Care Across America
"Care Across America, an Approved Senior Network® Podcast"—your go-to source for engaging conversations and practical insights from home care and senior care experts across the United States. Each episode will spotlight industry professionals, and their referral networks, sharing impactful stories, proven strategies, and innovative solutions in senior care. This podcast is perfect for professionals, adult children of aging parents, and family members struggling with senior care choices and care.
Care Across America
Why Communication And Planning Keep Seniors Out Of The Hospital- Sid Gerber, Houston, TX
A quiet fever, a missed noon dose, a confusing discharge packet—small cracks that can send an elder into a chaotic ER spiral. We bring together two seasoned pros, Sid Gerber and nurse case manager Maddie Bunch, to show how thoughtful planning, trained caregivers, and fast communication keep loved ones safe at home and out of the hospital. Their stories span ICU nights, VA leadership, dementia care, and the hard lessons that come from watching systems strain under the weight of too many patients and too little continuity.
We dig into what’s really happening inside hospitals today: marathon ER holds, overworked teams, and hospitalists who don’t know the patient’s history. Then we move to the fix—actionable steps any family can take. Learn when to call urgent care versus 911, what a complete discharge plan looks like, and why having a sitter or caregiver at the bedside is no luxury. Hear how shift‑by‑shift reporting, early detection of UTIs and delirium, and a direct line between case manager and home care team can stop problems before they explode.
Preparation changes everything. We walk through advance directives, medical power of attorney, and out‑of‑hospital DNR orders, plus how to organize a next‑of‑kin kit so every sibling and caregiver has instant access. The goal isn’t to avoid hospitals at all costs—it’s to avoid preventable admissions, protect dignity, and ensure calm, informed choices when seconds count. If you’re caring for a parent with dementia, managing chronic illness, or just getting your family’s plan in order, this conversation gives you a clear, compassionate roadmap.
If this helped you feel more prepared, follow the show, share it with someone who needs it, and leave a review with the one takeaway you’re putting into action.
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My name is Sid Gerber. I'm president and owner of Personal Caregiving Services. We are licensed as a non-medical home health agency in the Houston, Texas market. I've been in long-term care for 33 years now. I started out as a nursing home administrator for eight years. Before that, I was in a totally different business, but really wanted to get into the health care administration focus. So I had sold my business that was a family business in 1989. Went to the University of Texas Health Science Center. Was actually, because I couldn't get into hospital administration, I asked a longtime high school friend of mine who is a long-term care administrator himself what there was, what opportunities there were for me. He suggested that I get my long-term care administrator license. And I did that through the University of Texas Health Science Center here in Houston. I was thrown into a class of 35 graduate nurses who were also taking the long-term care administrative curriculum. Completed that in 1992, and my first building was after two weeks, the current administrator of that building, which is a 200-bed Medicaid facility here in Houston, said, I'm leaving for another job in Dallas, and you can have this if you want it. So I went ahead and stayed with that building for about four years and then left to go to two other facilities. My last facility was in 1996. I was at the groundbreaking ceremony for a exclusively an Alzheimer's and dementia facility, skilled nursing facility, and took it out of the ground and stayed with them for another basically three and a half years and left in 2000 to really it was at that point in time. I of course worked in for-profit corporations. And the key for them was filling the building and census. I had a weekly census meeting every week. And the first question was, What's your census today? And what are you going to do about increasing it? And so it's not what I signed up for. I decided to leave and go out on my own and became a geriatric care manager, consulting with family members, adult family members, and spouses who had mostly elderly that needed some guidance and education and coordination of care. So I did that, oh gosh, from 2000 to about 2009. I had my own business in consulting and doing that. And then some of my private clients would ask me to help manage their private caregivers. And I suddenly realized that because they were not my employees, they weren't going to do what I asked them to do and trying to improve the quality of care and life of the clients I was consulting with. So I realized at that time I might as well jump into it and become licensed with the Texas Department of Health and Human Services. In 2009, I started my own non-medical agency, and that's where I am today. I have approximately oh 80 caregivers in my pool. Most of my caregivers are trained in Alzheimer's and dementia care because the predominant focus on my services or dealing with clients who have Alzheimer's and dementia. And that's my story.
SPEAKER_03:That's a great story. All right. Let's talk to Maddie. Maddie, tell us about your history.
SPEAKER_01:My name is Maddie Bunch. I'm a nurse case manager, the BSN. I went to college at the University of Bridgeport in Connecticut and did my clinicals at Yale, New Haven and Bridgeport Hospital. I decided after meeting an orthopedic surgeon in New York one day, after he said to me, if I was interested in a job, call him and go to Texas. I packed up and moved to Texas and went to work at the Institute for Rehabilitation and Research. I found I my first role was the 11 to 7 shift in the ICU of PEDs and adults. And there I was, the only RN, and it was my first night at work. I went, oh, this went well. This will go well. But anyway, it turned out great. I had a long career with Tier and moved from Tier to the VA hospital in Houston, where I worked in the brain injury and spinal cord injury as a nurse manager and returned to Tier under a federal grant to establish case management in the community. And then was moved up to nurse manager of their outpatient clinic. And when I was in the outpatient clinic, I would see the nurses come in at that time. Insurance companies had nurses, registered nurses for workers' comp. And I was watching and I thought, there's more to this service than just the workers' comp market. And in 1984, I left here and started a company with another woman. She was an occupational therapist. And we had the company for 13 years. Our focus was catastrophic injuries. And we subsequently sold it. And when I left that company, I started M Bunching Company, which is my existing company now. That was in 1996. And retirement is this is my retirement, is what I tell people. I'm retired now, I'm having fun. I focus on medical case management mostly. I do receive many dementia patients or Alzheimer's patients, but people come to me often because of the medical side of the need for their elderly or their loved one.
SPEAKER_02:And so, Sid, how do you guys, you two of you, work together?
SPEAKER_00:We complement each other because I, of course, have the caregiving staff, and we have worked really very closely together with some of the cases that that Maddie has presented. And like she said a minute ago, some of these clients are cases have or more complex medically. And so she brings that forte to the table. And I bring, like I said, the caregiving forte. And we've worked very well. The important thing is communication. We found that out is essential. And we even have our caregivers reporting to Maddie directly on a shift-by-shift basis so that she has a very clear because things can change. Some of our clients can change on an hourly or even a minute-to-minute basis. And again, this kind of gets us into the issues that we're going to be talking about, which is how to minimize the admission to hospitals. Because if you have that quick of response and communication, we can try to prevent the hospitalization at all costs. And that's basically why we have created this accommodation for both of us and the client of family members.
SPEAKER_03:It sounds to me like you guys are a powerhouse team together because I and I know that a lot of families don't realize this, but especially when it comes to the medically complex, um, the care management or case management, whatever, whichever way you want to swing it, is so important in all of this. Even down to a missed medication can be the difference between say a Parkinson's patient really having a good day or a bad day, or there's just so many little things. So for the not complex and the fact that you both have care management and case management experience is so nice for families. I feel that like as a nurse, I've done that whole care management thing in the past, and I that is a lifeline for families, having somebody to manage that care and to be available to talk to and to really have somebody, especially if they're not, even if they're down the street, it really there's so much interpretation of medical language that people don't understand. If they don't have a healthcare person in their life that a nurse in their life or a doctor, somebody who can explain things, it becomes overwhelming really fast.
SPEAKER_01:Yes, it does.
SPEAKER_00:It truly does, excuse me. It's also a first time for everybody. And of course, the the education is essential, and that's what Maddie and I do provide is that we're always making recommendations, we're always educating our family members and our clients because they don't know. They absolutely have no idea, and we try to avoid the pitfalls. And the healthcare system is broken, and I think the three elements that my business model is based on is the fact that there's very little transparency, there's very little communication, and there's very little family support, if at all. So I pass that on, and my expectations are very high with my own caregivers. I need them to promote those three elements that are missing. And that's, I think, that's helped my reputation in the in the industry is that without those three elements bridging those the gaps in healthcare, nobody else is going to be an advocate for them because they just don't know how to be an advocate.
SPEAKER_03:They don't know what they don't know.
SPEAKER_01:Yes, they don't remember what they don't know. Even at this stage of our careers, there is never, if the family needs us, we are the few that the two of us, whether it's Sunday afternoon, we may not want to do it, we're tired, but we will go out and make a home visit, or we will meet a patient who's being discharged from the hospital because nobody else is able to be there. And that makes a big difference, especially with the older folks whose family may be out of town, especially.
SPEAKER_00:Yeah. That's a very good point, Maddie, because I tell clients that look, I'm available 24-7. I have a staff coordinator and supervisor who's also available 24-7. We have a weekend scheduler on the weekends. And I want to be responsive because that's what most of our clients are. I have to say this, they get overwhelmed, they get very emotional at the least little thing, but we are understanding of that, we appreciate that, and we are responsive. So we basically operate as a concierge practice.
SPEAKER_03:Yes, that's lovely. That is great. It's good for people to know that because they're not gonna get that level of service and individual attention from most generic home care agencies. It's just not that's not available to not possible.
SPEAKER_01:Yes. And now, I'm sorry. No, go ahead. I was gonna say the hospitals are so inundated with patients that even their discharge packets are not intentionally incomplete, but they're incomplete. So I open it and I call back the nurse, whether it's a CID patient or another patient, and I say, I need more information. I have caregivers in the house. I need to know when he last ate. Did he get his medicine at noon today? Or are we starting all over again? I need a med list. And we've been able, both of us have been able to create a huge resource of people we know in the medical community. And we take, we use acts, we make act, we access that. We because it's critical.
SPEAKER_03:Isn't that funny how people go home and there's there like from a nurse perspective, there's no one to report off to. There's no one to give report to to say, from if you work in the hospital, you from one shift to another, nurse to nurse, we give report to the next shift and we say, here's what's happened, here's what's going to happen, here's what needs to happen. And then, but when you go home, it's like you're they tell the family members if there is any who are not gonna remember all of this, probably. But they get this folder and they go home and they are just kind of hoping that everything's gonna go okay. And there's no one to give report to to say this is what you need to do now. And they're just too overwhelmed to absorb it anyway. So having folks like you to be able to call back and ask those questions is so nice. So very nice. I know that we want to talk a little bit about the current condition or status of hospital stays. So I'm gonna ask you guys this question, and you either one of you can answer it.
SPEAKER_02:Sure.
SPEAKER_03:So, what is the current condition or status of hospital stays today in terms of care, treatment, and have and hazards for the health and well-being of patients or clients being admitted and discharged from the hospital? What's going on there? What do you guys see?
SPEAKER_01:What I see is most patients who are over 75 are admitted because they're concerned if they cannot find anything with the patient, they're worried they're missing something. The patient's 75 or older, they will be admitted regardless of what they think the diagnosis is. That's number one. Number two, they could be in an emergency room for 12 to 48 hours, depending on the day, the night, the day, whatever's going on in the ERs. Number three, they I tell everyone, you cannot leave an elder person in the hospital without a sitter, a caregiver, or somebody from the family. It's not that they don't want to take care of him. The nurses, too, are very overwhelmed and very short-staffed.
SPEAKER_03:You can't leave a 40-year-old in the hospital cells at this point, even if they can talk.
SPEAKER_01:There's I would go, what did the doctor say? I don't know.
SPEAKER_02:Yeah, exactly.
SPEAKER_01:Something I don't remember. So it's it's a very stressful time in the health care in the hospitals.
SPEAKER_02:Yes.
SPEAKER_00:The other thing I might mention is the health risk of being in the hospital for any period of time. And COVID was a good example of that, but even some of the other diseases or illnesses that can be contracted in the hospital. I've seen people who've gone into the hospital with without pneumonia come back out with pneumonia or some other contagious illness or disease. So it's very important to try to minimize that exposure as best as you can. And again, Maddie mentioned the understaffing, which is true not just in the hospitals, really, but basically in every corner of the country and really just about every facility that's providing care assistance. Very true. Yeah, even in assisted living communities, we're seeing that. Yeah. But yeah, the and the other thing, too, is I gotta say this because Houston is probably the medical capital of the world. Yeah, I don't know how many hospitals we have, and just in our medical center alone, I think there are 10 to 12 hospitals. But one of the things that I found out in the nursing home industry is that you're doing you're doing tasks. There's no time, literally no time, I know in the nursing home to have one-on-one caregiving, not even close to one-on-one caregiving, where the staffing ratios in a typical nursing home today, even on a day shift, could be in an eight-hour shift, could be one to twelve or one to fifteen. That means that you may have at the most 10 minutes for each patient. So the same is true in the hospital setting. And that's what Maddie was was discussing earlier. But they're just doing tasks, and there's no understanding of what the history of the patient is, other than looking at the chart. They don't have any knowledge of the family and other conditions or circumstances that led them to the hospital. And the other problem is that there's the family practitioner doesn't usually go into the hospital because hospitalists are now managing the whole admission and during the time of admission. And occasionally a consult will be called on, but it's very rare. So that's where some of the breakdown in communication is.
SPEAKER_03:Yeah, you don't see the primary care physician making rounds the way they used to. There's no it's a hospitalist system that sees somebody you've never met that doesn't know you, doesn't know making rounds and hoping for the best.
SPEAKER_01:And they may have 27 patients on their care. Yeah.
SPEAKER_03:Yeah, they have it's so many people to see and to round on. And what's the best way? I know the next thing we want to talk about is what is the best way to keep people from going to the hospital in the first place? What can we put in place to help avoid hospitalizations?
SPEAKER_01:Education with excellent communication is to me is one of the keys. Teaching a family member or help having them understand the importance before you call 911. Yeah, make sure it's a 911 call. If your mom has a temperature, maybe call urgent care first. But don't just call 911 and go to the main hospital down in the medical center. You you could be there for three days in the ER at times. Education with the caregivers. I like working with SIDS folks because they want to learn, they want to hear what I have to say, and they follow through with it. Occasionally there's a little bit of pushback, they don't know me or whatever, but not tremendously. Takes one time explaining, hey, I'm teaching you skills you're going to use for the rest of your life. And that is critical with the caregivers. But the families are a big part of why people end up in the emergency room, in my opinion. They react, they don't think it through, and they just head on in.
SPEAKER_00:They get emotional. That's right. No matter how significant or insignificant it might be, they're going to be very emotional, and they just make a knee-jerk re have a knee-jerk reaction to taking somebody to the hospital. And like you said, particularly for people who are chronically ill, and if there's a significant change, of course, then it would be important to call their physician and let them know. And again, it's the responsiveness of the physicians to uh because usually and I hate to say this, but a lot of doctors on the weekends in particular. Particular, they're not available, or somebody's on call. And the first answer is if this is an emergent, if they don't get anybody on the phone, then the first message that you hear is we'll call 911. So we're encouraging people to call 911 when it may not even be necessary. Yeah.
SPEAKER_03:It's I a simple urinary tract infection that could be treated at an urgent care can make somebody act kind of wild. They can really have some mental issues, especially as we get older when for something that could be easily treated, but it looks scary in the moment. If you're not aware, you don't have the skill to assess what this could be. You don't know, then it the first thought is let's just take them to the emergency room, or take them, or you're right. You call the doctor and they say, if you really think that you're not sure, or they'll give it back to the family member, then you maybe need to take them to the emergency room.
SPEAKER_01:And the facilities, the facilities tend to do that. They they, I mean, they're employees as well, the facility, and somebody calls and said, I don't feel good, or I'm short of breath, they may not know the patient has oxygen right there in the apartment or has pulmonary disease chronically. The excuse they're going to react, call 911, the person is over 75, and they're going to whism off to the emergency room.
SPEAKER_03:And do you I it's funny that you say for folks over 75, I wonder, I guess I doctors today, or the ER physicians or the hospitalists are covering all the bases so they don't get accused of missing anything. That's right.
SPEAKER_01:So it's easier just to admit and make sure, and then I had a patient who the first words out of her mouth when she didn't feel well was, I'm going to the ER. This was inadvertently her pattern. She'd go to the ER, they would admit her, and then the next day she'd call me and say, Get me out of here. But she didn't have any children close by. And so she would just call the concierge at her apartment building, say, I need to go to the hospital. And they would call 911 and then she'd say, Get me out of here.
SPEAKER_03:Yeah.
SPEAKER_00:She got some attention and had some fun, but one other thing that I think needs to be addressed is the fact that many people still don't have an advanced directive. Yes. They haven't made a short or and or a long-term health care plan in the event that something occurs medically and or don't even have a medical power of attorney. And they have to react to it's it's they have to react to a situation instead of being proactive. And I think it's absolutely essential that people have those documents available and ready. A lot of people don't even know what an out-of-hospital do not resuscitate is because in some situations, which I've seen both in the nursing home and at home, is that if the family they may have an in an in-hospital do not resuscitate, but they don't even know what an out-of-hospital do not resuscitate is. And if once they call an ambulance, and if they do, if their wish is not to be resuscitated, as soon as the ambulance arrives and loads that patient on the way to the hospital, if they code, they're going to do everything they can to save that patient. So that's an important document to have in some cases.
SPEAKER_03:And having 10,000 copies of that document available to every adult child. You got it. And the person in the house, in the car, I can recall from having family members that we manage to care for. You constantly have to be re-giving that those documents to the hospital with every admission, with every change. The doctor doesn't have a copy, or even if the doctor has a copy, if it's eight o'clock on a Sunday night, that's not available. So you have to have another copy in your hands of all those things.
SPEAKER_00:So that's the worst the worst case situation I had in the nursing home was we knew that somebody had an out of hospital an in a DNR, but couldn't locate it. And if you call 911 and they're coming into the facility, they're going to do again, they're going to try to resuscitate, even though the family knows that there's there should be an out-of-hospital, an in-hospital, in-facility DNR. So that can be very problematic, especially if you're trying to resuscitate a 95-year-old woman who's frail and elderly, and you know, you're going to cause more harm trying to resuscitate that individual. So it's very important that you locate the documents and they're readily available. And you, like you said, Valerie, that you've got a number of copies available and accessible.
SPEAKER_03:Yes, everybody. I sent my family members a box, and there's a I can't remember the name of it right now, but they sell packets and binders online and all kinds of stuff for organization of this stuff. So I it's called a knock box, and it's got next, it's called next next of kin, is what that what knock stands for. And it's this file folder box full, and you don't have to buy one to do this, but it's got a slot for their insurance papers, a slot for their DNR, a slot for their power of attorney. It's got all the things it and lets you organize that information, which I'm sure you've done a lot of, both of you, for making sure everybody knows where all those documents are, and and that can save so much time and heartache knowing where those documents are, knowing that person's wishes, and all the kids knowing the same thing at the same time.
SPEAKER_01:Yes, that's really critical is knowing the person's wishes at the same time. All children should hear it, all adults.
SPEAKER_03:Yes, yes, for from the person, the adult, the from the mom and or the or dad, if possible, from their mouths. This is what I want, this is what I don't want. And yeah, talking to you two, this is great. I wish every family had the opportunity to talk to some well-versed veterans in this area because there's so many things that can be avoided, and we hate having these conversations with our parents, but everybody's gonna get older, hopefully, if you're lucky, and everybody's gonna pass away.
SPEAKER_00:You can't put you can't put aging off.
SPEAKER_01:No, you cannot run. That's exactly right. I have even I have gone as far as had to arrange funerals for families that they didn't have any, and they had no plan.
SPEAKER_03:Yeah.
SPEAKER_01:And it was that's rough, it's hard on them and it's expensive, it's sad and it's expensive, but more important, they feel so trash, they feel sad because they didn't recognize to do it. They not only do they have the grief of the loss of a parent, they're grieving that how could they let this slip by?
SPEAKER_03:It is it's rough. And if you've ever had someone pass away suddenly in your life at a young age or middle-aged, even who didn't they're young enough that they didn't realize really quickly how important it is to put a plan in place because having to have people who never thought they would have to make these decisions go and choose all these different things and how much to spend. It I think funerals are really way more expensive than people realize.
SPEAKER_02:Yeah, that's true.
SPEAKER_03:And uh it's really hard, even if your parent was older, it's hard, it's a hard moment. So, yeah, having everything arranged in advance is such a good thing to do. Yeah, I want to thank both of you for thank you, sharing your wisdom with us and letting everybody know what the important things are. And Houston is very lucky to have you both. So thank you so much. Thank you for being on Care Across America. Thank you.
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