refer out?
- Will we be able to reach you on a holiday, weekend, or at night in the event of an emergency?
- When will we get a written care plan? Should we expect a high-level overview or specific instructions and recommendations for daily management of the case?
- How will you communicate with the family?
- What fees should we expect? What are your payment terms? If billing hourly, what is the billing increment (e.g., 6 minutes, 10 minutes, 15 minutes)?
- Can we speak with your references?
There are at least five potential benefits that an experienced GCM can deliver to the family.
Personalized advice and service: A great GCM will get to know the patient's medical and personal history to find the right approach where family members and friends might have failed to make progress. He or she will raise red flags on potential pitfalls that the practitioner or the patient's family may have no experience with. From sharing specific resources to smoothing over ruffled feathers, the value of a GCM is tough to overstate.
Accessibility: This is especially important for families who live far away from the loved ones under care. However, even local families will get relief and a greater ability to focus on their own work responsibilities, children, and commitments while knowing that their loved ones are in good hands.
Continuity of care across facilities and medical systems: Many studies have demonstrated that continuity of care is a critical factor in creating better health outcomes, reducing the incidence of complications, lowering medical costs, and necessitating fewer emergency hospital admissions.
Cost management: Yes, working with a GCM can save the family money. An experienced professional can help eliminate duplication of services, find underutilized services, and maximize the use of what the family is already paying for.
Quality control: A GCM is not a licensed physician, but he or she can be invaluable in supervising care, advocating for the parent inside the facility, and voicing the need for additional services.Managing the expense of a GCM
The one obvious downside to hiring a GCM is that these professionals can be expensive. Some long-term-care policies cover a portion of the fees, but hiring a GCM is often an out-of-pocket expense for the family. Fees can range between $50 and $200 per hour depending on the patient's condition, needs, and location. Even with the promise of efficiency and cost savings in the long run, this may stretch family budgets.
If that is the case, there are other options practitioners and clients can explore together.Alternative budget-friendly resources and action plans
To start, every family (even the ones with the financial means necessary to pay for a GCM) should explore resources that are inexpensive or even free.
Start with the local office for the aging, as these organizations offer education, care coordination, facility liaisons, legal assistance, transportation, and more.
Beyond that, the most obvious alternative to hiring a GCM is to have one or more family members step into the role and take on the care management responsibilities. Someone will have to connect the dots between the needs of the ailing person and the professionals or services that can help fill those needs.
A CPA financial planner can be a valuable ally when it comes to financial matters, such as strategizing on ways to pay for the care, bringing in estate planning attorneys when needed, and optimizing decisions from a tax perspective. However, there is only so much a CPA can do before the subject matter gets too far removed from his or her area of expertise.
In that situation, family members must be informed and educated about two critical points.
First, they must work directly with all service providers. The list includes tax preparers, financial planners, attorneys, insurance companies, facility personnel, medical staff, the home care team, and much more. Yes, a CPA financial planner can recommend professionals or assist with coordination. However, there is a clear line beyond which the care must be assumed by a GCM or a family member.
Second, it is common for family members to feel overwhelmed and underqualified when facing the need to manage medical and life care for an ailing person. Remind them that this tough situation, just like any other challenge they have ever faced, has three zones:
The comfort zone, where they know what they know: The comfort zone may feel very small in the beginning, but it is always there. Remind them to anchor into what is certain, known, and familiar.
The discomfort zone, where they know what they do not know: This is an opportunity to get educated and talk to others who have faced this challenge and handled it successfully.
The high-risk zone, where they do not know what they do not know: The best way to navigate these waters is by doing some research or hiring a specialist.Guidance through a complex decision-making process
Practitioners should make it clear to the client family that they are qualified to help with certain aspects of the situation. They can help families weigh the pros and cons of decisions, especially ones with financial or tax consequences. Beyond that, the practitioner should use his or her network to connect families with other professionals they will need in order to avoid expensive mistakes and take care of their loved ones and themselves in the process.
Tracy Stewart, CPA/PFS/CFF,is the owner of Tracy Stewart CPA PLLC in College Station, Texas. Her practice focuses on the financial issues of aging and elder care. Theodore J. Sarenski, CPA/PFS, is president and CEO of Blue Ocean Strategic Capital LLC in Syracuse, N.Y. Mr. Sarenski is chairman of the AICPA Advanced Personal Financial Planning Conference. He is also a past chairman of the AICPA Personal Financial Planning Executive Committee and a former member of the Tax Literacy Commission. For more information about this column, contact firstname.lastname@example.org.