Care Manager

1
Care Managers Role in the Estate Planning
Process

• Martin M. Shenkman, CPA, MBA, AEP, JD
• Marci Sadorf RN, CMC
• and
• Stephanie Chong LICSW, ASWCM
• August 23, 2011

2
Topic

• Importance of Care ManagerDefining Care Manager

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Care Manager Importance

• Why the role of Care Manager will grow in
  importance
• By 2030 it is estimated that 1/5th of all
  Americans will be age 65 or older
• 125 million Americans (45 of the population)
  have at least one chronic condition paralysis,
  Alzheimers disease, mental disorders, HIV/AIDS,
  allergies, asthma, diabetes or high blood
  pressure
• 60 million people (22 of the population) suffer
  from multiple chronic conditions

4
What is a Care Manager

• Registered Nurse (RN), Social Worker, geriatric
  or other specialist
• Comprehensively evaluates clients physical
  health and wellness, memory and mental health
  status, functional abilities, informal and formal
  social support networks, financial resources and
  living environment
• Makes recommendations for care based on the
  information gathered from the assessment, coupled
  with an understanding of the clients wishes

5
Professional Credentials -1

• Practitioners should understand the credentials
  so that they can draft minimum criteria into
  operative clauses mandating that specified
  matters be handled by a care manager
• CMC Certified Care Manager. A nurse may take
  exams after meeting practice requirements. gt 2
  years full time paid supervised care management
  experience. If you dont have a masters degree an
  additional 2-4 years of paid full time experience
  may be required.
• CCM Certified Case Manager. License or
  certification in profession and at least a
  Bachelors degree. Depending on level of licensure
  in profession must grant ability to practice
  independently without supervision of another
  licensed professional. 1 year full time
  supervised case management experience of another
  CCM. 24 months of full time case management
  experience without supervision of CCM.

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Professional Credentials - 2

• RN Registered Nurse. 2-4 years (associate or
  bachelors) of college with a specialty in
  nursing. Must pass state boards.
• C-ASWCM Certified Advanced Social Worker In
  Case Management. Masters degree in Social Work
  from an accredited university. 20 contact hours
  of continuing professional education. 2 years
  paid supervised post-MSW case management
  experience.
• C-SWCM Certified Social Work Case Manager.
  Adherence to NASW code of ethics and standards
  for continuing professional eduction.
• C-SWCM Certified Social Work Case Manager.
  Applies to those with a bachelors degree in
  Social Work. Requires 3 years of paid supervised
  experience.
• The above are required by NAPGCM for membership.

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Professional Organization

• In addition to the general license (e.g., RN,
  Masters in Social Work) another accreditation can
  be obtained from NAPGCM. Must first have a
  license (e.g., as a nurse). Examinations, years
  of practice, etc. are prerequisites.
• The NAPGCM designation.
• National Association of Professional Geriatric
  Care Managers this is the organization which the
  different health related professional.
• There is a code of ethics and standards that may
  provide a greater level of security.
• See www.caremanager.org for more details.
• You can identify a care manager in your clients
  location (e.g. by Zip code, etc.).

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Topic

• Care Managerand the
• Estate Planning Team

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Care Manager as Catalyst to Planning

• What role might a care manager play in an estate
  plan
• Encourage patient to proceed with other planning
• Ease the family into the planning process
• Example When an evaluation is conducted in the
  home a family member is generally requested to be
  present so that they can see the process, the
  issues identified, etc. The family will see first
  hand how and why the care manager is identifying
  issues. Often the family has experienced the
  issues gradually come on and isnt is as aware of
  the progression or overall impact. This can help
  the care manager prioritize with the family.
• Evaluate needs of the client and create an
  assessment of current and future care needs
• Helping the family understand care options
• Addressing family conflicts and disagreements
  that impede the planning process
• Coordinating the various advisers

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Estate Planning for Aging Patients and Those with
Chronic Illness

• Vitally important to protect patient, caregiver,
  family and other loved ones -
• Example 3rd party objective assessment of what
  is happening with the patient and in the
  patients home or other living environment
• Integrated holistic plan social, financial,
  retirement, investment, insurance, estate
  (legal), tax and more
• Planning team is safest and best way to protect
  the patient

11
Estate Planning for Aging Patients and Those with
Chronic Illness

• Social Workers and Nurses are Mandated
  reporters by the Department of Health and Human
  Services Care manager must report any suspected
  incidence of financial, physical, or other abuse
  or even self neglect Not required to crack the
  case but merely to report to adult protective
  services who can evaluate the situation and
  determine if they should intervene
• Example If the clients children live at a great
  distance knowing that this obligation exists will
  give them some peace of mind as their elderly or
  infirm parents care
• Who should be named agent under financial power
  and health proxy
• Example Interview and get to know every person
  in the clients system and help the client
  process the pros and cons of options, as in
  selecting who should be a financial or health
  care agent. Can also interview named agent to
  assess if the named agent will step up to the
  plate if the need to act arises

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Care Manager as Member of the Estate Planning Team

• Aging population and prevalence of chronic
  illness
• Contributions to the estate planning process
  which a care manager can make will benefit the
  team and client in many ways
• Example Care manager is charged with creating a
  care plan and can assess the cost of that plan
  and design a plan within a budget. This data is
  an integral part of the overall financial,
  retirement and estate plan. It is part of the
  foundation of determining the clients capacity
  to gift or otherwise transfer assets
• Example Care manager can help evaluate an
  assisted living facility which might cost
  4-9,000/month versus continuing in home care
  which might be much more costly, in light of the
  clients wishes and while interfacing with the
  financial planning team to assure that the
  relevant financial and legal issues are
  coordinated. Care manager can provide written
  corroboration to support an institutional
  trustees making additional distriubtion
• Attorneys, accountants and wealth managers that
  control the process must be informed of how and
  why to increase care manager involvement

13
Care Manager Required as Part of One Trust
Companys Program

• At least one national financial institution has a
  special elder division within their trust group
• For admission to this group the client must have
  an initial assessment by a care manager
• To continue to remain within this bank division
  and receive services the client must have an
  annual review by a care manager
• This may be the model of how all plans should be
  structured and a glimpse as to the future of
  planning for those with chronic illness or
  disability, or as clients age

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Topic

• Care Managerand Chronic or Acute Illness

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Newly Diagnosed

• Care manager can assist the newly diagnosed
  patient in coping with anxiety, depression,
  disturbed sleep patterns, pain, eating
  difficulties, cognitive challenges, difficulties
  concentrating, etc.
• Example Care manager can walk the client through
  the process and try to stay ahead of the process
  the client is experience it is a process to
  educate client, assisting the client to obtain
  the help they need to address the challenges they
  face, prioritizing what needs the most attention
  this can include the range of topics the estate
  planning team many address. The care manager can
  help facilitate having the client obtain a
  durable power of attorney if feasible or if not
  assist in a guardianship proceeding. If there are
  cognitive challenges these must be addressed.
  Help establish a care plan, re-evaluate plan as
  time progresses, adjusting the care plan,
  continually monitor plan of care which is fluid

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Newly Diagnosed

• Patient must accept/address diagnosis as a
  prerequisite to dealing with disease, others, and
  eventually the planning process
• Kubler-Ross Model Denial, Anger, Bargaining,
  Depression, and Acceptance
• Example The care manager can inform the estate
  planner of the stage the client may be at to help
  identify the appropriate time to address
  additional planning Care manager can help
  client through the process to help them reach the
  point of decision making

17
But You Look So Good

• Difficult for others to understand invisible
  symptoms such as fatigue that have no external
  signs
• Example Cognitive issues, especially early
  stages of dementia may be difficult to identify
  and ascertaining whether the client is able to
  address complex issues, while a legal decision,
  may benefit from the input of the care manager
• Endeavoring to relate to fatigue that Multiple
  Sclerosis or COPD bring Yeah I was up late
  too
• Of 120 million Americans living with chronic
  illness only about 7 million use a cane or other
  assistive device most symptoms are invisible
• Example Care managers can explain the disease
  course to the planning team so that they can
  better identify how it may impact planning
• Care Managers assisting family/loved ones, and
  other advisers, to understand patients
  circumstances is an essential prerequisite for
  these other people to participate productively in
  the estate planning process

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Inform the Team

• Members of the patients estate planning team
  must understand patients current situation and
  likely disease course, and the personal/family
  environment care managers in home interviews
  and skill set are unique
• Example Care managers have the medical
  background, but also the interpersonal skills to
  translate a medical understanding of the clients
  disease course to the non-medical personnel
  comprising the estate planning team the perfect
  intermediary
• Is the caring son really caring or setting
  elderly and infirm mom up to benefit him over his
  sister
• Planning can be better tailored to meet the
  unique needs of the patient with knowledge the
  social worker is best at gathering and
  communicating

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Chronic Illness Variables Affect Planning

• Is the situation acute or chronic
• At what stage of the illness has the patient been
  diagnosed
• Example ALS is a chronic and progressive disease
  which has no cognitive impact but a substantial
  debilitating physical impact that will impede or
  prevent participation in the planning process and
  the execution of documents understanding the
  time frame in which work should be completed,
  i.e., the stage in the disease process at which
  the client is at, is vital
• What time frame does the patient reasonably have
  within which to implement planning
• Example Patients with Alzheimers disease
  survive 4-8 years after diagnosis. Diagnosed at
  65 life expectancy is about eight years.
  Diagnosed at age 90 life expectancy less than 3 ½
  years.
• What type of current support system does the
  patient have
• What will the likely future support system be for
  the patient

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Chronic Illness Variables Affect Planning
(Continued)

• Who will provide what services and assistance to
  the client
• Example Nearly 3/4ths of Alzheimers disease
  patients are cared for by their family, AD also
  has a dramatic impact on the AD patients
  caregivers and immediate family Caregivers
  life expectancies can be shortened from 4-8 years
  as a result of the stress of caregiving
• Who is appropriate to designate as a health care
  proxy in light of the chronic illness involved
• What is the current, and likely future economic
  impact, of the chronic illness on the patient and
  his or her support system
• How might the patients disease course affect the
  economic and personal support system the patient
  has
• How might all of this affect the determination of
  an investment plan, crafting trust distribution
  provisions, etc.

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Topic

• Care Managerand Competency Issues

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Competency

• Care manager can assist in
• Obtaining and interpreting letters from the
  clients neurologist or psychiatrist
• Obtaining supporting corroboration
• Example The care managers role is helping the
  client to see the correct professionals,
  physicians, neurologists, etc. If a guardianship
  procedure is called for the care manager would
  shepherd the client through the necessary
  appointments
• Interpreting the medical terminology
• Documenting clients psycho-social status and how
  it has evolved over time
• Example The care managers assessment and charts
  on the client will reflect this information.
  Periodic reports over a long time period will
  often clearly identify a trend line that can be
  invaluable in assessing the clients status and
  changes

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Competency (Continued)

• Assessing certain aspects of a clients cognitive
  functioning by administering a Folstein
  Mini-Mental State Exam (MMSE)
• Example Care manager may administer an MMSE
  along with SLOMS (St. Louis University Mental
  Status Exam) which evaluates cognitive decline in
  individuals with a higher education, and other
  tests to ascertain cognitive status
• Evaluating clients executive function (e.g.,
  organizational skills, reasoning ability, etc.)
• Example Care manager can evaluate how well the
  client functions in the environment, how well
  they manage their medication, pay bills, are they
  instrumental in other activities of daily living,
  etc. Conducting the evaluation in the home
  enables the care manager to identify issues in
  the home (e.g. piles of bills, clothes hung in
  the shower like a closet, etc.) these are
  observations an attorney or CPA meeting in the
  office will not be able to make
• Analyzing the degree of potential physical,
  financial or other harm to the client (Comment to
  ABA Model Rules of Professional Conduct, Rule
  1.14)

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Elder Financial Abuse and the Role of the Care
Manager

• Often a result of waning competency
• Mandated Reporter (see above)
• Help protect against these risks
• Example Placing a care giver in the home, or
  identifying that the care giver is not through a
  licensed agency so that there is oversight.
  Implement a plan of a bank, financial or
  accounting professional to pay bills, etc.
  Caregiver can identify solicitors calling and
  attempting to bilk the client
• Identify potential gaps in planning and care that
  may expose patient to financial or other abuse
• Care manager meeting in patients home (or
  wherever patient lives) may identify signs that a
  meeting in a lawyers office will never indicate

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Topic

• Care Managerand Estate Planning Documents

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Powers of Attorney and Health Proxies

• A power of attorney should expressly authorize
  the agent to hire a care manager and obtain a
  report consider making this mandatory once per
  year or quarter
• Health proxy could have coordinated provision
• Perhaps care managers health/personal report
  goes to health care agent and financial report to
  agent under power
• Example Court appointed guardians require this,
  perhaps other agents should similarly require
  this. The care managers billing includes this
  level of detail and may serve as an important
  means of communication
• Health care agent only receiving report may serve
  as a check and balance on the agent under the
  power
• Is a HIPAA release necessary and if so how should
  it be worded

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Power of Attorney Illustrative Language

• The fiduciary is authorized and directed to make
  payment for a mandatory independent interview by
  a licensed care manager (Evaluator) in
  Grantors home or other place of temporary or
  permanent residence, not less frequently then
  quarterly.
• The Evaluator shall be selected in the
  reasonable discretion of the agent under the
  Grantors health care proxy but shall not have
  provided other services to the Grantor or
  Grantors family.
• The Evaluator shall be required to provide a
  written summary of the Grantors general status
  addressing Evaluators observations as to
  Grantors physical and psycho-social
  circumstances, any other relevant observations
  and recommendations, to the fiduciary, within
  Fifteen (15) days of the interview.

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Trust Provisions Integrating Care Manager Input

• Revocable living trust with institutional
  co-trustee is often best protection
• Incorporate periodic review in home by
  independent care manager and issued to
  independent institutional trustee
• Report can identify abuse and other problems
• Indications of additional services or steps can
  be taken
• See earlier example of trust company requiring
  evaluations
• Few trusts include such a mechanism and those
  skilled in finance and law dont have the ability
  to address these matters
• Even institutions that have in house expertise
  the creating and use of an independent social
  worker as a check and balance can be a great
  safeguard

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Topic

• Care Managerand Income Tax Considerations

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Income Tax Considerations

• Medical expense deduction, payments for medical
  bills, including those for a care manager, have
  to be primarily to alleviate physical or mental
  defects or illnesses
• To deduct the unreimbursed cost of certain
  long-term care services if you qualify as a
  chronically ill individual.
• Taxpayers CPA should address if an ongoing plan

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Topic

• Alzheimers diseaseCase Study

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Case Study Alzheimers disease

• Those with AD generally survive 4-8 years after
  diagnosis, although some have survived as long as
  20 years
• Diagnosed at age 65 life expectancy is somewhat
  over eight years
• Diagnosed at age 90 life expectancy is less than
  3.5 years
• Clients diagnosed with AD have about half the
  life expectancy of clients without AD
• Nearly 3/4ths of Alzheimers disease clients are
  cared for by their family
• Chronic stress that comes with caring for a
  spouse with AD may shorten the life expectancy of
  the caregiver by 4 years
• Caregiver spouse or partner will require special
  consideration in their planning to address the
  personal impact of their caregiving yet most
  plans burden the caregiver with the additional
  role of agent and trustee

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Topic

• Conclusion

34
Conclusion

• Care managers can and should play a more regular
  and significant role in estate planning generally
• Estate and related planning for patients with
  chronic illness should endeavor to make a care
  manager a regular part of the patients estate
  planning team

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More Information

• See www.RV4TheCause.org for sample forms,
  PowerPoints to educate consumers/patients and
  professionals and other practice aids
• See www.caremanager.org for details on finding a
  care manager