DUE TO INCREASING life spans, older adults are living longer with functional disabilities. Many families can't effectively manage their care, and healthcare has become more complex and fragmented. Private geriatric nursing care managers (PGNCMs) can fill the void while improving the quality of life of older adults and their loved ones. This article will explore this nursing role and how you can move into it. (See Care or case management? Looking at the differences.)
Range of duties
In this multifaceted and creative role, care managers help people care for their older relatives or loved ones, especially those with chronic needs related to physical problems or dementia. They may be hired to resolve a specific problem or they may provide long-term oversight and become part of the family. Proficient care managers follow the nursing process: assessment, nursing diagnosis, planning, interventions, and evaluation. The care manager can:
- monitor the client's condition with visits and telephone calls.
- accompany clients to appointments.
- send regular (often monthly) written reports on the client's status to the client, the family, or both.1-3
- assess the client's situation to identify problems and offer solutions.
- arrange and monitor in-home help.
- review financial, legal, and medical issues.
- act as a liaison to family members.
- assist with moves to retirement, assisted living, or long-term-care facilities.
- offer eldercare counseling and support.
- be a consumer advocate.4
While the primary client is the older person, the family and significant others in the older person's network are the unit of service. Decisions should benefit all without compromising the client's personal values, dignity, integrity, or factors that make life meaningful. Privacy and confidentiality must be honored.5
While care managers may be social workers, psychologists, or gerontologists, nurses, particularly those with a home care background, are especially suited to the role.6 That's because nurses' clinical knowledge and results-oriented practical approach are a significant part of care planning. Nurses can identify and address clients' physical problems early, and their knowledge of medications, including drug interactions and adverse reactions, is another important advantage.
Clients tend to trust nurses, and most older adults are used to interacting with them. Older clients like knowing they can tap into their extra attention and support in times of crisis.2
Developing a relationship
A typical client might be an 85-year-old widow living alone. The referral might come from one of her adult children who lives out of state. With the client's or legal guardian's signed consent, the care manager begins the relationship with a comprehensive assessment.
Care manager assessments are usually broader in scope than those used by hospitals or home care agencies. Areas to explore include family and social supports, home safety, spirituality, finances, nutrition, environment, mental status, depression, functional ability to perform activities of daily living (ADLs) such as bathing, eating, and toileting, and instrumental ADLs (IADLs), which include independent travel, financial management, and shopping. Tools are also available to assess for alcoholism and drug abuse, domestic violence, sleep quality, sexuality, activity tolerance, personal values, and cultural beliefs. In addition, the assessment can include medical record review and communication with the older adult's healthcare providers.
The assessment provides a comprehensive list of problems needed to formulate nursing diagnoses. The care manager is likely to use community resources to meet many of the client's needs.
Professional recommendations can include a combination of community resources that the care manager or a family member will monitor. Families using a private care manager have an important advantage: objective referrals. Referral sources should be personalized to the family's needs and not limited to specific provider groups, which is a practice of some healthcare corporations and agencies.5
The care plan should maintain the client's goals and personal values and keep the client in as independent a setting as possible. The care plan can be adjusted as the client's needs change.5
Nurses interested in care management should have the following attributes.
Clinical expertise allows for early recognition of changes in the client's status and for planning interventions appropriate to the client's and caregivers' abilities. A broad working knowledge of community resources is essential.7
Organizational and leadership skills let the care manager coordinate client care from multiple providers.7
Strong communication skills enable the care provider to promote trust and continuity of care. The care manager must be comfortable with written, telephone, face-to-face, and electronic communication so that information is transmitted accurately and consistently.7
Care managers need to be skilled in therapeutic communication techniques and know how to get along with professionals, older adults, and their adult children, one-on-one and in groups. Parental frailty can accentuate family dysfunction, so the care manager must be able to facilitate accord among adult children. Cultural sensitivity is a must.
Financial and insurance awareness. The care manager must be able to tap the client's personal resources when they're needed but also protect these resources from being used unnecessarily. If the care manager accepts fiduciary responsibility, the professional relationships with the older adult must not be exploited by misuse of funds. The care manager must comply with legal issues related to tax and citizenship issues.5,8
Signed contracts, which are essential, must provide concrete details delineating the proposed services, with fees clearly stated. Charging fees in exchange for service is a difficult challenge for nurses, who may be altruistic and used to working for specific salaries in not-for-profit settings.8
Care management services can be billed by the task or the hour, with costs varying by geographic area. Fees may range from $50 to $200 an hour. Some nurses develop specific fee schedules for home visits, telephone calls, travel, and e-mails. A few employers, insurance companies, health plans, and financial service providers are beginning to subsidize or cover these services. Long-term-care insurance may also pay for private care management.3
Clients who can't afford care management should be referred to public agencies, such as the area agency on aging, or served on a sliding scale or pro bono basis.3
Self-discipline and self-motivation are needed to weather the ups and downs of entrepreneurship. A professional in this role should be comfortable with risk. Many care managers hold dual jobs until their practice makes enough to support them. This requires a high level of physical and emotional energy. Most businesses aren't self-supporting for 2 or more years.8
Ethical accountability. The care manager must be socially and professionally responsible. One major ethical dilemma care managers encounter is balancing the client's wish to live independently with the need to maintain client safety.8 Any marketing or advertising should be done with honesty and integrity. Clients should receive full disclosure regarding any business relationships.1
A sense of professionalism. This confers a sense of occupational identity and assures consumers that the care manager has met specific standards of practice. Nurse care managers should participate in continuing-education programs and maintain appropriate licensures and certifications. As of January 1, 2010, all care managers will need to be certified to belong to the National Association of Professional Geriatric Care Managers (NAPGCM) and hold at least one of four certifications (see Get professional support):9
- Care Manager Certified—CMC. See the National Academy of Certified Care Managers, http://www.naccm.net.
- Certified Case Manager—CCM. See the Commission for Case Manager Certification, http://www.ccmcertification.org.
- Certified Advanced Social Worker in Case Management—C-ASWCM—and Certified Social Work Case Manager—C-SWCM certifications. See http://www.socialworkers.org/credentials.9
Choosing a business structure
A private geriatric nursing care practice can be categorized as one of these major organizational structures or legal entities:
Solo practice: a business owned and controlled by one person. Most PGNCMs begin their agencies this way. Few legal restrictions apply and profits are taxed at the care manager's personal tax rate. Profits are entirely the owner's, and decisions can be made quickly and with flexibility. Dissolving the business is simple too.8
Disadvantages are the heavy responsibilities and multiple tasks, such as marketing, bookkeeping, managing people, counseling, and being on call 24/7. An agreement with another care manager to fill in is possible but may compromise client service. Because the owner has unlimited financial responsibility, creditors can come after personal assets. Borrowing money and obtaining long-term financial capital is difficult, but the need for it is less.8
Partnerships: general or limited. A general partnership is a business with two or more owners. All are liable for the business's success or failure and must report profits or losses on their income taxes. A limited partnership has one or more partners who are invested in the business but don't make business decisions. The investing partner is liable only for the amount of the investment. The advantage of a partnership is that financial, business, and emotional issues can be shared. Vacations and other time off are easier to arrange and lending sources may be more lenient.8
Disadvantages include disagreements among partners and the extra time and compromises needed to discuss issues, resolve problems, and make decisions. The ideal partnership has two equally committed people with compatible values and similar visions for the business's future.8
Corporations: the most complex but most advantageous way to organize a care management business. Corporations are considered legal entities and liability is limited to the corporation's assets. Ownership is easily transferred. Lenders are most open to dealing with corporations, and the corporation can provide fringe benefits such as health insurance, stock plans, and pensions. Attorneys are needed to set up care management corporations. Accountants can help to organize the corporation's books and see that taxes are paid correctly.8
Creating a business plan
After choosing a business organizational structure, the care manager needs to create a business plan. Having a plan greatly increases the business's chances for success. Putting thoughts in writing organizes ideas and forces a focus on goals and potential obstacles. A care manager needs a written business plan to borrow money from a bank, although 80% of care managers don't look for loans. Many start their businesses in their homes.8
Business plans should begin with a mission statement and description of the care manager's role, a market analysis or a description of the potential client base, the size of the service area, and other professionals, including competitors, providing related services to the target market.8
A marketing or sales plan is an important piece of the business plan. Marketing involves educating consumers about the care manager role and promoting name recognition to potential customers through newspaper articles, radio or TV spots, and the Internet. Face-to-face interaction, individually or in groups, is the best but most time-consuming marketing activity. Maintain communication with current and past customers. Word-of-mouth referrals are often the best source of business.8
Networking with other professionals and key business leaders is essential. Some care managers integrate their businesses with other professionals, such as physicians, attorneys, and accountants.8
Before the business is operational, these types of insurance are needed: professional malpractice, business liability, workers' compensation, business overhead, and Social Security Disability.8
Unique and rewarding career
The rewards for working independently with older adults and their families are unparalleled. Nurses are in a prime position to individualize healthcare for older adults so that they retain their dignity, uniqueness, and a sense of self. Our aging population deserves no less from us.
Care or case management? Looking at the differences
How do we distinguish between care management and case management? Care management is a short- or long-term relationship that addresses the health and psychological needs of clients regardless of the diseases involved. Case management, often funded by public money, focuses on a specific illness episode and usually is a means to control healthcare expenses by emphasizing cost-containment.1
Get professional support
Joining the National Association of Professional Geriatric Care Managers (NAPGCM) is highly recommended. Competent care managers adhere to its Standards of Practice established and updated in April 2008. Access information at http://www.caremanager.org.