Options For Elder Care

Choosing a Medicare Insurance Program

My first stop in the older adult Continuum of Care is Health Insurance; probably the first and one of the most important decisions you will make when become eligible for Medicare at age 65.

                                                              Medicare Part A

Most people do not pay a monthly Part A premium because they or a spouse has 40 or more quarters in which they paid Medicare taxes while working.  Medicare part A covers inpatient care in hospitals,  skilled nursing facility, home health and hospice care

                                                              Medicare Part B

Most people pay a standard monthly premium for Medicare Part B. However, some people may pay a higher premium based upon their modified adjusted income. Most elect to have this premium taken directly from their social security check. For most items and services covered under Part B, you must also pay a COPAY, COINSURANCE, and a DEDUCTIBLE. Part B covers those services not covered under Part A such as outpatient services, doctor services, emergency room services, and office visits.

                                                           Medigap Policy

Medigap policies are designed to "fill in the gap" to pay for COPAY, COINSURANCE, and the DEDUCTIBLE and with some policies, services not covered by Part A & B. Medigap policies typically do NOT cover prescription drugs. The positive implication of purchasing a medigap plan is you have total freedom of choice, you can receive care anywhere you want as long as the provider accepts Medicare. You also do not have a "Managed Care Agency" monitoring your usage of coverage from hospital length of stay, to durable medical equipment. The most common medigap policy in Pittsburgh is offered by Western PA BC/BS. You do not need to purchase a medigap policy if you have a Medicare Advantage Plan. RECOMMENDATIONS: I believe the negative of extremely high cost for the medigap policy, less coverage for Skilled Care, along with with the need to purchase a part D supplement far out-weights the benefit of freedom of choice in the Pittsburgh area where we have excellent Medicare Advantage Networks with two large providers.

                                               Medicare Advantage Plans (Part C)

Medicare Advantage Plans are private insurance companies approved by Medicare to provide this coverage. When you join one of these, you are still in Medicare. Medicare Advantage Plans provide all the coverage of Part A & Part B and generally offer extra benefits that may include Part D drug coverage. These plans have networks, which means you need to see doctors in the plan and go to hospitals in the network for care. In many cases, the cost for these plans can be lower than the original Medicare Part B premium. Recommendations: Make sure you live in a service area of the plan you join and that the plan has a large established network. You can't go wrong if you live in Allegheny County and choose one of the two largest providers in Pittsburgh - UPMC Health Plan (UPMC for Life)or Highmark (Security Blue HMO or Freedom Blue PPO)...more about these plans below:

HMO -  Health Maintenance Organization - a type of health plan where you you can only go to doctors and hospitals in the plans network to receive coverage, with the exception of an emergency. If you choose the UPMC for Life coverage you can only receive care with UPMC providers or facilities. (you cannot receive care in the West Penn/Allegheny Health System) Security Blue's Network also includes the West Penn/Allegheny Health System along with UPMC facilities.

PPO -Preferred Provider Organizations - with this type of plan you have the choice of using hospitals and providers in the network or can choose to go outside of the network for additional costs. freedom Blue is an example of this type of PPO in Pittsburgh.

Final words: I have worked for both major and some minor providers of health care in Pittsburgh. As a previous insider, my recommendation is the Medicare Advantage plans. If a decision regarding care is ever made that you disagree with, you have the ability to appeal this decision immediately in most cases.

If you need assistance in determining the best Medicare plan to meet your individual needs, Options For Elder Care would be glad to assist. 412-443-1365 web:  www.optionsforeldercare.com or e-mail: info@optionsforeldercare.com

Lets tackle Medicare Part D next time!

my Best,

Bobbi

The Vision of a Geriatric Care Manager

I am a runner. That is how I solve my day to day problems. I find the solution for everything when I am on my five mile run at North Park.

After dropping my nine year old off at school I head for Panera's for my morning coffee. There is always a group to welcome me as I enter. The first hello is usually from John who had bypass surgery a few years back and is caring for his mother who is residing in a personal care home. Teddy is having problems with his right knee and will probably need a another knee replacement. There are other's, one caring for a wife with MS, another who's wife was just diagnosed with breast cancer. They all appreciate the advise of a RN Geriatric Care Manager.

After getting my caffeine boost, I am ready for my run and stretching in the parking lot by the boy scout house. There are the "regulars" like Bob and his wife who have been dealing with managing the care of their aging mother on their own for almost a year and Mark who is 90 with rheumatoid arthritis, but still walks 3 miles 5 times a week. As I make the five mile loop, I am stopped several times by the "regulars" for advice on medical or elder care concerns. I am not only assisting them with their concerns but solving my problems in this hour of running. After my run when I am cooling down in the parking lot there is  poor Paul. He  has a tiny dog, Buddy, who appears to have a very enlarged liver and extreme difficulty breathing. Paul and Buddy  are "regulars" to North Park. Buddy hangs out in the car until Paul is done running. Paul and I discuss Buddy regarding aggressive therapy vs palliative therapy. Buddy is in the geriatrics of his life and Paul comes to the decision he will do anything to make Buddy comfortable, but does not want to inflict any treatment that would cause pain or suffering. He also decides that he will not keep Buddy alive for his own personal need to have a companion, but try to make all decisions with what would be best for Buddy. We part on those words.

As I drive home I see a vision of Geriatric Care Management across the Continuum, but I wonder where does it start and when does it end? Let me think about this on my next run.

Until next time, my best,

Bobbi

Geriatric Care Management in Pittsburgh, PA

I just returned from the National Association of Geriatric Care Managers annual conference in Boston, MA. While at the conference, discussing Geriatric Care Management with all my colleagues, I came to the realization that Geriatric Care Management is a term easily recognized in other areas of the United States but not in Pittsburgh, PA. So I decided my first blog should be to help define what a Geriatric Care Manager is and the services they can potentially provide.

What is a Geriatric Care Manager?

The National Association of Professional Geriatric Care managers define a Professional Geriatric Care Managers as:

A Geriatric Care Manager is a health and human services professional, such as a gerontologist, social worker, counselor, or nurse, with a specialized body of knowledge and experience related to aging and elder care issues.  A Professional Geriatric Care Manager (PGCM) is a geriatric care manager who is a member of the National Association of Professional Geriatric Care Managers (GCM) and had committed to adhering to the GCM Pledge of Ethics and Standards of Practice,

The PGCM assists older adults and persons with disabilities in attaining their maximum functional potential.  The PGCM strives to respect the autonomy of the individual and delivers care-coordination and support services with sensitivity to preserve the dignity and respect of each individual.  In addition, the PGCM is an experienced guide and resource for families of older adults and others with chronic needs.

I start my definition with “Caveat Emptor” as we are not all alike in our practice or, in my opinion, equally qualified. In my social interrelations with local Geriatric Managers and National Geriatric Care Managers I have found there is a range of PGCM’s – from those who have the lesser credentials of working as a nurses aide and then obtained an on-line certificate in Gerontology, to those with the highest credentials of a PHD in gerontology in combination with a RN Nurse Practitioner.

So, when you are looking for assistance for your parents, be sure to determine exactly what the PGCM’s background is prior to retaining them for service. Of course my opinion is biased being a RN, but if I were to choose a PGCM for my parents care I would want someone who could not only manage the social aspects of their care but also medically coordinate their care and act as a liaison with all parties involved in this coordination. Only someone with an Undergraduate Degree or Masters in a field of Science is able to do this. (Registered Nurse, Physical Therapist, Occupational Therapist, to mention a few). If the services you need are purely social in nature (assistance with shopping, counseling, immediate placement, Medicaid applications) then a social worker with a Masters Degree or a Masters Educated Gerontologist might be your best choice.

Additionally, I would assure the PGCM you are considering hiring has a certificate in Care or Case Management (CCM - Certified Case Manager or CMC - Care Manager Certified). To become certified, a professional has to meet the requirements to be called a Case Manager and then take an exam to obtain the certification. They also have to be re-certified every so many years, which requires proof of continual education in the field of case management.

What do Geriatric Care Manager’s do?

What PGCM’s do varies depending on the qualifications of the PGCM. Here is the National Society of PGCM’s Definition:

Care management services are offered in a variety of settings.  Professional Geriatric Care Managers (PGCMs) can serve the needs of their clients with the following services:

• Short-term or on-going assistance for long distance caregivers or other requiring assistance.
• Personalized and compassionate services focusing on the individual's wants and needs.
• Accessibility: Care is typically available 24 hours a day; 7 days a week.
• Continuity of care management by facilitating family communication, reducing the burden on families and preventing unnecessary expenditures.
• Efficiency and flexibility based upon a client-centered approach eliminating bureaucratic constraints.
• Cost containment by avoiding inappropriate placements, duplication of services, and crisis intervention to avoid hospitalizations.
• Quality control: care management services that follow GCM's Standards of Practice

Options For Elder Care (OptionsForElderCare.com) only employs Registered Nurses with a minimum of 15 years experience in case management and geriatrics. In addition to the above services this is the definition of services we provide:

• We are the medical coordinators of care for the geriatric client
• We are the liaisons with all the parties, family, doctors, caregivers, etc.
• We are the education and support system for geriatric client and his family.
• We're that one person that all the parties can call and understand the long-term plan and the steps to get there.
• We’re continually planning and implementing, always evaluating what we're doing as well as the outcomes.
• We strive to do the right thing at the right time, trying to save some money for the client and yet get the best outcomes that we can, functionally, financially and in every way.

How Are The Services of a Professional Geriatric Care Manager paid for?

Hopefully in my lifetime we will see reimbursement for Geriatric Care Managers by Medicare. Unfortunately Geriatric Physicians are becoming scarce because the geriatric services cost the hospital $1,350 more per person than the savings they produced, and Medicare, the insurer for the elderly, does not cover that cost. RN Geriatric Care Manager’s may be the solution for our country’s surging elderly population. (More on this later...)

Until that happens Geriatric Care Managers service is privately paid for. The average national hourly rate for PGCM’s is $80.00 - $150.00 per hour. Again, make sure you are getting a qualified PGCM. You may also hear of care managers who work telephonically from insurance companies or Care Managers through your local area on aging. The service they provide should not be confused with the services a Professional Geriatric Care Manager can provide.

Until next time, my best,

Bobbi

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For Geriatric Care Management Assistance from Registered Nurses Contact Options For Elder Care
by phone: 412-443-1365
or email: info@OptionsForElderCare.com
or visit our web site: OptionsForElderCare.com