TECHNIQUES FOR DEALING WITH CLIENTS WHO ARE NOT

QUITE INCAPACITATED

MARY K. KOFFEND
President
Accountable Aging, Inc.
8133 Mesa Drive, Ste 108
Austin, TX 78759
512.342.9800
www.accountableaging.com
Email: mary@accountableaging.com

State Bar of Texas

ADVANCED GUARDIANSHIP LAW
March 9, 2007
Houston

CHAPTER 8
 Mary Koffend
Accountable Aging, Inc.
8133 Mesa, Suite 108,
Austin, TX 78759
512.342.9800
FAX 512.342.9813

BIOGRAPHICAL INFORMATION

Mary Koffend is a specialist in eldercare services and government-funded programs. She

served elder and disabled clients for more than thirty years with the Social Security
Administration (SSA) throughout Texas, primarily at the manager or senior manager
level. Mary was ultimately responsible for Houston's largest and most complex SSA
client service operation. During her career with SSA, she received the highest
acknowledgements for her contributions from the agency. After retiring from the SSA in
1998, Mary managed the Medicaid provider services programs for the State of Texas. In
2002, Mary and her husband, Mick Koffend became the founders and principals of
Accountable Aging, an eldercare service provider.

AAI takes an approach to care management that is not typical of workers who normally
populate this field. AAI has seven (7) employees, including an advanced practice RN
(Clinical Nurse Specialist (CNS) – Gerontology), and serves the IH-35 corridor from San
Antonio to Dallas and routinely uses the skills and knowledge of other RNs and a
gerontologist.

Mary graduated with honors from the University of Texas, was a member of Mortar
Board and an Outstanding Student.

In addition to her professional expertise, Mary has met the challenge of making difficult
decisions on behalf of elder and disabled members of their own families. She brings
compassion, commitment, and a highly personal understanding of the real concerns
families must address to ensure the family's financial, residential, emotional and physical
well-being.
Techniques for Dealing with Clients Who Are Not Quite Incapacitated Chapter 8

TABLE OF CONTENTS

I. WHO ARE THESE CLIENTS? ................................................................................................................................. 1

A. Clients with serious mental health issues. ......................................................................................................... 1
B. Clients with increasing dementia....................................................................................................................... 1
C. Clients with poor judgment, or alcohol or drug issues. ..................................................................................... 1
D. Clients who are stubborn, strong-willed individuals on a disaster course......................................................... 1
E. Clients who are over or under medicated. ......................................................................................................... 1

II. WHAT CAN A CARE MANAGER DO IN THESE OR SIMILAR SITUATIONS? ............................................. 1

III. HOW DO I FIND THE RIGHT CARE MANAGER FOR MY CLIENT? ............................................................. 2

IV. IF A CARE MANAGER IS NOT AN OPTION, WHAT OTHER RESOURCES ARE AVAILABLE TO
HANDLE THESE NOT QUITE INCAPACITATED CLIENTS?......................................................................... 2
A. Bill-paying/financial management .................................................................................................................... 2
B. Therapy.............................................................................................................................................................. 2
C. Family Facilitation/Mediation ........................................................................................................................... 3
D. Medication management. .................................................................................................................................. 3
E. Personal Assistance services.............................................................................................................................. 3
F. Visiting physicians............................................................................................................................................. 3
G. Meals-on-Wheels............................................................................................................................................... 3
H. Transportation services...................................................................................................................................... 3
I. Facilities.............................................................................................................................................................. 3
J. And more ............................................................................................................................................................ 3

V. CONCLUSION ......................................................................................................................................................... 3

APPENDIX A: ELDERCARE RESOURCE LIST ................................................................................................ 4

Techniques for Dealing with Clients Who Are Not Quite Incapacitated
TECHNIQUES FOR DEALING WITH
CLIENTS WHO ARE NOT QUITE
INCAPACITATED
In the last 5 years as geriatric care managers, our
company has worked with many clients who for
various reasons have issues of capacity but are not
quite incapacitated. Some of the referrals for working
with these clients have come from attorneys. I want to
discuss techniques for dealing with these clients from
my personal perspective and also from the perspective
of what I would have wanted the attorney who worked
with my Mom with Alzheimer’s to have done.
I. Who are these clients?
I have experienced at least five categories of
clients who are not quite incapacitated.
A. Clients with serious mental health issues.
Sue, age 75, had had several commitments to the
Austin State Hospital. She has one family member
with problems of her own on the east coast. Sue has
issues with authority figures and has physical health
problems, but also is a hypochondriac, must have
medication management, is self-absorbed, and is
terrible at decision making. For all “trusted” friends
or advisors, she is known to call multiple times daily
and change her request in mid-conversation.
B. Clients with increasing dementia.
The last time you saw Bernice in your office, she
was articulate and neatly dressed. Today she is
forgetful, her lipstick smeared, and her clothes not
clean. You send a staffer to her home to take her
copies of documents. The staffer reports Bernice’s
house smells, mail, newspapers, magazines and stuff
are everywhere, and the door was unlocked when she
arrived.
C. Clients with poor judgment, or alcohol or drug
issues.
You are working with Milton to complete his will
and powers of attorney. Milton was a referral from an
old acquaintance. Milton has children living at a
distance but no close contacts except old business
colleagues. In the conversation, Milton appears to be
making illogical decisions and seems very indecisive.
He is coherent and in many ways competent, but his
decision making seems flawed. You are unable to
determine in the conversation the basis for the poor
judgment. You check for alcohol on his breath.
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D. Clients who are stubborn, strong-willed
individuals on a disaster course.
You are called by the daughter of Alma with a
request for assistance. Her mom is living alone in a
house with much needed repairs. Alma’s weight now
exceeds 300 pounds, and she can not wear shoes. She
no longer leaves home and only has a prescription for
her medication because she fell and EMS took her to
the hospital. Alma still talks to old friends and
neighbors but is unwilling to have help in her home or
move to a facility. “She can take care of herself” even
though she can’t cut her toenails and is giving her
credit card to someone to buy groceries for her.
E. Clients who are over or under medicated.
Mr. and Mrs. Johnson had several health issues
each and had planned to move into a well-respected
assisted living facility. Both were stabilized in their
medication regime. Mrs. Johnson had managed their
meds, but in the hustle and bustle of moving
preparations, Mr. Johnson took over. He did not have
a process to manage the ten meds she took and the
twelve he took and over-medicated himself. He
became lethargic and with slurred speech. He was
dizzy and confused. He refused to move to the
assisted living, and his wife and son called their
attorney.
There are many other scenarios, and if you have
been an attorney working with seniors you too can tell
stories. Hopefully you identified with some of these
examples. So what’s next?
Working with a geriatric came manager can be
the most effective technique for dealing with clients in
these situations. A geriatric care manager is an
individual or organization whose role it is to provide
umbrella oversight and problem resolution.
II. What can a care manager do in these or similar
situations?
Tackle the problems. Care managers are
problem solvers. They come in as a knowledgeable,
objective third party to ask questions and resolve
issues. They can analyze medication issues, intervene
with community resources, and help with safety
concerns. They can find good service providers for
assistance with everything from help with downsizing
to choosing good facilities or in-home caregivers.
They work with insurance carriers, government
program providers, and financial institutions to cut
through the red tape and obtain solutions to problems.
Techniques for Dealing with Clients Who Are Not Quite Incapacitated
Take Bernice, the lady with increasing
dementia. The care manager met with Bernice. The
immediate problems were safety and financial
management. The care manager arranged for a daily
caregiver to clean the house, do laundry, de-clutter the
property over time, and drive Bernice on errands. The
care manager also arranged for a bill paying service to
insure funds were handled timely and properly. The
care manager next tackled issues of good medical care
and medication management. Bernice was a very
outgoing and social person whose main friends were
now her dogs and strangers she saw walking down the
street. The care manager invited Bernice to
accompany her to some assisted living facilities to
help assess the facilities from a senior’s perspective.
Bernice willingly chose a place where she wanted to
move and the care manager worked with the family
and other resources for the move, downsizing, and the
eventual sale of the dogs and the house.
The story of Bernice is shared to illustrate the
ongoing role of a care manager. The attorney who
met with Bernice in her disheveled and confused state
needed to know that someone reputable was handling
the many issues involved. Rarely is there one issue
and one solution, so having a person whose job is to
manage the spectrum of issues is most effective.
Care managers tackle problems and know
resources. They use their special skill sets to build
relationships and to look at solutions to problems with
a uniquely creative eye. They are a single point of
contact which makes life easier for the not quite
incapacitated senior, the referral source, the family,
and the resources. Care managers are good at
prioritizing the problems and creating solutions that
build in a support system for the next problem that
will occur. Rarely are these not-quite-incapacitated
persons living in a vacuum, and care managers are
experienced at working with individuals, families, and
other interested parties with family
facilitation/mediation type skills.
III. How do I find the right care manager for my
client?
Care management as a profession is growing
as the elderly population grows and the need for this
service grows. It is valuable before a client crisis
occurs to get to know the care manager in your area.
Because care managers need to know the resources in
a given area, they are generally known by
organizations like the Alzheimer’s Association and
other disease support groups like Parkinson’s, etc.
Many of these organizations keep a list as does the
Area Agency on Aging. Some care managers
advertise with local senior guides and also in a multi-
state publication called New Lifestyles. Some are
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members of a national association of geriatric care
managers. Appendix A lists some of the ways to
locate a care manager with helpful phone numbers and
websites. If your client lives in a small town or more
rural part of Texas, care managers like other services
are less available. There are some care managers who
serve a large geographic area and some in towns like
Weatherford, Kerrville, and College Station.
However, availability in south and west Texas is more
limited.
Once you find out who the care managers are
in your area, and those of you who live in the
Metropolitan areas of Dallas-Ft.Worth, Houston,
Austin and San Antonio have many choices, what’s
next?
Care managers are often individuals with a
background in nursing or social work. A recent
national trend is multi-disciplinary firms that include a
nurse, a social worker, and a CPA or person with
financial focus. It is good to match the client with a
care manager most able to focus on the primary
issues. Interview the care managers and learn their
area of expertise to streamline your referral process.
Some attorneys have made multiple referrals and had
the client meet with them in the client’s home or the
attorney’s office. The ability to build a trusting
relationship with the client in these complex and
difficult situations is more important than in many
referrals.
Care managers are rarely funded by insurance or
nonprofit agencies at this time. They are paid
generally by the senior, the family, or a trust. If there
is a family member willing to pay, indigent clients can
still receive services. Most care manager’s charge an
hourly rate for their services. This rate varies by
expertise, service level, etc. and costs from $60 to
$150 an hour. Some services may also come at a flat
rate for the service such as bill-paying, assessments,
monitoring visits, etc.
IV. If a care manager is not an option, what other
resources are available to handle these not
quite incapacitated clients?
Listed below are areas in which the client could
use assistance and sources for that assistance.
A. Bill-paying/financial management: CPA firms,
bookkeeping services, local non-profit organizations
with volunteers such as Family Eldercare in Austin
and Sheltering Arms in Houston can provide these
services.
B. Therapy: There are licensed therapists in most
communities that have been approved by Medicare
and/or Medicaid for services. Payment can be made
for services directly to the client and also to the
client’s family.
Techniques for Dealing with Clients Who Are Not Quite Incapacitated Chapter 8

specialize in helping persons in downsizing their

C. Family Facilitation/Mediation: In addition to
use of attorneys for mediation, therapists and case
managers can provide this service. Persons need to be
excellent listeners and knowledgeable of procedures
. specialized errand persons who take and pick up
D. Medication management: Private home health
companies can use their staff to organize meds and
handle referrals. If needed, they can come to the
home daily for administration.
E. Personal Assistance services: There are licensed
services in most communities that can provide
assistance with bathing, dressing, food preparation,
laundry, errands, transportation, etc. Private
individuals can be filled for these services as long as
someone is available to manage the process including
payroll, taxes, back-ups for absences, etc. There are
some personal assistant services that do have nurses
on staff to help with additional issues.
F. Visiting physicians: House calls were non-
existent for many years, but now are available in
many cities. Services are provided by doctors or
advanced practice nurses. Some of the providers are
part of a group, some are part of the American
Academy of Home Care Physicians, and some are
known only in the community.
worldly goods and supervising the moving and
arranging the new home so all is set up when the
person comes home. There are beauticians and
manicurists that come to the home. There are
laundry and cleaning, buy groceries, mail packages or
whatever is needed.
V. Conclusion
There is no cookie cutter solution for the client
who is not quite incapacitated. Having a care
manager to resolve issues and be the single point of
contact is the best option for the client and the
attorney. When that is not available, relying on a
strong family member, pastoral care leader from
church, longtime but younger friend who is the power
of attorney is next best. Use of some of the many
resources listed also can serve to prevent a crisis and
buy some time until some of the issues such as
medication management placement may be addressed.
The care of the not quite incapacitated person is
always complex, problematic, and ever changing. It is
time consuming, exhausting, requires creativity, and
rarely receives acknowledgement. Good luck—

G. Meals-on-Wheels: This is an excellent

community resource which provides one nutritious
meal per day for a donation as well as a concerned
volunteer who provides personal contact.

H. Transportation services: Taking away driving

privileges is a problem even when substitute services
are available and a nightmare if there is no substitute.
Personal Assistance Services can provide
transportation. Some taxi services provide services by
appointment. Most local transit authorities have some
program, and there are often volunteer caregiving
services for routine doctor’s visits, grocery store trips,
etc.

I. Facilities: There are many types of facilities.

Independent, assisted, and nursing homes provide a
continuum of care. There are three-bed unlicensed
personal care homes, licensed personal care homes,
board and care homes, Section 8 housing. Here it is
very important to match the needs of the client with
the facility. Clients with behavior issues who are not
incapacitated are many times difficult to place and
require frequent intervention and assistance.

J. And more: As the elderly population grows, more

businesses are seeing the needs of this population and
rising to meet the needs. There are companies that
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Techniques for Dealing with Clients Who Are Not Quite Incapacitated Chapter 8

Name Topics Web Site Phone Number

Medicare Overview of Medicare www.medicare.gov 800-MEDICARE
Current rates
Nursing Home Compare
Supplier and Physician Directory
Medigap Compare
Medicare Part D Prescription info and
enrollment
Publications
Home Health Compare

American Association of Excellent articles http://www.aahsa.org/

Homes and Services Directory of Facilities
for the Aging Not for Profit organizations

Social Security Publications and Forms www.ssa.gov

Links to disease associations www.firstgov.gov
FAQ's
Medicare 800-772-1213
Medicaid
Benefits
Info in multiple languages

Administration on Eldercare national resources www.eldercare.gov/

Aging and Statistics
Eldercare Locator Local Area Agencies on Aging
800-677-1116

The American Society on Constituent Groups-Business Forum on

Aging Aging www.asaging.org
Great articles
Legislative Issues

New Lifestyles Commercial publication of resources www.newlifestyles.com/

in many areas - booklets and online info

National Association of Listing of affiliated members www.caremanager.org

Professional Geriatric Standards of Practice
Information and articles about the
Care Managers profession 800-869-9549

Directory of home care physicians,

American Academy of Home assistants www.aahcp.org
Care Physicians and nurse practitioners by state