My adventure into Geriatric Care Management grew from a small seed of thought, which grew into more serious thoughts due to my experiences as the Director of Social Services at a Skilled Nursing facility (SNF). Time after time, as a discharge planner, I would need to facilitate a discharge home for senior after senior knowing that the plan was a short term plan; without greater and more secure safety nets the senior would end up back in the ER and then back into the SNF.

Upon discharge a Visiting Nurse Service can and usually does provide brief services which are paid by Medicare. Unfortunately, these services are short lived and do not address the long term needs and services, therefore the senior is back in the emergency room within weeks, if not sooner. These seniors are known by the EMT’s and the Emergency room staff closest to their homes. It is quite common for these seniors to have multiple trips to the ER and the SNF before one would question …why ? and/or or say, “Well, this patient needs to remain in a SNF. ” Why…is simply answered, and NO, more often than not, it is not time for permanent placement. The reality is there are many long term residents living the remainder of their lives in a nursing home at a much greater expense, when they could be in the comfort of their own home, with a 24-hour caregiver providing ongoing one-to-one attention at a much lower, daily rate.

I would see this repeatedly and feel so frustrated that I could not do more to guarantee greater success at home. I knew with better safety nets in place and closer monitoring and medical attention at home, most ER trips could be eliminated as well as the subsequent return to the SNF.

The formula seemed simple but I could not do what was needed as a discharge planner in a SNF with a caseload of 100+ seniors.

I would say to myself, “These seniors need a Senior Manager to go to their home, assess the ongoing needs, make recommendations and set up services. Ongoing monitoring would insure that the recommendations were being followed, and as a trained Senior Manager it would be easy to see signs of change or concerns and make the necessary adaptations.”

As time went on I thought of this more and more, and went online to “Goggle” keywords. To my amazement I found out that there really were Senior Managers and they were called “Geriatric Care Managers.”

I felt it was time to take this seed of thought and actually pursue what I had thought about so often. I would build a private practice that would allow me to reach out to seniors and their families and give the gift of providing “Options” that families were probably not aware of…”Growing Options”. I pursued the necessary credentialing and became a Certified Care Manager (CCM).

Since that time I have slowly and successfully been privileged to work with many seniors and their families, and fulfill a vision I knew was possible to provide the bridge to success once leaving a SNF after subacute rehabilitation or discharge from an Emergency Room.


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