Private Care Management - Professional Assistance for the Care of Elderly and/or Disabled Clients
by Margy Campbell
The Growing Challenge
The over-80 population is steadily increasing and creating a challenge to lawyers - older clients with problems in their decision-making capacity. It seems that more and more frequently lawyers are faced with the issue of mental capacity of their clients.
Rule 1.14, ABA's Model Rules of Professional Conduct, 2002 Revised, concerning the client with diminished capacity, provides some guidance. The rule triggers protective action when an attorney reasonably believes that a client has diminished capacity, there is a potential for harm to the client, or the client cannot act in his or her own interest.
The Questions Are
Whom can an attorney speak with about a client who may demonstrate diminished capacity? Who can assist the lawyer in determining whether a client has diminished capacity? Who can assist the client in finding private and community services to assist with the clientÕs ongoing needs?
The Answer Is
A professional Private Care Manager.
Demographic Overview
A recently published MetLife study notes that Americans born in 1939 and earlier represent close to 35 million individuals. This represents 12.6% of the current total population, or about one in eight people. 42% is male, 58% female, with those 85+ representing 1.5% of the population in 2000. By 2050 this segment will represent almost 5% of the total U.S. population. Those age 85 and over are the most rapid growing elderly age group, growing 274% between 1960 and 1994. By 2030, the 65+ population will more than double to about 71.5 Million, and by 2050 to 86.7 Million.
What is Care Management (CM)?
CM is much broader than medical case management. The CM planning process includes the client's cognitive, medical, mental health, social, environment, financial, legal and spiritual needs. The process is a series of steps taken by a professional care manager (PCM) to help address an older or disabled individual's needs.
What is a Private Care Manager (PCM)?
PCM is a professional career niche that has been developing slowly over the past 15 years throughout the United States. Among the ranks of professional PCMs are social workers, nurses, accountants, lawyers and other professionals who address the needs of the aging and disabled population by offering very personalized services.
A PCM serves older and/or disabled persons, their family members and their professional care team by providing crisis management intervention and preventative services intended to increase the quality of life for the client. They can offer assurance and peace of mind to the client, their adult children, and other professionals who are on the client's care team. A PCM's mission is to allow an individual to "age in place" by providing the client with community and private supports that will allow them to live in the least restrictive setting while allowing quality of life and utmost safety.
PCMs are generally available 24 hours a day, 7 days a week, 365 days a year. They respond to the needs of the client at the convenience of the client. They consult with the client, care providers and others on the client's care team who need to understand, assess and manage the client's cognitive, medical, mental, social, environmental, financial, legal and spiritual needs.
PCMs are independent specialist in the aging and disability field who can assist when family members and other professionals have questions regarding capacity, medical care, family dynamics, housing options, community resources, end-of-life decisions, personal interests, and other topics specific to an individual's needs.
Overview of PCMs' Responsibilities
Assessing Clients - The assessment process is comprehensive and systematic. It includes assessing the person's functional and cognitive capacity and limitations, medical and mental health care needs, current living environment for safety and appropriateness, current social support system, financial position, ability to access community supports, legal and insurance information, and end-of-life wishes and spiritual care needs. The assessment also looks at other needs, strengths, abilities, and existing resources and supports that are currently being used.
Planning Care - A plan of care is developed by taking the findings of the assessment and developing a written plan that will address each area of concern, offer solutions to the problem and assign a date when that problem may be resolved. The plan takes into consideration the access of community supports and the client's ability to pay for private services.
Coordinating and Plan Implementation - The PCM reviews the plan with the client and other interested parties and begins to implement the care plan by coordinating care services in the most cost-effective and timely manner. The implementation takes into consideration the client and their family's desires regarding services, providers and the use of services.
Monitoring the Care Plan - The plan is then monitored by the PCM to make sure that it is working, the services are of the highest quality, and the services are implemented in a timely manner and to the satisfaction of the client and their family.
Are Private Care Managers Licensed?
Currently there is no licensing in any state for PCMs, although many care managers are licensed in their professional and academic careers such as social work, nursing, accounting and law. In 1985 the National Association of Private Geriatric Care Managers (NAPGCM) was founded to provide a network throughout the U.S. for professionals doing the work of PCMs. NAPGCM conducts research, offers national and regional conferences, peer support and publishes a GCM Journal. NAPGCM also encourages all PCMs to obtain a Certified Case Manager (CMC), certification through the Individual Case Management Association (ICMA), hold membership in NAPGCM and adhere to the code of ethics developed for the organization.
Issues of Diminished Capacity
The PCM is generally a trained clinician who can, along with the client's geriatrician, a psychiatrist, psychologist and other mental health professionals, assist with a determination of diminished capacity through an evaluation of the client and/or the review and summary of a capacity evaluation.
PCMs generally have an understanding of mental health diagnosis found in the Diagnostic and Statistical Manual of Mental Health Disorders Ð IV (DSM-IV). They should have an understanding of clinical medical information and use of medications and formal diagnostic testing. They also need to understand functional behavior as described by interested parties and detailed on capacity instruments and recognize subtle cues regarding an individual's capacity during interviews and fact gathering sessions.
PCMs also understand the formal clinical evaluation report. They are able to easily summarize the sections of information included in the report which contain demographic information; legal background of the client and the reason for initial referral; history of presenting illness - medical history and current symptoms; psychosocial history; informed consent from the client; behavioral observations; tests administered; validity statements noting the opinion of the extent that the tests results were valid; summary of test results; impression and a formal recommendation.
PCM as a Court Visitor or Expert Witness
In a guardianship and/or conservatorship case, a PCM acts as a court visitor to determine whether a proposed protected person has the capacity to attend a court hearing. The PCM visits with the client and interested parties and assesses the client's ability - emotionally and/or physically Ð to attend a hearing. The PCM then makes recommendations to the court through a formalized written document.
A PCM can be used as an investigator in determining whether or not a guardianship and/or conservatorship is in the proposed protected person's best interest. The PCM can also recommend a specific guardian/conservator to the court based on information gathered through the investigative process.
PCMs are also used as expert witnesses in court hearings in contested guardianship/conservatorship proceedings. The PCMs' experience in the field of gerontology, social work and/or nursing can be a valuable asset to the legal teams working for the benefit of their clients.
Why Use a PCM on the Legal Team?
As lawyers use accountants for information specific to a clientÕs tax position and estate plans, private care managers can assist lawyers with issues concerning a specific clientÕs capacity, by accessing community resources and through court visitor and expert witness testimony.
As a member of the client's legal team, a PCM can offer professional insight to the team, streamline the services offered, ensure continuity of care and help avoid duplication of services. The PCM can also assist with family meetings and help adult children in understanding that the client's needs and rights are paramount to the legal process.
As a member of the legal team, the PCM can offer assistance to the lawyer by providing insight that may not be readily seen by other team members, and when necessary, providing referrals to other professionals. A PCM can also assist with providing protective action, as outlined in the ABA's Model Rules of Professional Conduct, Rule 1.14, 2002 revised, in the event that a lawyer reasonably believes that a client is exhibiting diminished capacity.