We Became "Therapists Without a License”-A Phenomenological Study of Care Managers Working with Older Adults during a Pandemic 1

The study sought to understand the lived experience of Care managers employed by aging networks and their role during the COVID-19 pandemic in helping older adults living in the community maintain their independence. The COVID-19 pandemic propelled care managers to navigate new challenges by developing innovative ways of providing services to older adults. Purposive sampling was used (n=15) to recruit Care Managers to participate in focus groups. Qualitative data were transcribed and analyzed using NVivo-12 software. Five themes emerged from the data: Older Adults with Mental Health, Emotional Distress, Challenges Accessing

The study sought to understand the lived experience of Care managers employed by aging networks and their role during the COVID-19 pandemic in helping older adults living in the community maintain their independence.The COVID-19 pandemic propelled care managers to navigate new challenges by developing innovative ways of providing services to older adults.Purposive sampling was used (n=15) to recruit Care Managers to participate in focus groups.Qualitative data were transcribed and analyzed using NVivo-12 software.Five themes emerged from the data: Older Adults with Mental Health, Emotional Distress, Challenges Accessing Resources, A Shift to the Care Management Role, and Support from Management.The essence of the experience was that care managers who work in the aging network play a significant role in the lives of older adults living in the community by providing community-based long-term services and support.During COVID-19, the role of the care managers was amplified, with care managers providing psychological and emotional support to older adults due to the shortage of mental health providers.Care Managers worked with limited resources to identify innovative ways of providing services during this public health crisis.

Background
The older adult population is growing rapidly, with the expectation that 1 in 4 people will be over 65 by 2030(United States Census Bureau, 2023).Most older adults, approximately 97%, live at home (U.S Census Bureau, 2018), thanks in part to the support provided by the aging network, a state and federally-funded system that offers various health and human services to help older adults maintain independence in their homes (Roberts et al., 2018;Siegler et al., 2015).However, accessing certain services, such as mental health services, poses challenges for older adults due to factors such as chronic illnesses, being homebound, and physical limitations (Cheng et al., 2020).
The United States has a fragmented system where social and behavioral health services are separate.The fragmented system often leaves many older adults without behavioral health services (Jones & Dolsten, 2024).Older adults living in the community are at higher risk of institutionalization when their behavioral health needs are unmet (Tilly, 2016).
The U.S. employs almost 30,000 health and human service providers, such as care managers in the aging network, caring for more than 10 million community-living older adults through Meals on Wheels programs and home and community-based services (Bartels & Naslund, 2013).Though the care manager's role is significant in the aging network, it is essential to note that they do not provide clinical or psychological services.Furthermore, the role of care managers in aging networks is not regulated, and individuals in these positions have varying qualifications and degree specializations, ranging from an associate's degree to a master's degree in fields like social work, accounting, psychology, and sociology (Mbao et al., 2023).Despite this, care managers employed by aging networks, such as Area Agencies on Aging (AAAs), play a crucial role in helping older adults maintain their independence by conducting home assessments, care planning, and making service referrals.This is particularly important for racial/ethnic minority older adults with limited resources and informal support (Siegler et al., 2015).Therefore, it is crucial to understand how this workforce that cares for the millions of older adults fared during the COVID-19 pandemic.
The COVID-19 pandemic posed new challenges and opportunities for care managers as social service providers, which resulted in developing innovative ways of providing services to older adults.Covid-19 greatly impacted older adults, with a rate of eight out of ten Covid-19 deaths among adults aged 65 and over (Gold, 2020).The deaths due to COVID-19, quarantine, and social distancing led to increased depression, anxiety, and loneliness among surviving community-dwelling older adults (Gerlach et al., 2021;Banerjee, 2020).In addition, insufficient resources to deal with the stress brought on by the COVID-19 pandemic, such as a lack of technology to connect with family, friends, and providers, inability to engage in physical exercises, and living in fear of contracting COVID-19 (Vahia et al., 2020), all contributed to this age group relying more on aging network care managers for support.Care managers play a significant role in the lives of community-dwelling older adults; thus, it is necessary to understand how this population of care managers handled their work during the COVID-19 pandemic.There is a lack of research on how COVID-19 impacted care managers working with older adults in the community.As such, this qualitative study begins to fill this gap in the literature.
The specific research question was: What was your experience as a care manager working with older adults with mental health issues during the COVID-19 pandemic?
The study had two aims: 1) understand how Covid-19 has impacted the role of aging network care managers in providing effective services to older adults with mental health needs, 2) understand the lived experiences of aging network care managers working with older adults with mental health concerns during the COVID-19 pandemic.

Methods
The study was reviewed and approved by the Institutional Review Board.

Sample
Care managers were recruited from an aging network agency in Massachusetts that serves older adults and provides home and community-based services.Purposive sampling was used for this study to ensure that the participants fit the inclusion criteria and would be able to speak to working with older adults with mental health needs during covid-19.
The inclusion criteria for the study were care managers who worked with older adults 60 and above.We only looked at older adults because research shows that the behavioral health needs of older adults are unique and distinct from those of younger populations under 60 years of age (Maust, Kales, & Blow, 2015).At the time of recruitment, there were 90 care managers at the agency who fit the inclusion criteria.Initially, 20 participants were enrolled in the focus groups, although five changed their minds about participation after signing the consent form.The final focus group sample comprised 15 participants, representing 17% of the total sampling frame.We conducted two separate focus groups with six and nine participants, respectively.The demographic characteristics of the sample are presented in Table 1.All the focus group participants were female (n=15, 100%), the majority of whom reported having a bachelor's degree (n=12, 80%), and approximately one-third reported their race as white (n=10, 66%).
Care managers who were included in the study had the following titles: Homecare care manager: Care managers conduct reassessment, care coordination, and care plan evaluation for homecare services.The older adult in this program receives services funded through state and federal dollars.They often carry an average caseload of 80 older adults at any given time.The number of visits for each client varies between two and six visits a year, depending on the clients' assessed needs.The relationship between the client and the care manager can last for months or years and termination of the care manager relationship happens when the client moves to a long-term care facility, is deceased, or no longer has a need for homecare services.
Residence service coordinators: They have the same duties as homecare care managers, but all their consumers (older adults) live in the same building, so they can oversee all the building activities.
Geriatric support services coordinators: Care managers conduct reassessment, care coordination, and care plan evaluation for homecare services.The older adult in this program receives services funded through their managed care organizations.The only difference with the homecare case managers is who is funding their homecare services.Geriatric support services coordinators similar to care managers work with their client's long term.The number of visits a client receives depends on the assessed clinical need and varies.
Participants were informed that participation was voluntary and would not impact their employment, and they received a $15 gift card for their time.All participants in the study signed an informed consent to participate.A professional transcriber transcribed audiotaped data, and the first author read and reread the transcriptions to ensure they captured what was said.

Researcher's Expertise
Before conducting the study, the researcher had a prior understanding of working as a care manager with older adults, as she was the director of training at the agency site during the COVID-19 pandemic.This experience familiarized her with the care management role and provided inside knowledge of the challenges care managers face in providing services during the pandemic.

Analytic Framework
We used a phenomenological framework to capture the care managers' lived experiences while ascertaining and defining the phenomenon (Cilesiz, 2011).Phenomenology is a reflective study of pre-reflective experiences (van Manen, 2014).Lived experience presents to the individual the many truths and realities of life.By assessing lived experience, researchers may understand the meanings and perceptions of another person's world or just the meanings and perceptions.Phenomenology aims to describe the meaning of this experience in terms of what was experienced and how it was experienced (Teherani et al., 2011).

Data Analysis
Phenomenology was used to analyze the data because it helps in identifying the essence of the lived experiences of participants (Moustakas, 1994).In using phenomenology, we were able to "return to the concrete aspect of the experience" (Moustakas, 1994, p. 26) of the participants.Furthermore, the systematic analysis of phenomenology, enabled the researchers to present the meaning of the experience as revealed through consciousness.Phenomenology helped us to get an in-depth reflective description of the experience of what it felt like to be a care manager working with older adults with mental health issues during COVID-19.We were able to describe what we heard the participants say and as well as how the participants perceived their experience.Using Moustakas transcendental phenomenology, we conducted a detailed 5 step analysis of the data to help us understand the essence of the care managers lived experience.
The first step in the analysis involved transcribing audio files into text files.Once the interviews were transcribed and edited to de-identify any personal information, they were analyzed using NVivo-12 software.
The second step involved reading the text to understand the story and meaning before proceeding to the analysis.We identified 21 non-repetitive, non-overlapping signification statements with various perspectives about the phenomenon.The phenomenon that several participants shared in both focus groups was working during a pandemic, a role that was already very challenging before the pandemic.
The third step involved determining the meaning units, including a closer reading of the text.After meaning units were chosen, we marked each section into a statement of meaning ('meaning unit'), where the interviewer reflected a shift in meaning.
The fourth step was clustering the units into themes by finding common subthemes under which the transcript could recognize and organize separate meaning units.Here, we eliminated overlapping, repetitive, and vague expressions.
Five themes emerged from the analysis of participants' understanding of how COVID-19 influenced their work with older adults, as shown in Table 2.In the fifth step, the researchers took the data and described it in the language of the case managers working with older adults in aging networks during COVID-19, which are shown as significant statements in Table 2. "Finding therapists and providers is so difficult because everybody is booked because everybody is suffering from Covid."Emotional distress "They were scared.They felt like they were doomed to die because they were stuck in this building." "That is just frightening.And so many of my clients would call, and they were crying." Decline in resources "People could not get an appointment even if they tried.So, it's been pretty bad." "Finding the resources, the therapists that were seeing them in their home, who couldn't see them in the home."

Themes/Meaning
Evidence in participants' statements Becoming innovative "Covid has changed a lot of what we do with the elderly community." "We were becoming a therapist but did not even have a license." "I was really able to rely on those relationships I had with the aides because they were the eyes that were in the building." "Finding ways to reach consumers in socially distant ways.For the holidays, we did the gift bags on the doors, sent out cards." "Getting creative with the ways that we can reach consumers and how we do that program planning piece." Support from management "There was definitely support there and sort of acknowledgment, like "yeah, it has been a really hard time." "I'm not licensed, so I can't give a lot of advice.So, I go to my manager, and they were helpful."

epoche
We engaged in the 'epoche' process and bracketed our own experiences working during COVID-19 to understand the participants' lived experiences.Through reflexivity, we engaged in self-reflection about potential biases.The first author used memos throughout the research process to put aside the biases and judgments as an insider who works at the same agency as the participants.Additionally, while we knew it was not possible to reduce all the presuppositions, we tried to reduce them to the extent possible, as suggested by Van Manen (1994), "If we simply try to forget or ignore what we already know, we may find that the presuppositions persistently creep back into our reflections ."Therefore,we did not ignore our subjectivity; we bracketed our experiences and collected data from participants who have experienced the phenomenon.
We utilized the bracketing process (epoché) to avoid making personal judgments throughout the study.In addition, we used the subjectivity statement as another measure of validity.In a subjectivity statement, the researcher can describe their prejudgments and beliefs about the phenomenon before analyzing the data to see how their preconceptions changed after analyzing and engaging the data on participants' experiences (Moustakas, 1994).

Results
Five themes emerged from the data: older adults with Mental Health issues, Emotional Distress, Decline in Resources, Becoming Innovative, and Support from Management.

Older adults with mental health issues:
Care managers shared their experiences of working with older adults during the COVID-19 pandemic as a challenging time for both them and the older adults.As stated by one participant, "It was already a challenge working with them [Older Adults with Mental health] before Covid, So, with Covid, it is like, how do you even manage?".Before the COVID-19 pandemic, there was a dearth of mental health providers to work with older adults (Bartels & Naslund, 2013).The pandemic and the resultant lockdowns increased loneliness and depression among this population (Krendl & Perry, 2020), exacerbating the need and demand for mental health providers (Byers et al., 2012).Because the COVID-19 pandemic disproportionately impacted older adults, the need for mental health services among older adults was estimated to have doubled during the same period (Banerjee, 2015).This increased demand posed challenges for Care Managers in finding mental health providers who could continue to service older adults in the home, as evidenced by this comment from one participant: "Finding therapists and providers is so difficult because everybody is booked because everybody is suffering from Covid ."Even older adults previously connected to a mental health provider lost access to their clinician as most did not see clients for an extended period during Covid-19 (McElroy-Heltzel et al., 2021).
Emotional distress: Care Managers found themselves having to navigate and remotely help older adults who were dealing with emotional distress brought about by fear of COVID-19, loneliness, or seeing loved ones dying.One participant commented that older adults "Were scared.They felt like they were doomed to die because they were stuck in this building."Participants shared that more older adults were lonely and isolated from friends and families, fearful of death, and the Care Manager was the only person they spoke with most of the days.Fear and anxiety were overwhelming for many older adults as noted by one participant, "That is just frightening.And so many of my clients will call, and they were crying."The reduced contact with families, social networks, and care providers created unique challenges (Holmes et al., 2020) for both older adults and Care Managers, who became their clients' primary source of emotional support.Ultimately, the Care Managers felt they were practicing beyond the scope of their roles.One participant commented, "We were becoming a therapist but did not even have a license."Mortazavi (2021), noted that the importance of Psychological and supportive interventions for older adults during Covid-19 and that home care workers such as social workers were better positioned to provide supportive psychological care telephonically or virtually.

Decline in resources:
Before COVID-19, it was a challenge to find mental health providers for older adults, but COVID-19 magnified this challenge by making it hard for older adults to access even the few resources that they had available.The Participants reported a decline in providing services to older adults during the COVID-19 pandemic because, as noted by one Care Manager, "People could not get an appointment even if they tried.So, it's been pretty bad."Specifically, participants shared that they experienced several obstacles connecting older adults with resources during the pandemic, as most agencies had closed or moved to virtual platforms; as noted by a participant, "Finding the resources, the therapists that were seeing them in their home, could not see them in the home," thus, the Covid-19 pandemic magnified an already existing disparity for many vulnerable populations (e.g.older adults) accessing services (Panchal et al., 2021), who rely on in-home therapy due to barriers with transportation or mobility.

Becoming Innovative:
The pandemic led to a change in how the Care Managers provided care, which may have contributed to them becoming innovative and resourceful, as exemplified by the following, "I was really able to rely on those relationships I had with the aides because they were the eyes that were in the building ."The Care Managers learned to be resourceful and rely on collateral contacts who could be physically present in older adult housing to check on them and report back, and that is how they conducted their safety checks.In addition, to being innovative, the Care Managers in this study were resilient and adaptable throughout the pandemic despite many challenges.Many older adults who lost their social networks due to the closure of adult day centers and those unable to see family and friends due to social distancing measures relied on their Care Managers for emotional support.For example, one participant noted, "We found ways to reach consumers in socially distant ways.For the holidays, we did the gift bags on the doors and sent out cards."In addition, the Care Managers developed new ways of communicating with and meeting the needs of older adults, including cooperating with collateral contacts (e.g., personal care aides and homemakers) to help with the assessment process, as these individuals were still able to meet older adults in their homes and ensure their well-being.Similar findings were documented in a Swedish study, which found that care managers were creative during the COVID-19 pandemic and proposed alternative means of service delivery and coordination (Nilsson & Olaison, 2020).The ability to be innovative in delivering services may have contributed to the care managers' skills and knowledge regarding services and their confidence in their ability to make professional judgments while working with older adults during COVID-19.

Support from management:
To navigate the new role and challenges brought about by the pandemic, Care Managers reported that they found it helpful to conference with their supervisors to discuss difficult client situations.For example, one participant stated: "There was definitely support there and sort of acknowledgment, like "yeah, it has been a really hard time."Recent studies have found a significant relationship between supportive leadership and the psychological well-being of employees during the Covid-19 pandemic (Um-e-Rubbab et al., 2021).In addition to supervision, Care Managers who participated in training related to COVID-19 reported feeling a sense of community because they interacted with other providers who were also struggling with navigating the changes to their role.

The Essences of the Experience
Care managers who work in the aging network play a significant role in the lives of older adults living in the community by providing community-based long-term services and support.
During COVID-19, the role of the care managers was amplified, and they found themselves providing psychological and emotional support, which has historically never been part of their role but changed due to the additional challenges faced by older adults "feeling scared, feeling doomed to die, feeling stuck, feeling lonely."Despite a shortage of providers and limited social resources, Care Managers identified innovative ways of providing services to older adults during this public health crisis.Similar findings have been noted by Nilsson & Olaison (2020), who found that care managers used their professional discretion in decision-making during COVID-19.However, Nilson & Olaison reported that even before COVID-19, care managers have often acted as street-level bureaucrats and have been creative in their decisionmaking capacity.However, the challenge with COVID-19 was the lack of previous policies to use as a point of reference.
Care managers did this while navigating their personal challenges.Care Managers in the study reported dealing with the challenges of being parents and navigating remote schooling for their children while also working from home.Some participants lost their own loved ones to the pandemic.Pascoe (2022) and Baker et al., (2021) found that due to navigating their challenges, care managers neglected their self-care and were not provided with opportunities to reflect, which may have led to burnout.In our study, participants described having to adapt to social distancing and quarantine policies as overwhelming as it prevented them from conducting holistic assessments.For example, for the first time, they had to perform their assessments telephonically, preventing them from physically connecting with their clients.In their study, Mishna et al. (2021) found that using technology also overwhelmed care managers because they had to give out their personal phone numbers to older adults who called and texted outside of work hours.

Implications for Practice
The study findings have significant implications for care management practice with older adults, particularly those with mental health needs.Care managers had some decision-making power as "street-level bureaucrats" and were innovative in their approach to care.The pandemic has further highlighted their ability to be creative, flexible, adaptable and innovative while remaining client-centric.The role of aging network care managers can be expanded to include supportive psychological services.Aging network agencies also need to consider ways to provide opportunities for self-care and reflective practice, particularly when care managers work with older adults over the phone.Clear communications technology guidelines are also needed to prevent care manager burnout due to older adults having access to their Care Manager's phone numbers.

Limitations
This study has several limitations which warrant mention.The first is the small sample of Care Managers in one agency.Future studies can incorporate participants from multiple locations, especially since Massachusetts has 25 Aging Services Access Points (known nationally as Area Agencies on Aging).The other limitation is that the study was conducted during a global pandemic, which impacted people differently; hence, this study can only speak to the experiences of the care managers that participated in the research and cannot be generalized to other care managers in other aging networks.

Conclusions
The findings from this study highlight the role that Care Managers played in the lives of community-dwelling older adults during the COVID-19 pandemic.This study underscores the unique position of care managers as frontline workers who can help provide emotional support to community-dwelling older adults in addition to providing the social services they already provide.As suggested by the emerging literature and this study, older adults' future studies should explore ways to incorporate aging network Care Managers as essential providers of supportive emotional and mental health services for community-dwelling older adults.
To our knowledge, this is the first study that sought to understand the impact of COVID-19 on care managers' experiences in the aging network through their voices.Care Managers in aging networks have always been considered a lower tier of employees.However, during the COVID-19 pandemic, Care Managers became a lifeline for many isolated older adults who needed support from the aging network to maintain their independence.Care managers are skilled employees who can adapt even during a pandemic, as evidenced by how they adapted and became a lifeline for many older adults.

Table 1 .
Sociodemographic characteristics of focus group participants 2.2.Data CollectionFocus group interviews were held on Zoom.The first focus group was held on May 26, 2021, and the second on May 27, 2021.The researcher recorded the focus groups, which were then transcribed by a professional transcriber.Each focus group lasted about 60 minutes.Phenomenological focus group interviews aimed to describe what it felt like to be a care manager working during COVID-19.The following questions were included in the interview guide: 1) Talk about your experience working with older adults during COVID-19 .2) Talk about how your work with older adults has changed due to COVID-19.3) Describe the support you receive from your agency during the COVID-19 pandemic.4) Talk about the type of visits/assessments you are conducting, for example, in-person, telephonic, or telehealth.5) Talk about the training you received related to COVID-19 to help prepare you for home visits.

Table 2 .
Themes/Meaning Units from focus group participants