Posted by Robin McManus

As a fairly recent and idealistic graduate of a masters program in social work, I was attracted to the part of the job description for guardian case manager at JF&CS that advertised, "we make a real difference in people's lives." When I met my new client, Ann*, however, I began to wonder, was the difference referred to positive or negative?

Ann is a very vivacious and dignified 92-year-old widow who never had children. She had been living independently her whole life and was currently residing at the Jewish Community Housing for the Elderly (JCHE) Coleman House in Newton. As a longstanding member of the sisterhood at a local synagogue she was well respected by the Jewish community in Boston and beloved by many friends.

In recent months Ann's rapidly advancing dementia had caused her to severely neglect her health, nutrition, finances, and personal hygiene. Depression had also isolated her from the very community that was once such an integral part of her personal happiness. One of the cruelest parts of dementia is that Ann was not able to recognize any signs of this self-neglect and truly believed that she was well able to manage on her own; she had become very resistant to any assistance offered to her and often became belligerent with health care workers who tried to intervene on her behalf. The community at JCHE was becoming increasingly concerned and, simultaneously, Ann was becoming increasingly resistant to this concern. It had become crystal clear that Ann was no longer able to safely manage living independently.

Fortunately, help came through the collaboration of several organizations. First, a JCHE mental health initiative was funded by a grant from Boston Jewish Women's Fund. Through this initiative Ann was referred to JF&CS for consultation with Marsha Frankel, clinical director of Senior Services; Marsha then worked with Springwell Elder Protective Services on behalf of Ann. The result of this chain of interconnected efforts was a referral to the JF&CS Guardianship program, which could provide the services that best fit Ann's needs.

Now what? Guardianship is a tremendous and serious responsibility. How exactly were we going to help this woman without causing her stress and undue agitation? As guardians we are often responsible for making the tough choices to ensure maximum health and safety for our clients that they may not necessarily choose for themselves. The process began with the question, "What would Ann have wanted if she were able to competently and rationally make her own decisions regarding her care going forward?" This question sparked many conversations among JF&CS staff, her friends and neighbors, and also within our guardianship program office. As I moved through this process, I tried to remain unfailingly mindful of Ann's values and preferences that were rooted in the very core of her entire life: faith, charity, and community. With that as a continued focus, I searched for the least restrictive placement in a Jewish housing community that would also offer Ann the security and level of care she required.

After thoroughly researching options with assistance from colleagues in Your Elder Experts, the guardianship team agreed on a memory-supported unit at a Jewish assisted living facility as the best possible placement for Ann. She would be able to keep kosher and to practice her faith on a regular basis, which she had been unable to do in recent months. She would also be part of a community that would provide the social stimulation that she had always thrived on and enjoyed so much.

But the question remained: how would we convince Ann that this change was in her best interest? Accomplishing this required all my clinical skills, a great deal of thoughtfulness, and further collaboration between JF&CS, Springwell, and the JCHE staff.

Due to the thoughtful casework and teamwork, Ann transitioned easily to the new setting. I pinched myself. Was this too good to be true? As my exhausted head hit the pillow the night following her move, my anxiety level began to rise as I thought of her once again. I wondered if she was disoriented or frightened going to sleep in a new and unfamiliar environment and thought of all the possible negative scenarios that could be occurring at that very moment.

When I checked with the staff the next morning, and in the days and weeks that followed, my fears were allayed. I have been relieved and amazed to hear how well Ann has assimilated into her new living situation. Ann is benefiting and thriving in an environment where all her needs are met and where she no longer must deal with the stresses of daily life that had been haunting her in recent months. No longer must she worry about the steps involved in reheating her home delivered meals, or how to balance a checkbook, pay the bills, or any number of once simple tasks now made monstrous by her memory loss. She is now well nourished, clean, safe, and socially stimulated in a vibrant and lively community where, as a proud Jewish woman, she feels a sense of belonging. On my most recent visit with Ann she actually spoke the words that I never imagined I would hear when I took on this case: "I think this move was beshert. Do you know what this means, shana madel?" When she explained that beshert meant that it was meant to be, I was both amazed and very grateful.

A remarkable level of caring flowed from many directions toward providing Ann with the supports she needed in this new phase of her life. I believe that the success in this story stems from the thoughtful collaboration with the network of colleagues who worked with us to keep her priorities and best interests at the heart of the serious and difficult decisions we are responsible for as guardian.

The answer to the question? Guardianship has indeed made a positive difference in Ann's life.

*Name changed to protect privacy.

Robin McManus LCSW is a graduate of Boston College School of Social Work. She has worked as a geriatric social worker for a number of years and joined the JF&CS Guardianship program in September 2010.