Increasing numbers of older people are living to advanced ages in the United States. Most older people prefer to remain in their homes as they age, but that may be possible only with the help of family and friends. In many cases, with or without family assistance, other supportive services may be needed.
Finding the right long-term care providers and services can be difficult, however. Consumers often do not know exactly what kind of help they need, how to find and arrange for services, and how much they must pay for services. Persons with low incomes may be able to turn to a local government agency or a nonprofit social service agency for help. A different option has become available in recent years for people whose incomes are too high for publicly funded services — private geriatric care management. Typically, a geriatric care manager (GCM) will, for a fee, assess a client's needs, arrange services, and monitor care on an ongoing basis.
Geriatric care management can be a valuable option for older persons and their families who can afford such services. Care management generally is defined as a service that assesses an individual's medical and social service needs, and then coordinates assistance from paid service providers and unpaid help from family and friends to enable persons with disabilities to live with as much independence as possible. From assessment of needs to advice on available resources, a well-trained care manager can help individuals to remain as independent as possible, to live in one's home with assistance, or to assess other living arrangements such as supportive housing or assisted living facilities.
However, consumers need a professional who is trained to assess medical and functional impairments or limitations, and can advise the consumer on appropriate services and providers. Consumers must have confidence that people who say they can perform this work have the right education and training to do so. Many GCMs are licensed nurses or social workers, but these licenses do not necessarily guarantee an ability to address a client's financial or legal questions or provide comprehensive knowledge of all service options. In addition, many geriatric care managers are not members of any licensed profession. In most states, any person can call himself or herself a geriatric care manager and offer services to the public. Consumers can face the possibility of uninformed advice or outright fraud.
The use of care managers has become common in publicly funded state and local home and community-based care programs across the country. These programs employ or contract for trained nurses or social workers to assess a person's need for long-term care services and to organize the delivery of services. Many geriatric care managers began their careers in these publicly funded programs, which they left to practice in the private sector.
Since private geriatric care management is still relatively new, few consumers know about GCMs, their training, or the types of services they offer. To learn more about this field, in the summer of 2000, AARP conducted a survey of members of a national association of geriatric care managers. Survey results were compiled by Gail Kutner, AARP senior research advisor, and analyzed by policy researchers at the Institute for the Future of Aging Services.
This Data Digest reports on the survey findings. These findings can help lead to a better understanding of the education and training of these GCMs, and of the kinds of services they provide and the clients they serve.
The data for this report are derived from a survey questionnaire mailed in the summer of 2000 to all 1,306 members of the National Association of Professional Geriatric Care Managers who live in the United States. The AARP survey data comprise the representative opinions of the geriatric care managers who belong to this national professional association. A total of 712 completed questionnaires were returned, a 55 percent response rate. (At the time of the survey, 615 of the 712 respondents were providing services.)
Results from the AARP survey are summarized for the following categories: background and employment of GCMs, length of time in the profession, description of clients, services provided, costs of services, and views on certification.
Background and Employment
The respondents were generally well educated, and about two-thirds were licensed professionals. Nineteen percent of the respondents had a bachelor's degree as their highest degree attained, more than two-thirds (68 percent) had a masters degree, and another 7 percent had a doctoral degree. More than one-third of the respondents had a social work license (37 percent) and almost one-third had a nursing license (30 percent). (The remaining respondents either checked off the category "other" or did not answer the question about licenses.)
About two-thirds of the responding GCMs who were currently working in the field had four or more years of experience. Very few respondents were new to the field. (See Figure 1.)
Of the 615 GCMs currently working, slightly more than half (57 percent) were working full-time. More than two-thirds (68 percent) were self-employed, and 28 percent were working for an organization.
Description of the Clients
Although the focus of a GCM's work is generally on the needs of an older person, it is often family members who seek and pay for the GCM's services. Furthermore, the primary contact is often not the older person. Only 21 percent of respondents said they usually communicate with the client. One-quarter identified the adult child as the primary contact; 16 percent identified the spouse; and 13 percent checked off other relatives, friends, or neighbors.
Current GCMs were serving an average of 17 clients per month. They usually worked with clients or clients' families for an average of one year or less (45 percent) or between one and two years (21 percent).
(Click here to see Figure 1 - Length of Time Geriatric Care Managers Provided Services.)
The overwhelming majority of the 615 current GCM respondents (more than nine out of ten) assess a client's functional abilities and family and social support, and then develop a care plan. A similarly large percentage of these respondents also reported that they find appropriate services for the client, arrange for the services, and provide ongoing management of the care plan. (See Figure 2.)
A majority of GCMs provide family counseling and assess a client's financial resources. Less than one-third of the current GCMs offer general financial planning, however.
GCMs reported that they often interact with other professionals in the course of their work. (See Figure 3.)
(Click here to see Figure 2 - Percentage of Geriatric Care Managers Who Personally Provide Services.)
(Click here to see Figure 3 - Percentage Geriatric Care Managers Who Work with Other Professionals Frequently.)
Cost of Services
Respondents were asked how much they charged for their services, which might include: an initial consultation; fees on an hourly or per visit basis; fees for development of a care plan; and fees on a fixed-price contract basis. Hourly fees averaged $74 an hour. GCMs charged an average $168 to develop a care plan. Initial consultations averaged $175. Seven of ten current GCMs responded in the affirmative when asked if they had a statement that listed their fees.
Views on Certification
Only 242 respondents answered a question about the professional certifications they held. The number of responses, however, totaled 552, because some of the respondents listed more than one certification. The largest percentage of certifications were in social work (27 percent), followed by nursing (15 percent). Other fields in which respondents held certifications included case manager; psychology or counseling; and business, law, or administration.
Most survey respondents (78 percent) believe that certification as a geriatric care manager is important in addition to their professional licenses. When asked, in an open-ended question, for their reasons, they listed the following: to demonstrate expertise in the complex work of geriatric care management, to standardize expert knowledge, to raise the level of public awareness of this field, and to protect consumers from individuals who may have little or no training for the work.
However, there is still some debate about the issue within the profession and among researchers and providers. One reason for this debate is the predominance of nurses and social workers among GCMs; these professionals must obtain licenses in their own fields first. Some GCMs with nursing or social work licenses believe their professional education and training in these fields prepare them adequately for their care management responsibilities, particularly if they offer services that focus on their specific skills. The AARP survey showed that GCMs with a license in nursing are more likely to assess the health of a client than are social workers (94 percent vs. 62 percent) and less likely to provide family counseling (58 percent nursing license vs. 84 percent social work license). Many of these GCMs also partner with professionals in other fields (see above under "Services Provided"), such as lawyers and accountants, to fill the gaps in their training.
Another debate is about the type of certification appropriate for GCMs. Certification programs have proliferated in recent years. One survey lists more than 40 different certification designations, ranging from Certified Family Life Educator to Certified Occupational Therapist.
Two major certification programs for care managers, established in the 1990s, are:
- " Care Manager Certified " (CMC), offered by the National Academy of Certified Case Managers in Colchester, Connecticut.
- " Certified Case Manager " (CCM), offered by the Commission for Case Management Certification in Rolling Meadows, Illinois.
For either certification, applicants must meet specific education and experience requirements and pass a qualifying examination. The CMC examination emphasizes the core functions of care management (comprehensive assessment, care plan development and implementation, monitoring and evaluation) and knowledge of long-term care issues, such as aging and disability issues, community services, benefit and financing options, and legal and ethical concerns. The CCM examination, on the other hand, covers more medical and health issues. Many GCMs hold both designations.
This report has provided a preliminary overview of geriatric care management obtained from surveying GCMs who are members of a large care management organization. From this survey, several policy and practice issues emerge.
First, there is little information on the extent of consumer protection needed for persons using GCMs. For example, is there potential or actual fraud and abuse in this unregulated field? Are clients getting appropriate services and sound advice on services?
Another issue is developing appropriate monitoring processes to determine if there is a problem. No state has developed such a system. Care management firms that develop a network of GCMs around the country are discussing developing their own standards of practice and requiring their network care managers to hold malpractice insurance in their own licensed profession or through newer policies designed specifically for geriatric care managers.
One crucial area for professional control is development of a code of ethics for geriatric care managers. Many would argue that there is an inherent conflict of interest if an agency provides both care management and service, such as assistance with daily activities, including dressing and bathing. There is also a potential conflict of interest if an individual GCM serves as a care manager and a guardian, or has durable power of attorney.
Finally, many in this group of professionals say their biggest challenge is the lack of public awareness that geriatric care management even exists and what it can do for the consumer.
The rapid growth of the field is leading to confusion among professionals as well as among those seeking assistance. Consumers may need to be protected (through standards, certification, and codes of ethics) and also educated so they can make informed choices.
Written by Robyn Stone, DrPH, Principal Investigator; Susan Reinhard, RN, PhD, Co-Principal Investigator; Jean Machemer, MSG, Research Associate; and Danylle Rudin, MSW, Research Associate of The Institute for the Future of Aging Services, Washington, D.C.
Barbara Coleman, Project Manager, AARP Public Policy Institute
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Public Policy Institute, AARP, 601 E Street, NW, Washington, DC 20049