Types Guardanship

TECHNIQUES FOR DEALING WITH CLIENTS WHO ARE NOT QUITE INCAPACITATED

MARY K. KOFFEND President Accountable Aging, Inc. 8133 Mesa Drive, Ste 108 Austin, TX 78759 512.342.9800 www.accountableaging.com Email: [email protected]

State Bar of Texas ADVANCED GUARDIANSHIP LAW March 9, 2007 Houston CHAPTER 8

Mary Koffend Accountable Aging, Inc. 8133 Mesa, Suite 108, Austin, TX 78759 512.342.9800 FAX 512.342.9813

BIOGRAPHICAL INFORMATION Mary Koffend is a specialist in eldercare services and government-funded programs. She served elder and disabled clients for more than thirty years with the Social Security Administration (SSA) throughout Texas, primarily at the manager or senior manager level. Mary was ultimately responsible for Houston's largest and most complex SSA client service operation. During her career with SSA, she received the highest acknowledgements for her contributions from the agency. After retiring from the SSA in 1998, Mary managed the Medicaid provider services programs for the State of Texas. In 2002, Mary and her husband, Mick Koffend became the founders and principals of Accountable Aging, an eldercare service provider. AAI takes an approach to care management that is not typical of workers who normally populate this field. AAI has seven (7) employees, including an advanced practice RN (Clinical Nurse Specialist (CNS) – Gerontology), and serves the IH-35 corridor from San Antonio to Dallas and routinely uses the skills and knowledge of other RNs and a gerontologist. Mary graduated with honors from the University of Texas, was a member of Mortar Board and an Outstanding Student. In addition to her professional expertise, Mary has met the challenge of making difficult decisions on behalf of elder and disabled members of their own families. She brings compassion, commitment, and a highly personal understanding of the real concerns families must address to ensure the family's financial, residential, emotional and physical well-being.

Techniques for Dealing with Clients Who Are Not Quite Incapacitated

Chapter 8

TABLE OF CONTENTS I. WHO ARE THESE CLIENTS? ................................................................................................................................. 1 A. Clients with serious mental health issues. ......................................................................................................... 1 B. Clients with increasing dementia....................................................................................................................... 1 C. Clients with poor judgment, or alcohol or drug issues. ..................................................................................... 1 D. Clients who are stubborn, strong-willed individuals on a disaster course......................................................... 1 E. Clients who are over or under medicated. ......................................................................................................... 1 II. WHAT CAN A CARE MANAGER DO IN THESE OR SIMILAR SITUATIONS? ............................................. 1 III. HOW DO I FIND THE RIGHT CARE MANAGER FOR MY CLIENT? ............................................................. 2 IV. IF A CARE MANAGER IS NOT AN OPTION, WHAT OTHER RESOURCES ARE AVAILABLE TO HANDLE THESE NOT QUITE INCAPACITATED CLIENTS?......................................................................... 2 A. Bill-paying/financial management .................................................................................................................... 2 B. Therapy.............................................................................................................................................................. 2 C. Family Facilitation/Mediation ........................................................................................................................... 3 D. Medication management. .................................................................................................................................. 3 E. Personal Assistance services.............................................................................................................................. 3 F. Visiting physicians............................................................................................................................................. 3 G. Meals-on-Wheels............................................................................................................................................... 3 H. Transportation services...................................................................................................................................... 3 I. Facilities.............................................................................................................................................................. 3 J. And more ............................................................................................................................................................ 3 V. CONCLUSION ......................................................................................................................................................... 3 APPENDIX A: ELDERCARE RESOURCE LIST ................................................................................................ 4

Techniques for Dealing with Clients Who Are Not Quite Incapacitated

Chapter 8

D.

Clients who are stubborn, strong-willed individuals on a disaster course. You are called by the daughter of Alma with a request for assistance. Her mom is living alone in a house with much needed repairs. Alma’s weight now exceeds 300 pounds, and she can not wear shoes. She no longer leaves home and only has a prescription for her medication because she fell and EMS took her to the hospital. Alma still talks to old friends and neighbors but is unwilling to have help in her home or move to a facility. “She can take care of herself” even though she can’t cut her toenails and is giving her credit card to someone to buy groceries for her.

TECHNIQUES FOR DEALING WITH CLIENTS WHO ARE NOT QUITE INCAPACITATED In the last 5 years as geriatric care managers, our company has worked with many clients who for various reasons have issues of capacity but are not quite incapacitated. Some of the referrals for working with these clients have come from attorneys. I want to discuss techniques for dealing with these clients from my personal perspective and also from the perspective of what I would have wanted the attorney who worked with my Mom with Alzheimer’s to have done.

E. Clients who are over or under medicated. Mr. and Mrs. Johnson had several health issues each and had planned to move into a well-respected assisted living facility. Both were stabilized in their medication regime. Mrs. Johnson had managed their meds, but in the hustle and bustle of moving preparations, Mr. Johnson took over. He did not have a process to manage the ten meds she took and the twelve he took and over-medicated himself. He became lethargic and with slurred speech. He was dizzy and confused. He refused to move to the assisted living, and his wife and son called their attorney.

I. Who are these clients? I have experienced at least five categories of clients who are not quite incapacitated. A. Clients with serious mental health issues. Sue, age 75, had had several commitments to the Austin State Hospital. She has one family member with problems of her own on the east coast. Sue has issues with authority figures and has physical health problems, but also is a hypochondriac, must have medication management, is self-absorbed, and is terrible at decision making. For all “trusted” friends or advisors, she is known to call multiple times daily and change her request in mid-conversation.

There are many other scenarios, and if you have been an attorney working with seniors you too can tell stories. Hopefully you identified with some of these examples. So what’s next? Working with a geriatric came manager can be the most effective technique for dealing with clients in these situations. A geriatric care manager is an individual or organization whose role it is to provide umbrella oversight and problem resolution.

B. Clients with increasing dementia. The last time you saw Bernice in your office, she was articulate and neatly dressed. Today she is forgetful, her lipstick smeared, and her clothes not clean. You send a staffer to her home to take her copies of documents. The staffer reports Bernice’s house smells, mail, newspapers, magazines and stuff are everywhere, and the door was unlocked when she arrived.

II. What can a care manager do in these or similar situations? Tackle the problems. Care managers are problem solvers. They come in as a knowledgeable, objective third party to ask questions and resolve issues. They can analyze medication issues, intervene with community resources, and help with safety concerns. They can find good service providers for assistance with everything from help with downsizing to choosing good facilities or in-home caregivers. They work with insurance carriers, government program providers, and financial institutions to cut through the red tape and obtain solutions to problems.

C. Clients with poor judgment, or alcohol or drug issues. You are working with Milton to complete his will and powers of attorney. Milton was a referral from an old acquaintance. Milton has children living at a distance but no close contacts except old business colleagues. In the conversation, Milton appears to be making illogical decisions and seems very indecisive. He is coherent and in many ways competent, but his decision making seems flawed. You are unable to determine in the conversation the basis for the poor judgment. You check for alcohol on his breath. 1

Techniques for Dealing with Clients Who Are Not Quite Incapacitated

Take Bernice, the lady with increasing dementia. The care manager met with Bernice. The immediate problems were safety and financial management. The care manager arranged for a daily caregiver to clean the house, do laundry, de-clutter the property over time, and drive Bernice on errands. The care manager also arranged for a bill paying service to insure funds were handled timely and properly. The care manager next tackled issues of good medical care and medication management. Bernice was a very outgoing and social person whose main friends were now her dogs and strangers she saw walking down the street. The care manager invited Bernice to accompany her to some assisted living facilities to help assess the facilities from a senior’s perspective. Bernice willingly chose a place where she wanted to move and the care manager worked with the family and other resources for the move, downsizing, and the eventual sale of the dogs and the house.

Chapter 8

members of a national association of geriatric care managers. Appendix A lists some of the ways to locate a care manager with helpful phone numbers and websites. If your client lives in a small town or more rural part of Texas, care managers like other services are less available. There are some care managers who serve a large geographic area and some in towns like Weatherford, Kerrville, and College Station. However, availability in south and west Texas is more limited. Once you find out who the care managers are in your area, and those of you who live in the Metropolitan areas of Dallas-Ft.Worth, Houston, Austin and San Antonio have many choices, what’s next? Care managers are often individuals with a background in nursing or social work. A recent national trend is multi-disciplinary firms that include a nurse, a social worker, and a CPA or person with financial focus. It is good to match the client with a care manager most able to focus on the primary issues. Interview the care managers and learn their area of expertise to streamline your referral process. Some attorneys have made multiple referrals and had the client meet with them in the client’s home or the attorney’s office. The ability to build a trusting relationship with the client in these complex and difficult situations is more important than in many referrals. Care managers are rarely funded by insurance or nonprofit agencies at this time. They are paid generally by the senior, the family, or a trust. If there is a family member willing to pay, indigent clients can still receive services. Most care manager’s charge an hourly rate for their services. This rate varies by expertise, service level, etc. and costs from $60 to $150 an hour. Some services may also come at a flat rate for the service such as bill-paying, assessments, monitoring visits, etc.

The story of Bernice is shared to illustrate the ongoing role of a care manager. The attorney who met with Bernice in her disheveled and confused state needed to know that someone reputable was handling the many issues involved. Rarely is there one issue and one solution, so having a person whose job is to manage the spectrum of issues is most effective. Care managers tackle problems and know resources. They use their special skill sets to build relationships and to look at solutions to problems with a uniquely creative eye. They are a single point of contact which makes life easier for the not quite incapacitated senior, the referral source, the family, and the resources. Care managers are good at prioritizing the problems and creating solutions that build in a support system for the next problem that will occur. Rarely are these not-quite-incapacitated persons living in a vacuum, and care managers are experienced at working with individuals, families, and other interested parties with family facilitation/mediation type skills.

IV. If a care manager is not an option, what other resources are available to handle these not quite incapacitated clients? Listed below are areas in which the client could use assistance and sources for that assistance.

III. How do I find the right care manager for my client? Care management as a profession is growing as the elderly population grows and the need for this service grows. It is valuable before a client crisis occurs to get to know the care manager in your area. Because care managers need to know the resources in a given area, they are generally known by organizations like the Alzheimer’s Association and other disease support groups like Parkinson’s, etc. Many of these organizations keep a list as does the Area Agency on Aging. Some care managers advertise with local senior guides and also in a multistate publication called New Lifestyles. Some are

A. Bill-paying/financial management: CPA firms, bookkeeping services, local non-profit organizations with volunteers such as Family Eldercare in Austin and Sheltering Arms in Houston can provide these services. B. Therapy: There are licensed therapists in most communities that have been approved by Medicare and/or Medicaid for services. Payment can be made for services directly to the client and also to the client’s family. 2

Techniques for Dealing with Clients Who Are Not Quite Incapacitated

Chapter 8

specialize in helping persons in downsizing their worldly goods and supervising the moving and arranging the new home so all is set up when the person comes home. There are beauticians and manicurists that come to the home. There are specialized errand persons who take and pick up laundry and cleaning, buy groceries, mail packages or whatever is needed.

C. Family Facilitation/Mediation: In addition to use of attorneys for mediation, therapists and case managers can provide this service. Persons need to be excellent listeners and knowledgeable of procedures . D. Medication management: Private home health companies can use their staff to organize meds and handle referrals. If needed, they can come to the home daily for administration.

V. Conclusion There is no cookie cutter solution for the client who is not quite incapacitated. Having a care manager to resolve issues and be the single point of contact is the best option for the client and the attorney. When that is not available, relying on a strong family member, pastoral care leader from church, longtime but younger friend who is the power of attorney is next best. Use of some of the many resources listed also can serve to prevent a crisis and buy some time until some of the issues such as medication management placement may be addressed. The care of the not quite incapacitated person is always complex, problematic, and ever changing. It is time consuming, exhausting, requires creativity, and rarely receives acknowledgement. Good luck—

E. Personal Assistance services: There are licensed services in most communities that can provide assistance with bathing, dressing, food preparation, laundry, errands, transportation, etc. Private individuals can be filled for these services as long as someone is available to manage the process including payroll, taxes, back-ups for absences, etc. There are some personal assistant services that do have nurses on staff to help with additional issues. F. Visiting physicians: House calls were nonexistent for many years, but now are available in many cities. Services are provided by doctors or advanced practice nurses. Some of the providers are part of a group, some are part of the American Academy of Home Care Physicians, and some are known only in the community. G. Meals-on-Wheels: This is an excellent community resource which provides one nutritious meal per day for a donation as well as a concerned volunteer who provides personal contact. H. Transportation services: Taking away driving privileges is a problem even when substitute services are available and a nightmare if there is no substitute. Personal Assistance Services can provide transportation. Some taxi services provide services by appointment. Most local transit authorities have some program, and there are often volunteer caregiving services for routine doctor’s visits, grocery store trips, etc. I. Facilities: There are many types of facilities. Independent, assisted, and nursing homes provide a continuum of care. There are three-bed unlicensed personal care homes, licensed personal care homes, board and care homes, Section 8 housing. Here it is very important to match the needs of the client with the facility. Clients with behavior issues who are not incapacitated are many times difficult to place and require frequent intervention and assistance. J. And more: As the elderly population grows, more businesses are seeing the needs of this population and rising to meet the needs. There are companies that 3

Techniques for Dealing with Clients Who Are Not Quite Incapacitated

Chapter 8

Name

Topics

Web Site

Phone Number

Medicare

Overview of Medicare

www.medicare.gov

800-MEDICARE

Current rates Nursing Home Compare Supplier and Physician Directory Medigap Compare Medicare Part D Prescription info and enrollment Publications Home Health Compare American Association of

Excellent articles

Homes and Services

Directory of Facilities

for the Aging

Not for Profit organizations

Social Security

Publications and Forms

www.ssa.gov

Links to disease associations

www.firstgov.gov

http://www.aahsa.org/

FAQ's Medicare

800-772-1213

Medicaid Benefits Info in multiple languages

Administration on

Eldercare national resources

Aging and

Statistics

Eldercare Locator

Local Area Agencies on Aging

www.eldercare.gov/

800-677-1116 The American Society on Aging

Constituent Groups-Business Forum on Aging

www.asaging.org

Great articles Legislative Issues

New Lifestyles

Commercial publication of resources

www.newlifestyles.com/

in many areas - booklets and online info

National Association of

Listing of affiliated members

Professional Geriatric Care Managers

Standards of Practice Information and articles about the profession

American Academy of Home

Directory of home care physicians, assistants

Care Physicians

and nurse practitioners by state

www.caremanager.org

4

800-869-9549

www.aahcp.org