Ms. H was a 59-year-old female referred to us by her legal team who was seeking an Emergency Temporary Guardianship. Based on reports from her out- of-state sister who was one of the petitioners, Ms. H had her first bipolar episode during her freshman year in college. She also had periodic instability that resulted in several hospitalizations between the ages of 30 – 50, (both in New Mexico and in Louisiana). Beginning at the age of 51, Ms. H had numerous mental health inpatient hospitalizations. By the age of 58, Ms. H began a series of short-term inpatient hospitalizations, a result of her stopping her traditional medications. This was a decision she made based upon her acupuncturist’s recommendation that Chinese herbal supplements and acupuncture would work better.

There was a previous guardianship in Louisiana for several years. However, once it was removed, Ms. H moved back to Albuquerque where she had previously lived for a time; and soon becoming so mentally ill that she could no longer function. During her New Mexico hospitalizations, in addition to the diagnosis of Type I Bipolar disease, she was diagnosed with Frontal Temporal dementia; however this diagnosis was given without any formal testing. She was then discharged to a specialty dementia care assisted living, but within two days was readmitted to the psychiatric hospital. It was later determined that she did not have dementia.

Geriatric Care Management, LLC became the temporary and eventually permanent guardian for Ms. H in mid-2009.

After appointment of the guardian, she was discharged and readmitted to the hospital three times through police pick-up orders. However, this occurred before we were able to even establish a trusting relationship with her. She was hospitalized 11 times during the ten months prior to our appointment. She continuously exercised poor judgment, placing herself and property at risk, expressing delusions of grandeur, and placing herself at increased risk for financial exploitation. Her risky behavior miraculously did not result in her death or incarceration. We knew that our interventions needed great focus as they would ultimately shape her future — hopefully in the right direction.

Because Ms. H didn’t have a place to call home, the Disability Rights advocates in their quest to “honor the wishes of the mentally ill” were about to put her in harm’s way, insisting she could be discharged back to the community with no supports in place. The guardian began searching for a specialty assisted living for the mentally ill. There was none in the state of New Mexico. The only options were to live in the state institution for the mentally ill or be in a locked dementia care unit within an assisted living or a nursing home. Another consideration was that the average age of residents in these types of facilities is 82. Her youth would draw attention to her in a way that could cause alienation and discomfort about not fitting in, possibly exacerbating other mental health issues.

Through Audrey Zabin, Boston, Massachusetts (via the listserv) we learned of the McLean Psychiatric Hospital, part of Massachusetts General Hospital and Harvard Medical School. Their Pavilion Program offers a thorough evaluation process followed by the possibility of on-going residential treatment programs on campus. However, even once the treatment decisions were made, getting Ms. H from New Mexico to Massachusetts presented several logistical and other challenges.

At the time, she was under a legal commitment order to the New Mexico State Behavioral Health Unit. Therefore, both District Court and Mental Health courts had to approve any move out of the state or institution. Transportation arrangements were made that included a psychiatric flight nurse from Tucson, Arizona to accompany Ms. H on the flight and all its connections. We arranged for The Silver Runner, a division of our care management company, to pick her up and drive to northern New Mexico for a midnight discharge from the psychiatric hospital in order to allow time to travel back to Albuquerque, and get Ms.H through TSA. Getting through security was a challenge because during her last manic episode, she had lost all her acceptable forms of identification. (We were able to get her birth certificate from Louisiana and obtained another form of photo ID.)

In preparation for her hospitalization, we developed a very detailed timeline which included medical history and supporting documentation for the flight nurse to hand off along with Ms. H in the airport to Audrey Zabin, who then accompanied Ms. H to McLean Hospital and through the admissions process.

After admission, Audrey Zabin provided care management services for Ms. H while at the Pavilion and throughout her stay later at their residential program, Appleton. Through her efforts, the staff coordinated with Ms. H, the McLean treatment team, and myself, to solidify the ongoing management of her condition and stabilization. Through regular phone visits and scheduled team phone conferences, we were able to now address medical concerns: Ms. H needed surgery for the removal of a parathyroid tumor and extensive dental work. As an outof-state guardian, we needed to speak with the endocrinologist and surgeon before signing consents and we needed to be aware of the guardianship laws in both states. Ms. H had the outpatient surgery, which immediately corrected the calcium absorption problem that was causing osteoporosis.


Mrs. H’s continued rehabilitation and stabilization not only depended upon our team working together but utilizing key GCM skills to create structure and meaning to her life and to support her integration in the community. We engaged her in outpatient psychiatry appointments, cognitive behavioral therapy, helping her find interesting classes, engaging in regular exercise, and the adaption of life skills. In this case it was not only our GCM skillset and collaborative efforts, but the fact that the patient herself wanted to and was able to get better. An outcome we as geriatric care managers do not often see.

The Challenges:

(1) An inadequate healthcare system in the protected person’s state of residence.

(2) A medical history of questionable mental health diagnoses.

(3) Taking on the responsibility as legal guardian and moving ward across state lines.

(4) Navigating within the legal systems of three states.

(5) Financial planning with no health insurance.

(6) Working with a client whose cognitive status is influx as her treatment plan progresses.

(7) Being legally responsible to make healthcare decisions for a client who you have not seen during 13 months of treatment.

(8) Identifying and obtaining health insurance and for someone who has not had health insurance and then was receiving treatment out of state. (She had disability insurance but let it lapse after previous guardianship was removed in another state.)

(9) Coordinating all treatment plans and decisions with a variety of legal professionals involved in the case but not well versed in patient care.

(10) Coordinating treatment plans including surgery and working with multiple disciplines in treatment of her medical and mental health issues while she was in another state.

Advocare Care Management is the place to go for senior care in Coral Gables. We are senior care advocates and have access to numerous tools, resources, advice, and connections. We work with seniors or disabled adults in Miami-Dade, Broward, and Palm Beach counties. Our team is available 24 hours a day including evenings, weekends, and holidays. Contact Advocare Care Management today to get the help you need.

Reprinted with permission from Advocare Care Management is the solution that will help you to care for a loved one.