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Sunday, June 12, 2011

Care Management & Guardianship Business Seminar

When I started Bridge Builders, Ltd. over eight years ago I had no idea it would turn out to be such an adventure. I started with a business partner and we thought we had the tiger-by-the-tail. We believed everything we were told [actually by others who had no experience in this type of business] that all we had to do was hang out a "shingle" and we would have more business than we knew what to do with. NOT! Did we do any due diligence? No. We were starry-eyed and optimistic. I think that I can comfortably say that we made just about every mistake that could be made when starting and building this type of business. Some "mistakes" weren't really mistakes, we had to try ideas to see if they would work. Some did and some didn't. The partnership didn't last, which was traumatic. With hard work and a lot of determination I turned my business into a well-respected business, not only locally but statewide.
Recently, I was nominated for the Washington State Small Business Person of the Year Award for 2011 and was one of twenty-six finalists. Most of the other businesses were far larger and more established than my tiny business. I feel just a bit smug "rubbing elbows" with these "big leaguers."
I want to share what I've learned with others who want to start or who are struggling with similar Care Management and/or Guardianship businesses. I hope to help others avoid some of the pitfalls that I experienced. The industry of Care Management is really a very new concept and often misunderstood. A guardian is really just a "glorified" care manager as the only difference is that the guardian has decision-making ability [and a lot more paperwork!]. Lately, the media wants to make guardians villians and I'm afraid that care managers might come under fire as well. We all need to have high ethical standards in our business practices and stand up for our industry when it comes under attack by media who are only looking for articles that shock. In order to do this we care managers and guardians need to develop a close network with each other. I literally get calls from all over the country from people who have heard of Bridge Builders, Ltd and want to know if there is something similar where they live. It makes me and my referral look good if I can say "yes" and the care manager or guardian that I refer them to does a great job.
To this end I am sponsoring a seminar about this topic in August 2011. It is open to all who are interested and will provide difficult-to-find forms and "secrets" that the agencies we deal with don't volunteer and examples of how to fill out the forms; where to find the "go-to" people in your area; example business forms and where to find free business forms... and more!
Date: Tuesday, August 2, 2011
Place: Kitsap Conference Center, Bremerton, WA
Time: 8:00 AM to 5:00 PM
Cost: $250.00 (Breakfast and Lunch included)
***Early Bird Special of $225.00 of paid by June 30, 2011***
If you would like a brochure, please email and put "Business Seminar" in the subject line. You may also call us at (360) 683-8334.
This seminar has been approved for continuing education credits for Certified Professional Guardians in Washington State and I am happy to provide whatever documentation is needed for other professional organizations.

Sunday, January 30, 2011

Care Manager vs. Caregiver

I am frequently asked if my agency is a caregiving agency. I explain that we do Care Management, not Caregiving. However, we work closely with caregivers to ensure our clients receive appropriate care. Both a Care Manager AND Caregivers are important in providing ongoing care AND planning for future needs.

Caregivers are "in the trenches" and take care of the day-to-day needs of clients. Good caregivers are worth their weight in gold and don't be paid nearly enough for the work that they do. They will clean house, plan and cook meals, remind clients to take medications, run errands, buy groceries, do laundry, assist clients with shower and toileting, and deal with any number of other issues and crop up.

A Care Manager, depending on their specialty, can plan for the future. He/she can assist with getting long-term care insurance activited (some need close to an act of congress to get though the confusing web of documentation), assess the financial situation of the client and plan for the future such as applying for veteran's benefits, Medicaid or other assistance clients may need and knows what other resources are available within the community. A good Care Manager will advocate for the client's care preferences even though what the client's wishes may not seem to be in their own best interests. A good Care Manager knows their clients and can educate the Caregivers on the best way to get around resistance or behavioral problems. A good Care Manager knows what questions to ask medical personnel and/or the client in order to optimalize medical care. A good Care Manage can coordinate care given by caregivers, family and friends in order to ensure nothing falls through the cracks.

Even if you don't need the on-going services of a Care Manager, an periodic consultation can be invaluable to find out if you, as family or friend, are missing something.

To find a Care Manager in your area look up

Sunday, January 2, 2011

Recognizing Dementia Behaviors 1

The behaviors that are exhibited by someone with Dementia can be very confusing to family and friends. I'm going to tell several stories that demonstrate some of these behaviors with suggestions of how to manage them. I've changed the names and some features to help keep anonymity.

Adjusting to Living Away from a Spouse
After caring for his wife of 60 years for as long as he could, Joe had to finally put his wife, Cloe, into a residential facility. He never dreamed he would have to do this but his own health was declining and he just couldn't take care of her anymore. He felt incredibly guilty to "have to do this to her." On top of his guilt he had to contend with Cloe begging him to take her home every time he visited. She would vacillate between tearfulness to anger. Poor Joe was devastated. When I was at the facility I would make a point of finding her to see how she was adjusting when Joe wasn't there. She would be visiting with a caregiver, reading or just contentedly watching other activities. I made a point of explaining to Joe about "associative memory" and would tell him how I found Cloe behaving so that he didn't think she was pining away for him all of the time. Joe finally made the decision that he could no longer visit because Cloe's behavior was too upsetting for him.

Why does this happen? Memories often become spotty as dementia progresses but I have found that "associative memory" sometimes lasts a long time. Something the person with dementia sees triggers a particular memory and they react to it. The reaction has no reality to it and when the memory trigger goes away, typically the person will quickly calm down again. The memory trigger will often lessen and go away over time but it can take months. Here is a story that is a more amusing example of this:

A client of mine, Mary, was a smoker who lived in assisted living. Usually, as some point during my visits she would ask me to walk outside with her so that she could have a smoke, which I would do. This went on for several years. Then Mary's dementia got to the point that I knew I needed to move her to a dementia facility but I had a problem. She smoked. No dementia facility would take a smoker. While I understood the inherent liability issue, it was a real dilemma for me. Then, Mary got very sick. So sick that she ended up spending several days in the hospital. Low and behold she forgot that she smoked! I quickly got her moved into the dementia facility and told the staff that if she brought up smoking they should say something like, "I though you gave up smoking years ago." For months, every time I visited Mary she would at some point tell me that she was dying for a cigarette. I would say something about her giving up smoking and was able to redirect her to other topics. I talked to the staff who said that she never brought it up around any of them. I was that memory trigger. It look a good nine months for that memory to fade away.

When a Spouse dies.
I was contacted by a family who's grandfather had recently died. Visiting grandma was perplexing to the family because grandma would talk as though grandpa was still alive. When they would remind grandma that her husband had died, grandma would experience grief as though she had heard it the first time. The family didn't know how to best handle this situation.

When a person has dementia with memory problems, short-term memory is the first to go. Severe short-term memory can mean that hearing sometime distressing is just like hearing it the first time, each time. The best way to address this is to avoid reminding the person, in this case grandma, that grandpa has died. If grandma brings up the fact that grandpa isn't there have a simple explanation ready such as he went to the store and then redirect the conversation to something else. This may take some trial-and-error to find what works but it's far more compassionate than making your loved one experience the shock over and over.

Sunday, December 12, 2010


I apologize for so much time passing between blogs. Between the Thanksgiving holiday, which was complicated by a freak snowstorm, first-of-the-month billings and an exciting event that also required a flurry of time-consuming activity. I just haven't gotten anything written.

My exciting news, though, is that I have been nominated for the Small Business Association's Small Business Person of the Year Award. I am so excited! Of course, these things are never just handed out without some work on the nominee's part. I spent a good portion of last weekend, Monday, Tuesday and Wednesday getting a packet of information together. It had to be at the Seattle SBA office by Friday, December 10th. Evidently, 35 people statewide have been nominated. I was told that I will find out if I've won in early March 2011. If I win for Washington State, I will be invited to the SBA national celebration in Washington, DC in May. Just being nominated is a huge honor!

Building Bridge Builders, Ltd. into a viable business has been the hardest job I have ever had and it has been worth every minute. The services that we provide are so needed and there will be an increasing demand as the baby boomers age. It is a challenging business, though, and it takes a special person with a passion not only to serve our unique clientele but also to have the stamina to hang tough as this type of business is difficult to grow. While there are huge emotional payoffs when successfully helping clients to have an improved quality of life, the down side is that there are those who try to discredit this type of business. A business owner needs the fortitude to withstand those attacks, even though they might be infrequent. If you are considering starting a similar business, here are some suggestions:
  1. Consult a business advisor - The SBA offers assistance for free. The advisor can assist you with the details of the business end because you could have the best idea in the world but if you don't pay attention to the business end of things, you will fail.
  2. Don't believe people who say that all you need to do is hang out a shingle and you'll be swamped with work. This business needs time to establish credibility just like any other business. Bridge Builders, Ltd. is a great idea but we can have quite a challenge convincing prospective clients.
  3. Realize that you need to develop yourself as an expert in the field and this takes time. I am at the end of eight years and only this year have I been receiving comments that indicate that my staff and I are considered experts. Eight years may seem like a long time if you're just starting but, believe me, the years fly by.
  4. Watch your cash flow like a hawk. I only started tracking our cash flow on a weekly basis about two years ago. I wish I had started this at the beginning! I can now look back a couple of years to see if the cash flow is typical, better or worse. Also, if the cash flow is less than my target amount for the month, I tell my staff that they need to focus on tasks that generate billable time and/or it an employee would like to work a little less, now is the time. This can really made a difference at the end of the month.
  5. Be careful with credit. Early on I was seduced by easy credit. When you start a business it seems like everyone wants to give you credit. While most businesses require having a certain amount of debt because cash flow isn't consistent, use credit cautiously and wisely. My brother is growing a business without debt, which is great and I am very proud of him, but it really slows down the growth doing it that way.
  6. Charge what you are worth. That is a very difficult thing to do, especially in a business that provides services to people. But if you don't value your time, your client's or prospective clients won't either. Over the years, we periodically got calls from prospective clients who wanted something for nothing. After spending copious hours over the years trying to convince these people that we are worth what we charge, I just don't bother wasting my time anymore. If someone calls and, after discussing services and rates, says we're to expensive, I'm happy to give them some numbers where they might be able to piece the services together themselves. Sometimes these clients resurface later and sometimes they don't. I don't worry about it anymore.
  7. Hire qualified staff. My business advisor told me once that the staff of an entrepreneurial business need to be pseudo-entrepreneurs. These are people with the experience you need who are willing to work for peanuts because they believe in what you are doing. It will take longer finding these people but it is well worth the wait. My bookkeeper, who has been with me from almost the first, was looking for a part-time job with some challenge that would be flexible and fun. She hasn't been disappointed and I have been the blessed with her knowledge over the years. All of my staff worked uncomplaining for years without raises because there was no money for raises. How did I find these people? Sometimes by networking and sometimes they would hear about my business and come to me. I've learned to be choosy, though. It pays off in the long run.

You need to realize that this is a business that you will be in for the long run. I've had people call me saying that they wanted to start this type of business, run it for ten years and then sell it at a profit. They think that the need is so great that they will be swamped with work out of the starting gate. When I explain that it isn't so easy and why, I don't hear from them again. You need to understand that this business is about serving people. People are not a commodity to be sold at whim. If you are named as Power of Attorney for clients, it is expensive for the clients to change this. Guardianships need to go through expensive court hearings. Your client depend on your to be there for them. That's a heavy responsibility for some people. I find it to be an honor.

Sunday, November 14, 2010

Tips for working the Long-Term Care "System" - Federal Government

Trying to help a friend or loved one navigate through the elder care system can be daunting. Here are some tips so that you can avoid unnecessary aggravation:

Social Security: Did you know that Social Security doesn't recognize Power of Attorney documents? Well, they don't. It has something to do with Social Security being Federal and Powers of Attorney being State. So, if you need to do business with Social Security on behalf of someone else or manage someone's Social Security money. You either have to be their court appointed guardian or you need to apply to become the loved one's Representative Payee. You can find the application online if you look really, really hard. You can also go into the Social Security office and request an application.
  • If you go the the Social Security office do not go at the beginning or end of the month or the beginning of the week. The office is crazy busy during those times. Pick early afternoon on a Wednesday or Thursday.
  • When filling out the Representative Payee application you will need to include the name, address and phone number of your loved one's doctor. It doesn't say this in the instructions and there is no place on the application for it but if you don't have it the application will be handed back to you.
  • I have occasionally run into a situation where the doctor doesn't want to fill out the form. I have found that writing a letter explaining why I need to manage the client's [loved one's] money and why Power of Attorney isn't adequate in a very humble way seems to help.
  • When you receive the letter appointing your Representative Payee, keep it in a safe place because you will need to produce it at the bank and other places from time to time.

Veteran's Administration: They don't recognize a Power of Attorney, either. If your loved one cannot sign a release of information form allowing you to be their advocate, you have no choice but to initiate a petition to become the loved one's guardian. If you become the court appointed guardian, always keep a copy of your Letters of Guardianship handy so you can wave them in the face of the person who quips, "We only deal with the veteran, not the spouse [family, friend, etc.]. In this day and age of HIPAA Laws, everyone is afraid to say ANYTHING without the appropriate legal document.

  • Try to always have an appointment. The walk-in clinic is a real nightmare. If you can't avoid it, plan on being there an entire day.
  • If your loved one needs to apply for benefits for the first time, contact the local Veteran's center (VFW, DAV, etc.) to learn the best way to submit the application so that it will be processed as quickly as is reasonably possible.
  • If your loved one is a low-income non-service connected veteran, plan on the application taking a year. If they need financial assistance before then, get them signed up with your State's version of Medicaid.
  • You can fill out an application online at but please remember that you still need to print it out, have the veteran sign it and send it in even though you can electronically submit the application.
  • DON'T forget to send the required documentation. Can't find the DD-214? (Discharge papers) You can send to a certified copy on the web site.
  • If you send a copy of the DD-214, you will get a letter stating that you need to send the original or a certified copy withing a certain length of time. Writing them to tell them when you expect to be able to send it will keep the application "live."
  • Give the application a couple months before checking on the status but by all means check. Sometimes these applications seem to fall into a black hole or something. Be especially diligent if the veteran was just in the reserves. We have had more problems with applications going missing for the veterans who were in the reserves as opposed to active duty.
  • Once the veteran is approved for benefits, send updated medical records, bank statements and medical bills (paid) to the VA on a regular basis. You might want to mark your calendar for every three months or so.

If the process seems overwhelming to you, please get help with this. Call your local Area Agency of Aging to find out where you can go to get assistance. While it takes longer, the benefits from the Veteran's Administration come with fewer "strings" than the State Medicaid program.

Sunday, November 7, 2010

Amazing Will to Live - Update 11/7/2010

Amy has started eating, and keeping what she eats down. (She had been having a lot of nausea) Last Monday, she slept through the entire night for the first time since her surgery. She is now joking with the caregivers and recognizing the staff at the facility. She still has a fair amount of agitation but the caregivers and staff are trying to deal with it using exercise instead of medication. The medication makes her sleep during the day and then she is up all night. She is no longer on the oxygen. She actually gave herself a black eye fighting with the tubing! But her oxygen saturation is O.K. now. WOW!

The only real casualty was a cell phone that took a swim in the toilet. Those cell phones just don't swim well at all!

I'm looking forward to taking her to her appointment with the surgeon at the end of the month. I'm sure the surgeon will be amazed, too!

This is what Amy wanted, a chance to live pain free. She wasn't afraid to fight to beat the odds, even with severe dementia. She has taught me so much!

Sunday, October 31, 2010

Amazing Will to Live - Update 10/31/2010

"Amy" is still plugging along. Until this past week she hadn't been eating enough to keep a fly healthy but she is now starting to eat more at meals. [She has never been a big eater and doesn't have much in the way of "reserves", meaning fat.] She has been walking, joking with her caregivers and is recognizing the staff again. Is she out of the woods? Probably not. But she is a daily miracle!