Balancing Care and Conflict: Expert Tips on Managing Family Dynamics with Cheryl Acres
Onboarding new clients as a care manager often means stepping into the middle of complex family dynamics. Whether it’s differing opinions on care plans or long-standing family tensions, your role is to remain neutral and focused on the client’s well-being.
In this episode of CareCraft, Cheryl Acres shares her 46+ years of experience to provide actionable steps for navigating these challenging situations while onboarding new clients.
Steps to Onboard New Clients Effectively
Maintain Objectivity: It's crucial to make recommendations based on your professional assessments rather than getting swayed by family opinions. Keeping a clear focus on the client's needs helps ensure that your decisions are in their best interest, even when family members may have conflicting views.
Set Clear Expectations from the Start: Begin by outlining what your services entail, your approach to care management, and the roles and responsibilities of both your team and the client. This transparency helps manage expectations and prevents misunderstandings down the line.
Comprehensive Client Assessment & Care Planning: Conduct a thorough assessment to understand the client’s needs, preferences, and goals. This includes gathering medical history, lifestyle preferences, and understanding family dynamics. Develop a care plan that is tailored to the client’s unique needs based on assessment findings.
Engage Referral Sources: Keep your referral sources in the loop during the onboarding process. Share relevant updates and involve them in the initial stages of care planning. This not only strengthens your partnership but also reassures the client that they are receiving comprehensive care.
Red Flags to Look for in Client Onboarding
Not every client will be the right fit for your services, and recognizing this early can save time, resources, and potential conflict. Here are some warning signs to watch for:
Unrealistic Expectations: Be wary of clients who have expectations that are beyond the scope of your services or resources. Address these early by setting clear boundaries and explaining what services can and cannot provide.
Resistance to Collaboration: A client who is unwilling to collaborate on the care plan or disregards professional advice may not be a good fit. Successful care management requires a partnership where both parties are invested in the process.
Frequent Disagreements: If disagreements arise frequently during the onboarding process, it may be a sign of deeper compatibility issues. These conflicts can lead to dissatisfaction and a strained relationship in the long term.
Terminating a Contract When It’s Not a Good Fit
When a client relationship isn’t working, it’s important to handle the situation professionally and with empathy. Here’s how to approach it:
Document Concerns: Keep a record of any issues that arise. This documentation can be useful if you need to justify the termination of the contract.
Have an Honest Conversation: Address your concerns directly with the client or their family member. Explain why the partnership may not be the best fit and offer alternatives, such as referring them to another care manager or service provider.
Provide a Graceful Exit: Terminate the contract in a way that minimizes disruption for the client. Offer assistance in transitioning to another provider and ensure that all loose ends are tied up before sending the notice of termination.
Onboarding new clients is more than just a procedural task—it’s an opportunity to set the tone for a successful and collaborative relationship. By following these steps, recognizing potential red flags, and maintaining strong ties with referral sources, you can build a thriving practice that serves both your clients and your community.
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Transcript
[00:00:04] Ariadne: Welcome to the CareCraft podcast. I'm very excited to have today as our guest, Cheryl Acres. She's the founder and president of Comprehensive Care Management in Dallas, Fort Worth. She's been an RN for over 46 years with experience in acute hospitals and home health and she became a certified case manager in 1998. She has been a member of the Case Management Society of America and has served as the president of the Dallas Fort Worth chapter as well as contributing to multiple committees. So thank you so much for joining us today, Cheryl. How are you doing?
[00:00:38] Cheryl: I'm well. Thank you. How are you?
[00:00:41] Ariadne: I'm doing great. I'm super excited. Today we're going to be talking about how to effectively onboard new clients. And I know in your 20 plus years of experience, you've onboarded a lot of new clients in your practice. Can you walk us through a little bit of what your typical onboarding processes?
[00:01:01] Cheryl: Well, it usually starts with a phone call. I try to do a free consultation to see if it is really something I can do because I've received calls and I, somebody has said, Oh, I need a new will. Well, no, you need an attorney for that. And that's not me.
So I try to figure out, How did they hear about me? And where did the referral actually come from? Because sometimes that gives me some baseline information.
And then I try to understand what their needs and concerns are, because it's wide ranging. Some people are being very proactive and then some people are calling me from a hospital room and saying, I've, we've just been told mom has to be discharged and we don't know what to do.
I start with the basics, what's the problem, what the concerns are and try to figure out if it is a good fit.
But then I also try to explain what I do because as a, as what I'm referred to as a geriatric care manager, people often have no clue. You know, I worked in the insurance industry for nine years.
And so when I was a case manager working with the insurance world, people say, well, well, you're just trying to deny my benefits. I'm like, no, I'm trying to actually get you extra coverage because there's a lot of stuff going on. Do you know where your insurance is and what it does? And there'd be dead silence.
So again, going back to the building the foundation of understanding what their needs are, but also explaining what I do and how I can help them. And then also explain that Medicare does not pay for my services. I'm a private pay practitioner. So we, when we do come to an agreement that, okay, yes, we need to start with a full, basically an evaluation, which is your foundation assessment to understand all the moving pieces and parts.
[00:02:47] Ariadne: Is that like a standard evaluation that you use across the board or you kind of tailor it to the clients, whether, you know, it's more of a crisis situation or more of a planning situation?
[00:03:00] Cheryl: Well, if it's a crisis situation when the patient's in the hospital, I'm often meeting the person at the hospital or the family at the hospital.
So I kind of do a very abbreviated, you know, what's going on. Hopefully I can even talk to the social worker or the, case manager that's doing the discharge planning at the hospital because I was a hospital case manager as well when I was starting my business. So I understand all the nuances there and all the discharge planning processes.
So it's a very much a, okay, now what do we do? What are our options and how do we get there? And then once they come out, we've got some space to be able to go "okay, now we really need to look at the really big picture". So, when I do that full assessment, I do a written report, which is usually very extensive.
What's the medical history of the person who are the helpers, you know, because the helpers could be the family. It could be a neighbor. It could be a care agency. It could be a home health. I mean, it's all maybe all of the above and try to figure out in that evaluation. I do them in their home because I need to see that person where they are. See what's working and what's not working. And, you know, I'm sure everybody's heard the expression. You can't see the forest for the tree. So when you've been living in a, in a home setting, whatever that is, a condo, a house, whatever, you're used to seeing the same thing all the time, and you don't necessarily recognize that the throw rug with the thick pile is a tripping risk.
So, I do a full home evaluation too. I look for smoke detectors, carbon monoxide detectors, fire extinguishers, you know, Where are the locks on the gates? Oh, the locks are on the outside of the gates. Oh, so a thief can come along with a bolt cutter, cut the lock off and get in the yard. I just had a 98 year old client. Somebody kicked in their back door and thank goodness her grandson was there and he popped the guy in his nose and he took off, but they, they had a a not up to code door.
It was a hollow core door instead of a solid door that was, you going out to the garage. And yeah, they smashed it. I, I about flipped out when I'm like, what, what, what? Oh my, because she's also lives with her deaf daughter and the grandson just happened to be there in town visiting. He came over to their house to do the laundry.
The timing was impeccable and thankfully nobody got hurt. Nobody, nothing got stolen, but it was, it was very scary for everybody.
Part of that assessment I do a full medication review as a registered nurse. I know, I know medications, but I also understand that most people don't understand how their medications work. They get confused. Names sound funny. different. They sound similar. We've got generic names and brand names and it can very be very confusing. So part of that home assessment, I create a medication list for them because they don't usually hit, they, I've seen meds names of drugs that were written on the back of an envelope.
And they said, here's my medicine list. I'm like, no, no, that's, we need more than that. Because that's why the doctors want you to bring all your pills in. They don't have a good list. So I'll make you a list and you can update it. Somebody can update it, but then it can also be shared amongst people. The key people that need to have it.
So I spent a lot of time educating on medications. I spent a lot of time educating on disease processes. I'm also a certified dementia practitioner. So if there's any question about somebody's cognitive abilities, I often will do some memory testing with their permission, and it's been absolutely astounding sometimes what I have found.
And, you know that home evaluation when I'm doing one person, it usually takes me about three hours. It actually, I think the last one I did took me probably four to four and a half hours to do.
But a lot of time in the home is spent on education. I talk to people. I normally want to see their legal documents, the medical power of attorney directive to physicians. and anything else that they have. I don't want to look at their last will and testament.
No, you know, but here, you know, I'm here in Texas. So each state has different forms, but essentially these documents are similar in various states and they've been around for quite a long time, but a lot of people don't know how they work. They think, Oh, well, I've got medical power of attorney. I can over override what mom is saying.
And mom is full capacity. It's like, no, no, no. Because it clearly states on the form. If. If the person is impaired and certified by a physician. Now, somebody's in ICU and they're on a ventilator, they're drugged up, yeah, they really don't have too much capacity, but you know, at the end of the day, you got to say, no, you, your power of attorney is not available just yet.
So again, a lot of time educating everybody and a lot of times educating what the options are for care long term because people are unsure. Well, I had a call from a guy, a couple, you know, Two weeks ago, he says, I need, my wife needs to go to the nursing home. And I said, well, why? Well, she's weak. So I was like, well why is she weak?
Well, and he really couldn't tell me. And he was a very intelligent, well spoken man. He was still working and he was 80. And he said, well, she's got this and that, and I just really can't take care of her. I said, so what'd you help her with? And so then I got into the whole, you know, here's the difference between a nursing home and assisted living versus, else.
And I referred him to a gentleman that I know who has a placement service to help him find a place because, you know, he really didn't need me to help manage and coordinate the medical care because he was trying to plan ahead and find a location for his wife because he knew it was coming. So that's kind of the big crux of what I do.
And then at times when I'm doing that, initial evaluation. And I typically try to have the person that's needing the care there. And if there's a spouse, okay, but also an What I refer to as an adult child, or maybe there's two adult children that are local. Maybe there's one that's local and one wants to dial in over the phone to hear what's going on, because they may give me some different answers than what the mom or dad will give.
It's like, oh, oh, really? I didn't know that part of it, you know? So it's, it's kind of like an expedition into some ways. You have to learn to ask really Very specific questions. To try to figure out what's going on. Like, Oh, you know, have you ever fallen? Well, well, yeah, I just slid off the sofa. Well, When did that happen?
Oh, that happened like in the last two or three weeks. I fell off three times. And you're going, Oh, wait a minute. So, you know, people don't think of that as a fall. And I said, look, you know, if you go to the ground, whether you tripped over somebody tripped over the dog, or you just slid off the sofa, you misjudge the distance, that's still classified as a fall because you landed somewhere where you weren't supposed to be.
And they go, Oh, Oh, because that's really key information because, you know, you got to figure out why they're falling because if they keep falling like that, sooner or later, they're going to break something or hit their head. They're going to have a brain bleed, and then we got a whole nother problem. But again, when I'm there doing that assessment and with the conversation flowing back and forth I've had several times where the adult children realize that things are far worse.
Then they thought because the parents would be, no, honey, I'm fine. No, not so much. So I started on covering things, which, you know, is, is good and bad, but then the kids go, yeah, we're going to need your help moving forward. And then my, you know, they engage my services on an ongoing basis, which may include managing the medications, calling in refills, setting up medication boxes, going to doctor's appointments, You know, a couple of weeks ago, I fixed a doorbell.
It's like, you know, it's a shorter list of what I don't do as to what I do.
[00:11:39] Ariadne: Obviously that it seems quite extensive and like you were saying, you know, a lot of that is like knowing what are the right questions to ask to really get to the truth. So how has that changed for you over the years as you've had your practice and you've really like refined that evaluation piece?
[00:11:57] Cheryl: I think what one of the big things that's changed, which seems. a little bit weird, maybe. I've started asking people about their burial plans because I actually had a client.
He was actually, I've known, I'd known him for years. We used to play tennis together a week on skiing. His sons called me in. There were all kinds of issues and I, I should have been called in much earlier. He had multiple, multiple comorbidities and just, it was a train wreck. And at one point he went in the hospital, he was in ICU and.
I had to have the discussion with the family in the waiting room of the ICU about the do not resuscitate. And they were saying, Oh, no, he's got advanced directives. So that goes back to my point. They didn't understand. And these 2 were very me. Techie young gentleman, young kids in the tech world. You know, I said, no, this, that's his wishes.
This is what's going to happen because he was, he was in really bad shape at that point. So I said, I'll be happy. Cause he was, he was still able to talk and have a conversation. And so we met with the doctor as he was coming out of the room. Then we went in and talked to the gentleman and I said, you know, What would you like to happen if something, you know, let's say your heart stops beating like right now, what would you like the hospital staff to do because right now they would be coming in here, guns a blazing and trying to resuscitate you beating on your chest, shocking your heart and, you know, all the stuff that we, you know, we all kind of see on TV, but, you know, you're not used to seeing it in real life.
And he said, Cheryl, he said, just let me go. I said, okay. So we went back and talked to the doctor and they wrote a do not resuscitate order. Palliative care came in. We got him to an inpatient hospice the next day. He died the next day after that. And nobody knew what his burial plans were. And this, the family were asking me, what do you know?
And I said, he, I didn't ask the question. And now I ask the question because, you know, if you try to think they, somebody may have had a pre planned. funeral and burial plans set up years ago, where's the paperwork, you know, because People hoard paperwork, you know, we all have keep too much of it and it's like, well, where did you file it? You know so it becomes, it's a big, big question.
And then I think the other thing that I do quite a bit of when, you know, I ask people, you know, because paying for care is a big deal. It's expensive. And again, people think Medicare health insurance is going to pay for it. I'm like, well, health insurance isn't paying your mortgage.
And basically that's what renting a room is and assisted living. You're paying rent and the health insurance now. And they look at it and go, yeah, I guess you're right. You know? Okay. You know, I try to put a very straightforward terms that people understand. And if they have a life insurance policy, You know, a lot of times older people will stop paying on it because they, they, Oh, well, you know, my kids have enough money.
I don't need it. They stop paying on it and they don't realize they can actually sell it. And selling it, you know, there's actuarial tables and all this weird stuff, but you know, okay, don't pay on it, but go ahead and sell it and use the money for whatever you want to do, unless you're trying to apply for Medicaid and it's going to throw you off throw you off the, the financial criteria for qualifying for Medicaid.
So that's, you know, that's kind of one of those other things that people don't even realize. You know, so, you know, my goal is always to give people more information that they can use that they didn't know about or they didn't understand. In the first place, because I believe information makes you much stronger that you can make a better informed decision.
And as a case manager, I have an ethical obligation and a professional obligation to make sure that I'm not influencing somebody. Because when people say, well, what would you do? And I say, well, You know, I have a couple of options, but my options may be different from yours and you have to do what yours are.
But here's what some of them are. So now and here's how they all work. And if we don't understand them, well, maybe we need to talk to the doctor and get more options.
[00:16:32] Ariadne: Yeah, that makes sense. And I mean, what are the legal documents that you make sure to review with them? Like, do you have a checklist of sorts now that you go through?
[00:16:43] Cheryl: Well, the, the checklist is pretty much the same, the medical power of attorney. And here in the Texas area, you have, you can name a primary person, and then there's an option for two alternate or backup powers of attorney.
I've had the situation where the power of attorney, the husband and wife named themselves. Each is primary. She named her son as backup medical power of attorney. But she named the daughter financial backup power of attorney, husband died, then the son died. So there was no backup medical power of attorney to the son or the husband.
They, you know, and this lady at that point had advanced dementia was in memory care. So I actually had to go to court and testify to the court that I felt the daughter, who is the backup financial power of attorney should also be the medical power of attorney. Because there was nobody else. There was just the two children.
But you know, that's the one thing I tell people, you've got to keep these updated because I found them with only one person named on there. It's like, well, what would happen if that person gets really sick or ill and they can't make decisions for you. You need the backup of the directive to physician.
Sometimes people call it the living will. People think that's like the same as an out of hospital, do not resuscitate form. And it really is the person naming, telling the physicians. And I'm not a big fan of the Texas form because it says I want everything done to me or I want you to keep me comfortable.
There's no in between. There's four blank lines. You can write in specific stuff, but people don't know what to fill in and they usually don't fill in anything. So it's like all or nothing. And there's so much gray area in between.
I talk about the MOST form. It is not technically legal here, but I give it to them and say, here's some information you could discuss with your doctor about your decision making about what you might want to have done if you get really, really sick, but you're still wanting some treatment versus just let me go kind of thing.
And then the financial power of attorney, I try not to get into that too much. And I, but I do explain that. You know, because there's different financial powers of attorney. I just explain, you know, look, if you want to talk to your attorney about it, but you know, because some of them are active right now, there are sometimes they're active on incapacity.
But my new favorite document, which is called naming a guardian in advance of need, because this is a form now that you could get filled out. And you can say, if I become incapacitated or unable to make my own decisions, I, here are the list of people and you can name, I think it's like four or five people that you can name that you would want to be, want them to be your guardian, but you can also name who you do not to have as your guardian, like your ne'er do well nephew that you know is unemployed and living on the wrong side of the tracks kind of thing. So because guardianships can cost hundreds of thousands of dollars. I've got a client that I saw recently, the family's already spent a hundred thousand dollars in trying to get the dad into memory care and you know, out of the clutches of the stepmother and they've been married for multiple years. So there's, there's much bunch of stuff going on there because when you do a guardianship here in Texas, you've got to have an attorney representing the person. And if there's a question of incapacity, then you have another attorney that basically acts as the person.
And then you've got to have the attorney For the family member, and it could be multiple family members because it could be like two adult children and they don't agree. So they've got to have each their own attorneys. So that's four attorneys involved. So you can see where the money that gets very expensive, very quickly to change.
I often get referrals from elder law attorneys because I tell people I'm Switzerland. My job is to be the advocate for this person in need that's needing some kind of care. And my job is to figure out what the options are because, you know, there's usually multiple options you can do.
[00:21:11] Ariadne: Dealing with all the family dynamics is, of course, a huge part of your job. What happens when you know, A topic that's come up quite frequently on the podcast is clients that are not a good fit for you in particular or your company in particular.
So what happens when that starts happening in your process, whether it's, you know, after your initial evaluation or, you know, even earlier?
[00:21:38] Cheryl: Well, you know, I try to figure out. What the what's going on for starters, you got to say, okay, they're not liking something. What is it and try to talk about it and see if we can get it resolved.
But, you know, my thing is, I'm a subject matter expert. You know, even though I may be giving recommendations, they still don't have to follow them, but if I see where they're really not following things and it possibly endangering the person, the elder person that needs care, then I have to say, look, you know, this is very concerning to me and as an RN in Texas and probably every state, I'm a mandatory reporter to Adult Protective Services.
Which is done anonymously, and I'm not, you know, I don't have to tell anybody that I've done so, but if I report them to APF.
Say, I'm sorry, but, you know, there's no point in me working with you because you're not following any of my instructions. And I'm very concerned about your loved one. And so I will basically terminate services and send them a termination letter that says, you know, I'm no longer going to be working with you regarding the care of your whoever and call it good.
Because I kind of hate wasting my time, especially when, you know, there's nothing else I can do. And, you know, I may, depending on the person, I may even contact a physician's office, especially if I've already been to that specific physician, like the primary care doc, and just say, look, there's a lot of things going on here, and I'm not, no longer going to be involved, so don't call me about future appointments, but I'm really concerned about the care of the person. So, you know, I, but I, I put it in writing, especially when I'm terminating services.
If the person passes away obviously that's a termination of services. Unless there's maybe a second, like a, another spouse that I've been working with. Cause I've had cases where I've had both the husband and wife involved.
But I just send, you know, I send a sympathy card, but you know what I also do, I call all of the physicians. And they're, they're offices and let them know that that person has passed away. So they are not calling the family to do, it's time for your mother's annual wellness check. That just to me is, and I've had doctor's offices say nobody ever does this.
[00:24:12] Ariadne: So what, what is the actual process then that you go through for termination of services?
[00:24:17] Cheryl: Well, again, I'll have the discussion and I'll say, you know, I, this doesn't seem to be working. So I may try to refer them to somebody else cause there are multiple care managers here in the Dallas area, but you know, depends on where, where the referral comes from.
If the referral comes from an elder law attorney. I will be calling them to say, look, this is what's going on. This is very concerning because they may have the client come in and they'll do a little sit down and just say, especially if there's some kind of legal proceeding that they're in the middle of, because at the end of the day, if I'm called to testify in court, I will be saying, yes, I gave the family, the instructor, because my report will go to court.
That's why I spend so much time on it because I never know. And especially if it is an elder law referral for the most part, there's a guardianship or a question about something that's going to happen from a legal proceeding. So I need to make sure my reports 100 percent like super accurate and and appropriate.
So, you know, I let the elder law attorney know. But, you know, if the family member that is giving me a hard time, you know, who, who is it? Is it the person that has no authority because I got some of those now they have no authority but they're stirring the pot, so to speak, they're trying to create havoc I'm dealing with that yesterday and today.
[00:25:42] Ariadne: What do you do in those situations?
[00:25:44] Cheryl: Well, this person has technically no authority and we've already been to court on this one and the attorney wrote me the letter the thank you card, because the this family member thinks he's told me that he's like an LVN without a license. And he's saying, well, my, my, my mom has she's advancing into the next stage of dementia that she's, she needs finger foods.
And, but he's always complained about certain things. And I said, well, if you do chicken strips and sandwiches, then you're increasing a lot of carbs and fat into her quote unquote diet, that's going to affect her diabetes. No, he's like, that's not what I had. Yeah, that's what you said, you know, so he's he just he thinks he knows things and he really doesn't and it's it's kind of problematic but he, you know, the other family member is the decision maker he's the primary power of attorney.
So yeah, I mean, it depends on who's really kind of stirring the pot, because if it's a non authoritarian person.
I may say, okay, you're the decision maker. This is what your family member is doing. And this is not a good thing. So you need to reel them in. I'm telling them, but you probably need to kind of back me up too. So it, there's a lot of moving pieces and parts.
And I tell people, I've got to be Switzerland, but at the same time, you know, I've got to be able to say, look, this is interfering with your, your, my ability or your mother's care.
Cause if they're harassing caregivers whether it's at home or in a, if they're already in a community, I need, we need to put the kibosh on them. And it's not always a fight. You know, I've got some of the nicest families and, and that I deal with, and they're extremely grateful for what I do because they, they're not here.
Or if they are, I've got somebody that a sibling's threatened to kill the other sibling. And the judge said, Oh no, let's get Cheryl Acress on this one. Yeah, the probate judge, she named me personally. She says, let's get her in on this one. And the attorneys all went, yeah, cause she fixed this other case where there was a daughter that was crazy.
[00:27:57] Ariadne: I mean, it sounds like you have a great reputation then with all your referral sources. How how have you developed that over the years?
[00:28:05] Cheryl: You know, it's been, it has been interesting. I'm trying to think back how I got started dealing with some of the elder law attorneys. I'm trying to think because Virginia Hammerly, she's fairly well known here.
She actually writes in the Dallas Morning News every Sunday. She writes an article. I don't know, I got introduced to her and she's referred me out to several other attorneys and then she's got attorneys in her firm. She's a, she's a partner in the firm founding partner and, you know, my reputation has gotten around and the, the judges have gotten to know because that particular judge, she was, she retired last, last year.
Yeah, attorneys were arguing. I object, I object the, you know, the tit for tat back and forth, back and forth. And judge Robeson went, okay. Ladies, because it was both female attorneys, she says, ladies, I somehow I don't think Ms. Acres is going to sprinkle any fairy dust on these proceedings. And I looked at, and I just said, judge, I am fresh out.
And she cracked up, you know, she was trying not to laugh, but she did. And she's the one that said, let's get you're like you're saying on this case. So yeah, I mean, there's not that many care managers around.
It's fairly unregulated. Unfortunately, I see care managers now that don't even understand the differences in the levels of care. They don't understand some of the stuff about Medicare, prior authorization, predetermination.
And that's all my insurance background because I did workers comp too. You learn from your cohort. You learn from your bosses. What you do should do should not do, but you know, we all learn as we go along, hopefully, and unfortunately, unfortunately, I know a lot about insurance. So, which is very handy.
[00:29:53] Ariadne: Yeah, it's critical for a lot of these healthcare decisions.
[00:29:56] Cheryl: I know. And it's just it's, it's been an interesting journey.
That's why I got started in, in doing this. I was working in the case management industry as a, in, in for managed care organization. And this lady had had a massive stroke and had no legal documents. She had no power of attorney in place. And she was like 63. And the daughter had to get a temporary hire an attorney in the state of Washington to get a temporary guardianship so she could access the bank accounts, pay the bills so she could continue insurance.
The attorney called me back a second time and she after I gave her an update because I knowing what I know now, I think she was actually about to head into court.
She wanted the latest Update on what this lady was doing. And cause it was just her and me on the phone and she got the update done. And I explained that long term that this lady is not going to be functional and living on her own. You know, I'd never say seen, not set eyes on her, but no, I mean, that's, that's the stuff, you know, cause she wasn't responding to hardly anything and except pain.
And so she said, why are you doing this for someone else? And I was like, what, what are you talking about? She says, you should have your own business. Because you're the only health care professional I've ever talked to that's been able to explain to me in terms I understand so I can do my job better and go to court and do what I need to do.
And three years later, I started my own business. Took me a while, but it's been, it's been a journey because I've had literally no mentor and just flying by the seat of my pants. And I've been doing it for 17, 17 years in March.
[00:31:36] Ariadne: That's incredible. What what was that like initial process like in the three years where you slowly ramping up on the side or? How did you actually get started?
[00:31:44] Cheryl: I was still working for the managed care organization and there, there, there were changes coming, you know, with the nursing compact license. I don't know if you're familiar with it, but when you have a compact license, it allows you to work telephonically in other states.
You don't have to get a license in that state. California and Florida are still not in the compact. And so if I was doing telephonic case management in California, I had to get a license in California. And so at that point I was working every state and there I was. And there was a big there's a company called HPS.
So they do malpractice insurance, especially for nurses. And they said, If you were practicing in a non compact state, we will not honor your malpractice insurance and you could possibly lose your license. And I went, Oh, no, no, no, no, no, no, no, no. Work too hard to get it. And so I made the leap kind of cold turkey and quit my well, very well paying job and started my business.
I kind of did a little bit of legwork ahead of time, but not much. And so it was, it was a bit of a hard journey. And then my dad died in 2009 and I was flying back and forth to Canada. And it turns out the live in girlfriend got his will changed and yeah, we, the adult children got the short stick on this one.
Even the attorney says, Oh, you've done all the work for us. I'm like, yeah, because this is what I do. And not even knowing all the stuff I know now. And we should have won the case, but the attorney screwed us over with the mediation process. We lost the house, the trailer, the cars, all the vehicles, all the household goods.
[00:33:34] Ariadne: So you've lived it and you specialize in it.
[00:33:37] Cheryl: That's still is just, I shake my head and the attorneys that I knew here, I said, can you get the case here? Cause we'll win it. You'll win it for us. Cause you know, so yeah, I think I got one of my first cases from Jack Wilburn.
I got introduced. That's right. I think I got introduced to him from a social worker. She says you need to meet him and he's the one that's called me in on one of the crazy daughters and he's called me in on this case. I'm working on now and it's a young person, you know, so and because because I have been trained to deal with everything from pregnant people to newborn high risk newborns to adults, I can manage any age and I have because, you know, in the insurance world, I did transplants, head injuries, amputations, multi trauma, strokes, it's, it's like, here, here's another case for you. Even if you don't know anything about it, you, you, you start learning. I have probably learned more medical stuff by being a case manager in the insurance world than I would have at the bedside in a, whatever, teaching hospital, even.
[00:34:53] Ariadne: Just because of the diversity of cases that come across your desk.
[00:34:56] Cheryl: Such a diversity. You know, I, I have come across. Two people in my whole career that had Wilson's disease. And one of them was my, one of my cases in the insurance world. It was a young girl, and it's an abnormal accumulation of copper in the liver.
And it ends up that if the liver stops working, they need a liver transplant. And then this gal I know here, she said something about her sister having Wilson's disease. I said, she does? She goes, you even know what that is? I was like, yeah. Only two people I've ever run across that had Wilson's disease.
[00:35:30] Ariadne: Sounds very rare, but it is.
[00:35:33] Cheryl: Yeah, it's, it's very rare. And I'm dealing with somebody else right now, the sarcoma retooth disease. And it's very, it's a genetic disorder. I've heard of it. And I don't even know if I've seen it before.
[00:35:47] Ariadne: Well, what's your closing advice for other care managers? You know, especially if they're just getting started, how can they really improve their processes, make sure that they're onboarding or terminating clients effectively and keeping their referrals happy.
[00:36:04] Cheryl: Well I think one of the big keys is a lot of communication. Figure out who needs to be communicated with in what form or fashion and how timely does it need to be. I think part of the issue is too, what kind of care management are you doing? Are you going to be doing geriatric care management? 'cause that's, that's kind of a whole different process.
'cause you're dealing with older people that are failing and they usually know they're failing, you know? And their time is getting shorter period. So you've got that because there's independent care managers or case managers doing workers comp. Some of them are doing disability management. So, you know, depending on the type of practice.
You know, it's a whole different ballgame, you know, if it's workers comp, you have to stay up on all the rules and regulations that are specific to the state. But with the geriatric stuff, I mean, there's just so much communication and trying to be able to figure out how to say things. Appropriately with a degree of empathy, but being straightforward and honest, because, you know, when I've said, well, this is not a good thing, you know, I'm not sure that your mother has long to live.
That's kind of hard. And I'm like, well, if I lied to you and said, she's got another 10 years, then I you know, I got to sleep at night, but also you would come back to me and you say, well, you told me that my mother would live another 10 years and she died two weeks late, you know, so you've got to be very, very honest.
You know, you've got to develop your, your resource bucket of. Whatever resources there are transportation, you have to know how the communities work. You have to know who can do what, because I'm not doing everything, you know, but I need to know how to find a DME company. I need to know, find all kinds of stuff and be, you know, you've got to be real inquisitive.
You got to ask a lot of questions. And then, you know, if you're doing geriatric care management, you have to make a decision because some of the care managers, they say, and I can't do the legal stuff. And I'm like, bring it here. I like it. You know, it's, it's challenging, but I've learned a lot from the attorneys because they'll say, Oh, we did this.
And I'm like, well, what does that mean? Does that affect what I do? And so I have learned a ton. So, you know, you also have to figure out who you're going to network with to get referrals. Cause frankly, I have, I have received basically like one or two physician referrals in this whole time, even though all these physicians are saying, I'm so glad you're here.
I had one tell me in December when I figured out what was wrong with this lady. And I was talking to him when she was in the hospital, she had just gotten there the day before and I'm giving him all this history because the family member couldn't. And he goes, who are you again? He said, I told him and I, he says, I thought you were a physician.
And I was like, no. because I was just able to throw all this information and tell him basically I diagnosed the problem. And I was right. And sometimes it's really good to be right. And the son told me, he says, you saved my mother's life, literally. And now it's the other brother that's stir on the pot.
You can't, can't be much of an introvert. And then I do public speaking too. Which is always kind of fun.
[00:39:33] Ariadne: That's awesome. Where are you speaking next?
[00:39:35] Cheryl: I am speaking at a CCRC about Medicare Advantage plans and what's coming up probably for 2025 as best as we can tell.
Because I did a presentation to a support group at a Medicare day stay place back in July. I usually speak to them once a year. But, you know, I, the, what I talked to them about was, I, I a program called talking to your doctor and other mysteries because I try to make it fun. You know, I say, look, you know, figure out why you're going to the doctor, have a plan, have your questions written down because when you get in there, you forget, I forget.
So you know, we talk about what to do in the follow up and if they do referral, I've got another one called medication. It can be a real pill. Or not, because there's so many different medication modalities now. You've got patches, you've got lotions, you've got potions, you've got injections, you've got pills, tablets, capsules, liquid, powders.
That's, I think that's about all of them right now.
[00:40:44] Ariadne: The suppositories, I guess, I don't know.
[00:40:46] Cheryl: Well, you know, when I was doing the presentation today, it was some kind of all day seminar. Because I've spoken with the Alzheimer's Association too, they've asked me to do a presentation.
But this one, I was talking about the medication thing. And so I went through all the different ones, this gentleman sticks up his hand. He goes, and he kind of has a smile on his face. And he said, well, what about suppositories? I said, well, I was waiting to get to the very end for that one. He cracked up.
Everybody started laughing. I was like, do not mess with me. Cause I will get you.
[00:41:19] Ariadne: Well, so much for being on. I feel like it's been a wonderful conversation and we've only scratched the surface of everything. I know it's a lot of things that you've learned in your long career, but really appreciate it. And hopefully we can have you on again in the future.
[00:41:34] Cheryl: Yeah, it's been my pleasure.
It's been fun because I, I love trying, trying to explain what I do, but, you know, because I feel the need is out there for more and more people, but there's not enough of us to go around. And unfortunately there's a lot of people that can't afford my services, but, you know, there's been a few times when I just said to look here, go do this, go do that.
And if you get stuck, call me. You know, again, I got to sleep at night. So anyway, Aria, thank you so much. It's really, truly been my pleasure. Love to do it again.