Martha & Mary AT HOME offers geriatric care management | THE TIME OF YOUR LIFE

Charlie was an 84-year-old veteran who lived in Kitsap County. He had moved away, but came home to retire here. He didn’t have any family members close by.

Carrie Mulcahy

This article originally appeared in The Time of Your Life special section, Spring 2016.

The 25th annual Older Americans Conference is 9 a.m. to 1 p.m. Wednesday, May 18 at the Elks Lodge (4131 Pine Road NE, Bremerton). Is is free and open to the public.


Charlie was an 84-year-old veteran who lived in Kitsap County. He had moved away, but came home to retire here. He didn’t have any family members close by.

As Charlie aged, he began to have health problems and he wound up in a local hospital. When he was feeling better, he wanted to go home, but the hospital wouldn’t release him until they knew he was returning to a healthy situation where he would get the care he needed.

That’s when Carrie Mulcahy, Director of Care Management for Martha & Mary AT HOME in Poulsbo, got a call from Charlie’s attorney asking for help.

“Many times in situations like this, the person is helped through the Division of Aging,” Mulcahy said. “But there are those gray areas where there’s no one to help. That’s where we come in.”

The Martha & Mary AT HOME care management program started in 2011. In her role, Mulcahy assesses a person’s current living situation, reviews their medical records, and makes suggestions about their current and future care needs.

“Initially, we got Charlie home care services through Martha & Mary AT HOME,” she said. “The program sends private duty in-home caregivers to help clients with bathing, dressing, meal preparation, housekeeping and medications oversite.”

He was having stomach and bowel trouble and he wasn’t eating right, she said. “We worked with him and his caregivers to encourage a healthier diet. But he refused to go to the doctor. He feared he’d be sent back to the hospital and he didn’t want that.”

Fortunately, Mulcahy was able to find a physician who would see Charlie at his house for medical care.

Over time, Charlie ended up in the hospital emergency room following a bad fall. He was placed in intensive care where it was soon discovered he had Stage Four cancer.

Working with the hospital discharge planners, Charlie agreed to a short term stay at Martha & Mary Health and Rehab Center, but eventually he insisted on returning home.

“As time passed Charlie’s health got worse and he declined overall.  At that point we worked to get Hospice services started for him and increased his in-home care to 24 hours a day,” Mulcahy said.

“What’s important in this story, is that Charlie was able to receive care on his own terms, the way he wanted to,” she said. “He was able to be at home and his wishes were respected.”

Like Charlie, most seniors out there in their 70s and 80s wish to actively participate in care decisions about their own health, Mulcahy said.

Because of the geriatric care program at Martha & Mary, there is a stopgap program in place to help seniors who do not have family in the area. Mulcahy said she works with family members who are out of state, attorneys, neighbors and caregivers with power of attorney.

“Sometimes they just need a home care expert to look at the big picture,” she said.

Generally, when she is called she does an initial assessment, looking at the residence, for safety issues, for its ease at which the senior can get about, and then she reviews records from physicians involved in the case.

“I look at the situation holistically, and at any physical concerns from my head to toe clinical assessment,” she said. “I work with other health care professionals to develop a comprehensive care plan that is geared toward meeting safety, health and welfare needs.”

The initial assessment is about $300, and is privately paid, although some insurance companies are beginning to offer coverage for this service.

“From there, it depends on what issues are at play,” she said. “But a key focus of what I do, is to keep this services affordable for families that need it.”

Another example was a woman in her 90s who was hospitalized and needed to have her home assessed for safety. Mulcahy knew the woman didn’t want to go into a nursing home, but once she saw the home where the woman lived, she determined it would not be safe for her to return home.

“The stove didn’t work and she had been using the shower as a closet,” Mulcahy said.

In that case, she was able to recommend to the client’s family that the woman move to an assisted living facility.

Mulcahy said geriatric care management began on the East Coast more than 25 years ago. It’s only made its way to this area in the past five years.

She has an LPN and a bachelor’s degree in health care administration and a master’s degree in health care management. She is certified by the National Academy of Certified Care Managers and a member of the Aging Life Care Association and is required to take continuing education annually.

To contact her at Martha & Mary AT HOME, call 360-394-5458, or email


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