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Geriatric Case Management - Guiding the Future of "Aging in Place"



The term case management in the social service and/or medical field has come to describe the organizing of a fragmented group of services, or sources of funding, at the point of service delivery. With the future of senior and elder care rapidly moving towards the “Aging in Place” concept, the field of Geriatric Case Management (GCM) will become an important part of that equation. First, let’s describe what ‘Aging in Place” means.

"Aging in Place" means that a person or a couple has made a conscious decision to stay in the living situation of their choice for as long as they can with the comforts that are important to them. As they age, this may include adding supplementary services to facilitate their living conditions and maintain their quality of life.

Just how important is this?

Well consider the fact that just over two decades ago, there were just over 35 million American citizens aged 65 or older. And by 2030, according to the US Census Board, there will be about 70 million Americans aged 65 or older meaning this age group will comprise nearly 20% of our total population.

The social, economic, physical, psychological and medical challenges of this group will be stressing the fabric of our society, specifically services like nursing homes, assisted living centers and rehab facilities. In fact, we ran a story in our most recent newsletter about just such a problem that is facing the United Kingdom.

It was reported that in Ireland, a 92-year-old man had spent more than 70 days


at Sligo University Hospital despite being medically fit to be discharged. The case was highlighted by consultant cardiologist, Dr Donal Murray, who believed that the lack of room in rehab facilities and poorly staffed home health care providers was the reason for the man’s prolonged stay in hospital.

Murray said the man, who lives on his own in a remote rural area, was a classic example of someone who would do very well at home with just a bit of assistance from a home care aid or case management provider who could “keep an eye on him.” The problem for the patient reaches far beyond a lack of home care providers as it actually impacts his long term health. The doctor pointed out that “the longer he remained in hospital the more difficult it would be for him when discharged.”

This is a problem that is only going to increase as boomers age into the system and facilities continue to close or operate at capacity.

But even if we fully embrace the Aging in Place concept, there are some things that will always be true about aging -- no matter how much we stay fit, eat the right things and take care of ourselves, aging will inevitably change us – physically, mentally and emotionally. And we must be prepared.

Such changes include:

  • Vision

  • Decreased muscle mass leading to decreased strength

  • Endurance issues – both physical and mental

  • Higher risks of accidents that come with balance and bone density changes

  • Hearing problems

  • Less flexibility, mobility and agility

Unfortunately, no matter how much we try to hang onto our youth, these things will happen. Hence, planning for the future includes taking into account the changes brought on by age and preparing for them. These changes also have a profound effect on our daily activities, often called Activities of Daily Living or ADLs. Some of the common ADLs with those choosing to age at home include the following:

  • Maintaining independence without incidents or anxiety as our physical skills deteriorate

  • Driving or taking public transportation comfortably without mishaps or confusion leading to anxiety

  • Going to social events such as senior centers or trips to community settings without stress that cold lead to isolation

  • Maintaining the home, inside and out, which includes paying bills, taxes, physical improvements, etc.

  • Paying attention to one’s health including attending medical appointments, taking medication as needed and on time, exercising

  • Reducing the risks of physical and financial abuse

And if we plan to remain in the home instead of moving into a setting where facility staff are there to assist us as the changes occur, it begins to make sense to have a GCM as part of the team.

GCMs are health care professionals with a background in nursing, social work, gerontology or psychology who specialize in elder care issues and understand the needs of seniors. These managers are trained to provide services not only to the senior but to the family as well.

Let's look at some of the advantages of hiring a Geriatric Case Manager.

  • Financial – As we stated before, hiring a Geriatric Case Manager to provide a one time assessment for the family or ongoing support will lower expenses in the long run. GCMs are knowledgeable about the resources in the community, can work as a liaison with the individual’s power of attorney or elder law attorney, and provide insight into community resources that could help the family.

  • Decision Making – A GCM can independently assess the senior’s current situation and recommend changes to the home (such as putting in a ramp or changing the home around to accommodate someone with sight issues). They can also point out to the family when major concerns are present, such as dementia, that many family members may be unwilling to admit due to denial. Their ability to offer a way to navigate the transition from the home into assisted living or nursing care is invaluable.

  • Knowledge of the Medical System – GCMs can attend medical appointments with the senior and ask the questions that family members may forget, communicate family concerns with the health professionals, and make sure medications and medical orders are being followed within the home. Plus, with the knowledge of providers, they can find the right specialist for the problem needing care. A GCM is also able to help avoid unneeded hospitalizations which are costly, can be depressing and disruptive to the senior's sense of independence and long term well being.

  • Ongoing Supervision in a Facility – A GCM can help a family by overseeing the decisions made when your loved one is in a nursing facility. One of the issues that we have seen and will certainly only get worse, is the disruption caused within a family when someone must act as a caregiver while raising their own family and maintaining a job. A GCM can serve as an extra and discreet pair of eyes and ears to visit the facility at odd hours and check on a client’s physical care, emotional state, activity level, and social engagement. A GCM can also help facilitate communication between family caregivers and facility staff.

  • Support to Caregivers – if family members act as a caregiver, GCMs can help preserve the well being of the individual. In most cases, family caregivers take on too much for a variety of reasons and end up "burnt out” or loaded with resentments against the senior and even other family members. A GCM can assist in supporting the caregiver through knowledge of community resources that can prove helpful. This includes building your own “circle of care” in which you let other family members, friends, and community members help with caregiving duties such as driving, grocery shopping, or just spending time with your loved one.

At Connelly Law, we are always seeking community partners that are professional and exceptional providers to whom we can comfortably refer our clients and their families to. Last month, we met with Barbara Cannon, the founder of Answers for Elders, LLC which is located in Plymouth, Massachusetts. Her company provides geriatric case management services to seniors and their families in Massachusetts, Rhode Island and in the very near future, Connecticut.


Barbara is a Licensed Social Worker, Certified Geriatric Care Manager and Healthcare Consultant. She is the former President of the New England Chapter of Aging Life Care Association and has served on several governing boards at Quincy College, Board of Health and social service groups protecting children.

She has 30 years experience working with seniors and their families as an advocate, liaison and an expert resource. She has spoken on geriatric care management at the MIT Age Lab, various Councils on Aging, Law Firms, Elder Law Seminars, and at NAELA – National Academy of Elder Law Attorneys in Massachusetts.

Barbara provided her insights to us on the future of elder care and the ever expanding needs of our seniors.

"As we continue to watch the population of boomers explode over the next 10 years we are already observing the crunch of seniors finding professional as well as personal caregivers to help them through the senior years."

"There are fewer primary care physicians either due to them retiring, leaving their practices due to over regulation and finding it harder to provide quality one-on-'one care for their patients and there are less and less medical students choosing family or primary care as their career choice."

"There are fewer adult children as many of the boomers had one, two or no children and many of those children are not centrally located for caregiving or just have such busy lives themselves are unable to provide the level of care their parents need. We are also finding in rural or even wealthy communities that home health aides and home care agencies are unable to provide caregivers as the caregivers cannot afford to live in these areas or there is no transportation services for thorn to access in order to get to their clients."

"As we move forward in doing our best to find and provide resources to seniors here in Massachusetts, organizations like [ours]... have many resources and creative strategies for assisting families in gelling the support they need to assist their loved ones with everything senior."

"Aging life experts like those at Answers for Elders are licensed social workers,


nurses, care managers, paramedics, lead medics, with many years of experience working with seniors and their families to navigate the senior years."

"We perform a fully comprehensive evaluation of the senior's life circumstances to determine where they are in the trajectory of their life, what their goals and needs are so that we are able to make positive, fiscally responsible, medically and socially sensible recommendations as to what the next steps, and actions should be in the seniors life so that they are able to live the best quality life possible during the senior years."

Answers for Elders also offers important services for families.

"We mediate for families needing further, understanding of the seniors' wishes and being able to honor them," continued Barbara. "Crisis intervention for the family that is experiencing status changes in their loved ones medical or cognitive condition, i.e. new life limiting illness diagnosis, new diagnosis of dementia/ Alzheimer's and other chronic diseases that will change the direction of the senior's lives."

Other services include:

  • Finding the right elder law or estate planning lawyer

  • Helping [seniors] to understand how to choose the right skilled nursing/long-term care facility, assisted living. Independent living, continuing care retirement community, HUD senior housing and {explaining] the difference between all of them

  • When to Introduce hospice or palliative care to your loved one and how to have those conversations

  • Negotiating with home care agencies to get [seniors] the best price possible for home care needs

"We are the eyes, ears and advocates for those entering the crowning senior years. And as the senior population grows and [families] observe a senior's needs changing, they can call Answers for Elders for a free initial phone consultation. We will guide [them] and [their] loved ones to security," said Barbara.

Besides offering hands on services, Answers for Elders has an extensive multi-disciplinary network of providers they can refer clients to. Connelly Law Offices is proud to welcome Answers for Elders, LLC as one of our community partners.
You can go to their website by clicking on the logo below.

Attorney Connelly practices in the area of elder law. This area of law involves Medicaid planning and asset protection advice for those individuals entering nursing homes, planning for the possibility of disability through the use of powers of attorney for the both health care and finances, guardianship, estate planning, probate and estate administration, preparation of wills, living trusts and special or supplemental needs trusts. He represents clients primarily in the states of Rhode Island, Connecticut and the Commonwealth of Massachusetts. He was certified as an Elder Law Attorney (CELA) by the National Elder Law Foundation (NELF) in 2008. Attorney Connelly is licensed to practice before the Rhode Island, Massachusetts, Connecticut, and Federal Bars.


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