Case Study 1: Grandma Theresa

Grandma Theresa is an 86-year-old mother of two children who are now both married and living in a

different state with their families. They come home to visit their mother at least twice a year. Over the

last 2 decades, Grandma Theresa has been suffering from chronic diseases and has lost a lot of weight.

She has become fragile and has been living in a skilled nursing facility/assisted living for more than 5

years now. She is mentally unstable and cannot remember many things relating to herself and her

children. She has been suffering from diabetes and cardiopulmonary disease for the past several years.

Grandma Theresa’s children have informed the care team that their mother has always been afraid of

needles and has always rejected injections. As a result, her children stressed that their mother’s wishes

be respected.

Grandma Theresa was also recently evaluated for Alzheimer’s and other memory-related diseases and

has shown positive signs of Alzheimer’s. Recently, a case manager, Mrs. Jones, was assigned to Grandma

Theresa from the Department of Health and Human Services. Mrs. Jones has been very helpful to

Grandma Theresa in matters relating to her medical, social, cultural, and psychological care and well-

being. With the help of Mrs. Jones, Grandma Theresa is up-to-date with all her medications, treatments,

counselling, and other services she is entitled to have. A few days ago, Grandma Theresa’s children came

to visit her and were surprised by the tremendous improvement she has made. Luckily for Grandma

Theresa, she has Medicare Parts A, B, C, and D, and had saved some money over the years for her

retirement and long-term care. Those funds and benefits were used to pay for the expenses Grandma

Theresa incurred at the hospital.

Gerontology and Geriatrics

Although both gerontology and geriatrics deal with seniors or the elderly population, the two terms are

actually different. Caring for the elderly population is an integral part of the health care continuum. The

term elderly is mostly applied to individuals 65 years and older, and caring for this segment of the

population falls under geriatrics and gerontology. Gerontology deals with the process of aging of the

individual and how aging impacts his or her social, cultural, psychological, cognitive, and biological

aspects. Therefore, care for an elderly person must be given a multidisciplinary approach to address all

of the socio-cultural, biological, and cognitive aspects of the patient. Geriatrics, on the other hand, deals

with the treatment of medical conditions associated with the elderly. Grandma Theresa needed holistic

care. That means, she needed medical care as well as care addressing her social, cultural, psychological,

and cognitive needs.

Because Grandma Theresa cannot do many things for herself, she needs a trained and qualified case

manager to help manage her affairs. This is where Mrs. Jones comes in as a case manager. She makes

sure Grandma Theresa receives all of her health care services and has access to the resources other

benefits available to her that would improve her quality of life.

The elderly population need care, especially that relating to hospitals, clinics, home health, assisted

living homes, skilled nursing homes, continuing care communities, independent living facilities, adult day

care, or hospice. Although elderly care is very expensive, Grandma Theresa had most of her health care

expenses covered by Medicare Parts A, B, C, D, and her life savings.

Rationale of Case Management in Gerontology

The role of a case manager cannot be underestimated in geriatric care. From the case study, we see that

Grandma Theresa definitely needed assistance for her quality of care to improve. Aside from the

medical care she receives from the nursing facility, she needed help with her social, psychological, and

emotional care to meet her short- and long-term needs. She is no longer coherent and has been

undergoing psychological evaluations because of her mental status. Her family were concerned about

her safety because she is frail and may hurt herself or others. Grandma Theresa is not in her right frame

of mind to make reliable decisions regarding her care or her assets. She definitely needed a case

manager.

Case Management and Case Development

The Psychology School Guide (2018) refers to case management as a process of planning and

coordinating care to meet long-term and short-term needs of clients. Meeting these needs may help

ensure the quality of life and independence of the clients. The Case Management Society of America

(CMSA) (2017) defines case management as a collaborative process of assessing, planning, facilitating,

coordinating, evaluating, and advocating for options and services to meet the needs of the individual

and his or her family. The case management process helps clients gain access to resources that may help

promote their health with cost-effective outcomes. This cost-effective outcomes and other benefits

could only be accessed with the help of an experienced case manager.

Mrs. Jones had to work with Grandma Theresa and other internal and external stakeholders of the

facility. The goal of this collaboration is to promote quality care and cost-effective outcomes. The

internal stakeholders included members of the caregiving staff, including psychologist, therapist, and

clinicians. The external stakeholders may include all parties outside of the facility, such as state agencies

dealing with adult abuse, social services agencies, insurance companies, and so on. Mrs. Jones could tap

into her training to help Grandma Theresa by planning and coordinating care along with other members

of the caregiving team.

Who are geriatric case managers?

Geriatric case managers (GCMs) are professionals working with the elderly as social workers,

gerontologists, counselors, or other professionals who are trained in the discipline of human services

and gerontology. In this case study, Mrs. Jones was Grandma Theresa’s case manager.

Training and Qualifications

Mrs. Jones must have undergone training leading to a graduate degree in social work, psychology,

gerontology, or nursing and has been certified or licensed as a geriatric case manager. With her training,

Mrs. Jones is able to work with the other members of the caregiving team to help create a safe living

environment for Grandma Theresa. Together, the caregiving community will assess and evaluate

Grandma Theresa’s needs in terms of emotional and family support, community resources, financial

circumstances, and her physical and mental health. After the initial assessment and evaluation,

Grandma Theresa’s care plan is developed to address all of her medical and geriatric needs. Moving

forward, Mrs. Jones will continue to re-evaluate the plan based on her subsequent needs.

Case management development could be done formally or informally. It is good to know that there are

formal and informal case managers. The difference between the two is that the formal case manager,

like Mrs. Jones, is well-trained and had a professional certification or license to function in her capacity.

Specific requirements for geriatric managers may consist of a bachelor’s degree in gerontology or

related discipline, taking an internship, and passing the board certification examination. The Psychology

School Guide (2018) gives a detailed guide to candidates interested in a career in case management. The

link to the guide is available in the Reference section below.

The informal case manager may be a community volunteer who may not have the formal training but

has the basic knowledge of community resources and how to access those resources.

Benefits of Geriatric Case Managers

Geriatric case managers are part of an interdisciplinary caregiving team, having a better understanding

of the needs of their clients and their families and the steps to take to support them (Charles, Bremault-

Philips, Parmar, Johnson, & Sacrey, 2017). There are cases in which GCMs have deployed innovative

ways to help their clients by practicing a specific model of care known as the GCM model (Newquist,

2011). The GCM model is a client-centered, face-to-face model between the client and the case

manager. There are many benefits associated with having a geriatric case manager. Some of these

benefits include the following:

 Case managers have access to information of how a client may access both public and private

resources. This information may help the clients make use of entitled benefits.

 The use of case managers may help to save cost for both family members and the clients

themselves. Family members may take off from work, which may result in lost wages. The use of

a case manager may help save costs.

 Case managers may help monitor their client’s medical and social services, making sure the

client gets the best out of his or her care.

 Case managers may help the client make better financial decisions.

 Case managers may act as patient advocates, thus safeguarding their clients from unfair

treatments and abuses.

 Case managers may help educate family members about benefits and other cost-saving

measures.

 Geriatric case managers help their clients get the most out of their insurance benefits by

advocating for them and fighting denial of benefits by insurance companies.

 Case managers help to promote the patient’s self-determination, informed consent, shared

decision making, and autonomy.

 GCMs may help to educate other providers and the members of the collaborative care team in

recognizing the strengths, needs, and goals of patients.

Guiding Principles of Geriatric Case Managers

The guiding principles in geriatric case management are not different from the four general guiding

principles in health care proposed by Beauchamp and Childress (2013). These guidelines help providers

make decisions when faced with ethical situations. These ethical principles are autonomy, beneficence,

non-maleficence, justice, and fidelity, as follows:

1. Autonomy: This refers to the right of the patient to retain control over his or her body and partake

in decisions relating to his or her care. Providers may suggest treatments but may not force any

decision on the patient.

 In this case study, because Grandma Theresa is incoherent and cannot make decisions on

her own, her children are consulted before any action is taken regarding their mother’s

treatment, especially when they are considered the Medical Power of Attorney for their

mother. An addition to that group is Mrs. Jones, her case manager. The goal in this case is to

seek the patient’s interest in all matters relating to her care.

2. Beneficence: This principle states that providers must “do good” with regard to the treatment of the

patient. That is, treatment given to patients must be beneficial to them rather than having harmful

outcomes.

 This is also another area in which Mrs. Jones becomes very relevant as client advocate. With

the help of Mrs. Jones and the professionalism of the care team, Grandma Theresa is

assured of a treatment that is client-centered and would be beneficial for her. There is no

harm from the provider to the clients, and the general adage is what is good for one client

may not be good for another client.

3. Non-maleficence: Providers have the ethical principle to not do any harm to their clients.

 Any decision or treatment by practitioners should not cause harm to Grandma Theresa,

even if it is made for her benefit.

4. Justice: This principle stresses that an element of fairness should be established in all treatment

decision made on behalf of the patient.

 Grandma Theresa’s providers should uphold applicable laws when making their decisions.

5. Fidelity: This fifth principle is very critical for case managers. Case managers must follow through

with and keep promises made to clients. Fidelity plays a very important role in relational ethics.

Pollard (2015) summed up these ethical principles in his concept of relational ethics. He emphasized

that the central tenets of relational ethics include mutual respect, engagement, embodied

knowledge, environment, and uncertainty. Pollard insisted that the most important of these ethical

principles is mutual respect, followed closely by engagement. GCMs, providers, and other caregivers

must respect their clients and remain engaged with them at all times to ensure improvement in

quality of life.

Conclusion

It is extremely important that we care for our seniors who are plagued with chronic diseases, fragile

health, and mental instability. They are among the most vulnerable populations in our communities

today. We have learned from the lesson, especially with the case of Grandma Theresa, that our elderly

population needs medical, social, and emotional help. Without the help from the nursing facility staff,

case managers, and family members, it would be difficult for Grandma Theresa to have an improved

quality of life. There have been reports and cases of adult abuses, even in some of these nursing and

long-term care facilities. A prudent case manager may be very helpful to defend vulnerable clients such

as Grandma Theresa.

References

Beauchamp, T. L., & Childress, J., F. (2013). Principles of bioethics. Retrieved from

http://www.jblearning.com/samples/0763760633/60632_CH02.pdf

Case Management Society of America (CMSA). (2017). What is a case manager? Retrieved from

http://www.cmsa.org/who-we-are/what-is-a-case-manager/

Charles, L., Bremault-Phillips, S., Parmar, J., Johnson, M., & Sacrey, L. (2017). Understanding how to

support family caregivers of seniors with complex needs. Canadian Geriatrics Journal, 20(2), 75–

84. Doi:10.5770/cgj.20.252

Newquist, D. (2011). Do geriatric care management interventions make a difference? Prove it. Retrieved

from http://www.aginglifecarejournal.org/do-geriatric-care-management-interventions-make-a-

difference-prove-it/

Pollard, C. L. (2015). What is the right thing to do? Use of relational ethic framework to guide clinical

decision-making. Journal of Caring Sciences, 8(2), 362–358.

Psychology School Guide. (2018). Case manager careers. Retrieved from

Case Manager Careers