Care Manager/Elder Law Collaboration

This case was a great example of how an Aging Life Care Managers refers to an Elder Law Attorney when a complicated situation evolves that requires Elder Law expertise.

In the first week of March ElderTree was contacted by the son of a couple who live in Clifton. The husband was 74 and the wife was 77. They had been married for 52 years and lived in the house with one of their two sons. A meeting was established for the next day with the initial scope of business being “help us create a care plan for mom”.

The wife “Mary” was a cancer survivor and had a long-term history of depression which had impacted the entire family for many years. Mary was exhibiting signs of a new behavioral disturbance and possible dementia. Her self-care was poor, she was not sleeping, and her husband and son spent a large portion of their time redirecting her from driving and repetitive tasks such as washing the same dishes repeatedly.

Mary is a retired federal employee who is highly intelligent. Upon first meeting her, she presented socially appropriate with significant cognitive reserve. She was clearly agitated and pleaded with the Care Manager to take the car keys from her husband. Notes were made to consider a neuropsychological assessment to ensure appropriate autonomy and support as needed. Otherwise, it was noted that Mary needed routinization for her day, cueing for personal care, engagement support, and medication management.

The husband, “Randall” served as the communicator during the initial meeting with ElderTree, along with his son, “Mike”, who was finishing a practicum as a physician’s assistant. Randall appeared frustrated by his wife’s behaviors but also was not acting appropriately with how he was approaching the situation. Instead of gentle redirection, he was prone to criticism and anger. In addition, ElderTree learned that Randall, also highly intelligent, suffered from normal pressure hydrocephalus and had not been to the doctor in years. During our visit, Randall had difficulty with executive functioning related to finances and frequent perseveration related to a care plan for his wife, insurance navigation, and the family finances.

Over the course of three days, ElderTree made three trips to the home in an effort to obtain legal documents (which we soon learned were never done) and to set up a care plan for Mary which included home care support. Upon learning that legal documents were not in force and suspecting that Mary retained situational awareness enough to sign a Power of Attorney, ElderTree connected with an Elder Lawyer in the Fairfax area immediately. An associate from the firm was quickly dispatched to the home to begin setting up estate planning documents for both husband and wife.

The situation escalated quickly when Mary became physically aggressive with her husband and began exit seeking. Randall then began refusing care in the home because he found it invasive. The culmination of a very rocky weekend was when the couple fought in public resulting in the police being called and Mary being transported to the hospital for assessment and cognitive stabilization.  

Concurrent with this escalation, COVID hit and Northern Virginia went into lockdown. Mary was still in the hospital for stabilization and APS was tracking the case due to the police’s involvement. In conjunction with case management at the hospital, ElderTree began to look for an alternative placement for Mary to ensure her safety, health, and well-being post-discharge. The doctor had recommended memory care, however, assisted living communities had just begun to experience COVID outbreaks and few were accepting new clients. 

The care management and legal case pivoted from sustaining the situation in the home and signing POAs to placement in a secure memory unit for Mary. Eventually Mary was placed at Great Falls Assisted Living which had done a good job with other ElderTree clients who had a comorbidity of mental health and dementia challenges. Mary had to agree to go, however, since she was her own agent. The senior elder lawyer partner became involved and filed a petition for guardianship since during her hospital stay and subsequent placement in memory care, two doctors had designated Mary incapacitated.

Complicating the situation, the couple had always kept their financial resources separate and, without a financial power of attorney or advanced medical directive in place, Randall could not pay Mary's health care bills, enact her long-term care insurance, or approve the distribution from her IRA. Given Randall’s already amped up presentation around money, the situation was escalating from all sides very quickly.

ElderTree and the elder lawyer worked together to obtain the documents needed for the guardianship. A comprehensive assessment of the medical situation and psychosocial situation was done by ElderTree in support of the guardianship process. ElderTree also worked closely with the assigned guardian ad litem over the course of the next two months to ensure that Mary remained stable in assisted living and Randall had the necessary emotional and executive function support to move forward.  

As it got closer to the scheduled Webex guardianship hearing, Randall’s behavior became increasingly erratic. He began speaking about bringing his wife home and became emotional about needing to relinquish guns he owned if she were to come home. Seeing the erratic behavior, the elder lawyer, GAL, and Care Manger had numerous conference calls and eventually added Randall and Mary’s two sons as secondary guardian/conservators in the petition for guardianship, thereby allowing a secondary decision maker should Randall become unable to fulfill his duty.  

ElderTree served as a witness at the guardianship hearing, and ultimately Randall and his sons were named guardian/conservator for Mary. Ongoing care management support was also added to the final court order.

In the three months since the final order was approved, Randall remains unable to organize the documents needed for filing a long-term care insurance claim, and ElderTree is gently coaxing him along in the process.  

Mary was discharged from assisted living and spent some time in rehab following a newly diagnosed critical care event. Upon leaving rehab, she returned home with 24 hour care and a weekly visit and 24/7 on call support from ElderTree.

The elder lawyer remains involved with Randall to assist with dividing all assets in half and to prepare and file an inventory. The elder lawyer also ensured that Randall now has a POA and Advanced Directive with his sons identified as the POAs. The lawyer will also assist Randall with annual accounting done as Mary’s conservator.  

The collaboration between ElderTree and the elder lawyer continues to date and is indicative of how families can get what is needed when care managers and elder lawyers work together to ensure the best outcome for their clients.