Can you explain the role of a geriatric care manager and when I need to hire one? My mother is 90 years old and she is forgetful but managing at home. What services can a geriatric care manager provide to me?

Q: Can you explain the role of a geriatric care manager and when I need to hire one? My mother is 90 years old and she is forgetful but managing at home. What services can a geriatric care manager provide to me?


A: A geriatric care manager can provide many roles of assistance to you and to your mother. Your mother is the client.


The geriatric care manager can complete a home assessment to evaluate your mother in her home. The home assessment will include a discussion with your mother and a discussion with you about your concerns, what issues worry you, what you see as problems, and what short- and long-term goals you have for your mother.


This assessment looks at your mother's ability to care for herself, services that your mother may be eligible for in the community, home safety evaluation, financial and psychosocial issues, as well as short- and long-term goals. A written report will be provided to you and your mother following the visit. Included in the report will be the assessment.


After the written report (care plan) there is time for a discussion on how to proceed. You can take the report and follow up, or the geriatric care manager can proceed with implementing the care plan. When hiring a geriatric care manager, it is important that you interview the potential manager by phone or in person and ask about their credentials. Currently, geriatric care managers must be certified. Also ask about rates, and who provides the service (i.e. social worker, nurse or other degreed person).


Q: My uncle is in the hospital with dehydration. At home I noticed he was just getting weaker. Is he eligible for services at home or does he require a rehabilitation center to get stronger?


A: Services such as physical therapy, occupational therapy and nursing can be brought into the home. The physician at the hospital would order the services for the home. An agency such as the Visiting Nurse Association would come into the home the day following discharge for a home assessment. In that home assessment the nurse would determine the number of hours per week/number of days per week that services are needed. Many times, services are three to four times per week. Your uncle would still be on his own most of the day.


If your uncle went to a rehabilitation center (sometimes rehabilitation can take place in a nursing home) then he would receive therapy approximately five to seven times per week, nursing care 24/7, a nursing aide to assist with personal care and all his meals would be prepared. Medicare will cover for short-term rehabilitation as long as your uncle was admitted to the hospital and had three midnights in the hospital.


The length of stay in the rehabilitation center would be determined by the progress your uncle makes. He is eligible for up to 100 days paid by Medicare, as long as he continues to require skilled care. Skilled care is defined by requiring therapy and or nursing care. Keep in mind if your uncle declines therapy three days in a row, Medicare will stop coverage unless he has a medical need that will allow the facility to bill under Medicare.


Talk with the case manager at the hospital who can assist in finding a rehabilitation center or contact a geriatric care manager who can provide you with additional information on rehabilitation units.


ElderCare Resource Services is a partnership of geriatric nurses and social workers that helps families to investigate, assess and recommend medical and non-medical care and resources for seniors.


Send questions to SeniorSavvy@ElderCareResourceServices.com or ElderCare Resources Inc., 29 Gano Road, Marlborough, MA 01752, or call them at 508-879-7008.