For more than ten years before that 1990 crisis, Bob had managed to be a long-distance caregiver through frequent phone calls and visits. Louise, now 79, had remained at home with the aid of two helpers Bob hired: a handy man, who took care of odd jobs, and a visiting nurse, who spent an hour a week with her.

    But the coma "brought it all home." says Giese, president of a computer-networking company.  "No one was looking after my, mom on a daily basis.  Suddenly she needed that, and I wasn't there to give it to her."

        Giese may have felt alone, but he's one of a growing number of Americans who manage and monitor long-distance caregiving,, for an elderly parent.  "Distance just makes things harder," says Janet Wells, a senior program specialist with the American Association of Retired Persons, who managed the care of her own mother in Atlanta from her home in Washington, D.C. "While there will never be services that fulfill the role of family, they can fill a necessary void."
 

HIRING A "PROFESSIONAL RELATIVE"

        More and more the void is being filled by geriatric care managers, a fairly new breed of social workers or nurses who specialize in assessing the needs of elderly people and matching them with services.  Giese hired Marianne Ewig, a Milwaukee-based care manager, after he made a number of frantic calls to Wisconsin nursing homes and hospitals looking for assistance.

        "Marianne's name kept coming up," says Giese, who was relieved when she described her role as that of a "professional relative." Ewig assessed Louise's needs and monitored her condition at home until late 1990, when she located a new assisted-living center being built in Milwaukee.  After visiting and touring a number of facilities, Louise decided to move into the Arboretum, where she has a studio apartment with a porch, eats with friends in a central dining room, and has her insulin injections monitored by a nurse.

        Before Louise's move, Bob made several visits to help her sell her house, including hiring a real estate agent and attending the closing.  Ewig, for her part, focused on preparing Louise mentally for the move.  "I cannot imagine negotiating all of this at a distance without help," Giese says.

        He finds Ewig's help equally valuable in ensuring his mother's day-to-day well-being.  Ewig acts as eyes for Bob and ears for his mother, who is now legally deaf.  She monitors Louise's medical care, stays in contact with both mother and son, and is available 24 hours a day to handle emergencies.  Louise manages her own finances, with some help from Ewig and financial support from her son. (He covers the Arboretum's $1,500 monthly charge, pays $850 in annual medigap insurance premiums and supplements Louise's $600 monthly social security check.) For her time and skills, Ewi'g charges $75 to $150 a month, a fee that Bob pays out of pocket.

        A care manager's initial assessment of a parent's needs can cost from $200 to $750, and monthly management can run up to $400, according to the National Association of Professional Geriatric Care Managers.  To obtain free referrals to geriatric care managers near your parent, call the association at 602-881-8008, or write to: 1604 N. Country Club Rd., Tucson, AZ 85716.

        Many states are starting free assessment programs and offering reduced-cost case management.  Call the federally sponsored Eldercare Locator Service at 800-677-1116; or contact the Area Agency on Aging in your parent's community (see the blue pages of the telephone book).

        "What we do best is coordinate long-distance care"" says Patrice Gott, planning associate for the Area Agency on Aging in Uniontown, Ohio.  "Our one request is that you not wait until a parent has a broken hip, you're in a crisis mode and you don't know what resources are available." (For tips on how to be prepared, see the page on Planning for Long-Distance Care.)
 

KEEPING A PARENT AT HOME

        Whether you hire a care manager or take on the job yourself, your purpose is the same: to ensure that your parent is healthy, happy and safe.  If she wants to stay at home and can safely do so, that should be your first goal, says Peter Belson, director of clinical services for Family Logistics Inc., a Waltham, Mass., geriatric-care management company.  Sometimes all you need to do is find someone to shovel snow or serve meals.

        The local agency on aging, in your parent's community can refer you to volunteer or low-cost programs.  Some programs serve only low-income seniors, but others, including Meals on Wheels, have no income restrictions.

        In many communities, the agency on aging offers free, in-home screening and assessment by a registered nurse, who may recommend something as simple as installing safety bars in the bathroom.  If your parents needs are more extensive, the nurse can coordinate fee-for-service homemaking help, a home health aide, or a licensed practical nurse or registered nurse.  You can also arrange those services yourself. The non-profit Visiting Nurses Association, or VNA (800-426-2547), and private service firms such as Kelly-Assisted Living (800-937-5355) offer an array of help for your parent in his or her own home.

HOME AIDES

        Mark Nezovich, who lives 45 minutes from his parents' suburban Cleveland home, hired an aide through VNA when he realized that his father's emphysema and immobility were exhausting his mother. The aide's three visits a week to bathe and feed the elder Mark Nezovich, 77, at a cost of $11 an hour, are "a godsend," the son says.  VNA charges on an income- based sliding scale, starting at $9 an hour.

        VNA also coordinates the Senior Companion Program, which offers visits from other age-60-plus adults at a cost of $5 to $6 an hour, depending on where your parent lives.  Elders who keep loneliness at bay with such home visits may not only forestall nursing-home care, which averages about $36,000 a year, but also tend to require fewer hospitalizations and emergency-room visits, says Elaine Williams, regional director of VNA in Detroit.

ADULT DAY CARE

         Another option for warding off isolation is adult day care. The cost ranges from $35 to $60 a day, about half the cost of a full-time home aide.  For referrals to centers in your parent's community, call the Eldercare Locator Service. For free brochures about adult day care, write to the National Adult Day Services Association (National Council on the Aging), 409 Third St., S.W., Suite 200, Washington, DC 20024.

        If your employer offers elder-care counseling as a fringe benefit- and about one-fourth of employers do- you can use that resource to begin collecting information on services and facilities in your parent's area. When you're hiring long-distance, keep in mind many agencies do a thorough check on their employees- including credit histories, criminal records, training and references- not all do. Ask what screening an agency performs and whether its employees are insured and bonded.  If you want to hire someone on your own- say to perform yardwork- get recommendations from a senior center or a neighbor. Then ask for references and check them.

BRINGING MEDICAL HELP HOME

        If your parent is on the mend from an accident or has a medical problem, nursing assistance can help her stay in her own home.  Expect to pay, $20 to $30 an hour for a licensed practical nurse and $30 and up for a registered nurse, depending on where your parent lives.  While an LPN can administer some medications and change bandages, an RN is needed to monitor intravenous feedings and give injections.

        Home health services may be partially covered by medicare or medigap insurance.  If a doctor has decided that your parent needs medical attention at home, both nursing and homemaking assistance may be covered.  The need for a surgical dressing to be changed regularly, by a nurse for instance, may qualify your parent for benefits that would pay for help with bathing and dressing as well. To find out what insurance will cover, check out your parent's policy, contact her insurers or call the medicare hotline at 800-638-6833.

        You can find nursing help at a distance through the area agency on aging, a private geriatric care manager or an employer's referral service.  Make sure you call your parent in advance to let her know someone will be visiting.

MOVING TO ASSISTED LIVING

        When the upkeep of your parent's home becomes too burdensome, or her medical needs too great for inhome care, where can she go? A nursing home may not be the only answer.

        Many retirement communities provide several levels of support beginning with independent apartment living.  This may be all your parent needs, because such communities often provide one or more communal meals a day, plus on-campus services ranging from medical clinics and banks to libraries and hair salons. Apartment living can cost from $1,000 to more than $2,500 a month.

        If your parent needs help bathing, dressing and taking medicine, though, the assisted-living option is the next step.  Assisted-living costs range from $1,250 to S3,000 a month.
Even so, the cost is often less than half that of full-blown nursing-home care, says Jo Ann Clipp, research director for Jean Moreau & Associates, a Columbia, Md., consulting firm that specializes in nursing-home and care facilities. Total nursing-home care costs between $1,500 and $5,000 a month.  For any of these options, a large deposit of $100,000 or more may be required.
        Because the new care centers are often all-in-one facilities, apartment residents who develop a need for nursing-home care may have guaranteed placement, depending on the community. And seniors may have the option of returning to a fairly independent lifestyle if their condition improves. Most nursing- home stays last three to six months. 

CHOOSING A CARE CENTER

        Whether you decide to go it alone, or work with a geriatric care manager in choosing a care center, the first rule is: Don't wait for an emergency.

        That's what Ronald Cavill, a financial planner in Denver and Washington, D.C., did, defying the advice he's given hundreds of clients.  One week his 70-year-old mother, Lorraine, was swimming in Michigan's Lake Superior and the next she was lying on the floor of her bedroom, felled by a stroke. When the rehabilitation hospital decided that she wasn't making progress and that medicare benefits, which were paying her $1,000-a -day bill, should end, "we literally had days to find a facility that would take her," Cavill says.

        Cavill's sister was able to use the free elder-care service of her employer,  IBM, to find an assisted-living center near where Lorraine had spent her winters. Lorraine moved into Brentwood Health Center in Lecanto Fla., where she had her own apartment, took her meals in a cafeteria and received the physical therapy the she needed. Although she regained some mobility, in the past six months, her health has declined and she has moved into the traditional nursing home at the center, at $2,800 a month. Lorraine's assets have covered most of her costs so far.
 
        When your parent has to move anyway, you may want to discuss having her move to a retirement community close to where you live- or, if appropriate, moving in with you. Traveling several hundred miles may be no more unsettling than moving across town, especially if it means that you'll be able to visit more often.

        To begin selecting a facility, get referrals from the Area Agency on Aging and call the ombudsman for the elderly- a state government office.  The ombudsman can also provide information about the quality' of care at the facilities you are considering. Federal funding for the ombudsman program, was recently slashed in the budget, but other resources are available.

        If possible, visit with your parent and facility that you're considering, preferably without calling first. Talk with residents and employees, visit the communal areas, and get a sense of the overall mood, environment, and staffing levels. Ask to see at least three years' worth of state inspection reports, which will tell you what trained inspectors have found when they showed up unannounced.
 
        Most important, keep communicating with your parent and keep her involved in the choices affecting her life. By making key decisions and harnessing resources early, you can choose from the options that allow your parent the best quality of life.