Shay Jacobson, RN, MA, NMG, LNCC, CNLCP
Jennifer Gazda, LCSW
Martha Kern


In clinical circles, Maria might be called “complex”.  Maria has cerebral palsy and developmental delay.

At the tender age of 32, she is obese.  She has gastro esophageal reflux (GERD) and a stomach tumor.  She has the additional psychiatric diagnoses of schizoaffective disorder and bipolar disorder with active psychosis and incidents of agitation.

When Maria, in one such incident of agitation, struck the Director of Nursing at her facility, this assemblage of diagnoses became even more acutely problematic.

Maria needed to be placed anew…..but what one community could manage this collection of needs and the very real person who harbors them?

A Glass Half Full
Truth be told, Maria’s needs were not adequately met at the facility that would no longer accept her.  Thirty-two-year-old Maria was living among frail elderly individuals whose physical limits were similar to hers, but whose needs in just about every other sense diverged from Maria’s.  This community was not equipped to manage Maria’s psychiatric issues, as evidenced by her agitation and the incident with the nurse.

Following a stabilizing psychiatric hospitalization, Maria was discharged to an intermediate care facility for the mentally ill.  Here, her psychiatric needs would be addressed.  Her physical impairments, however, were left to flourish, worsen and render her bed-bound.  In a short span of time, Maria’s circumstances had deteriorated significantly:

  • There was no Hoyer lift to enable transfers from bed to chair or toilet.
  • The single elevator in the building was often out of order, meaning trays could not be brought up by kitchen staff and a non-ambulatory individual like Maria would not receive a meal.
  • Maria, as one of the only patients who could not transfer or ambulate independently, would often be left in bed past 1:00 pm.
  • Fully able to use a toilet, Maria was forced to use a diaper.  There was no equipment or staff able to move Maria from bed to toilet.

For those whose diagnoses span medical, physical and psychiatric spheres, placement is extraordinarily complicated.  Facilities tend to focus on, and be equipped for, one of these spheres but certainly not all.  Many communities specializing in psychiatric treatment cannot offer adequate care for an individual with severe physical limitations.  Similarly, a patient placed in a nursing home due to ambulation/transfer problems will find their psychiatric needs unmet and an elderly population surrounding them.

Fifty-Seven Facilities
Maria’s mother and guardian, Ruth, recognized that her daughter’s condition was unraveling and that something had to be done.  She also recognized that a placement such as this one calls for the skills and expertise of seasoned professionals.  Lifecare Innovations was hired to find an environment better suited to Maria’s range of needs, and to work with the existing facility to vastly improve the care they provided her in the meantime.

Lifecare Innovations’ clinical social work team has executed dozens of complex multi-need placements.  Facilities often enumerate obstacles to acceptance, given the limits of their licenses and in anticipation of complicated, difficult and costly care.  In Maria’s case, their objections tended to center on one or more of these elements:

  • Youth
  • Physical status
  • Cognitive impairment
  • Psychiatric diagnoses
  • Weight
  • Gender (some had only male beds available)

In sum, fifty-seven facilities were contacted and screened in search of one capable of managing Maria’s needs.  Despite our professional approach to each facility, knowledge of the assessment and screening process, and willingness to facilitate and manage all documentation and coordination for the transfer, nearly everyone concurred that Maria’s needs were more than they could handle.

But at long last, one of the fifty seven gave us a provisional “yes”.

Home, At Last
It was an intermediate care group home that met with Lifecare Innovations, Maria and her mother, and agreed – conditionally – that Maria’s needs could be met and her quality of life significantly improved in their 16-resident facility.

Equipped throughout with Hoyer lifts, this facility is fully accessible and encourages the use of motorized wheelchairs.  Two residents share each room and are free to decorate their spaces according to their personal tastes.  Nurses are always available.  Physicians from a variety of practice areas – primary care, psychiatry, podiatry – regularly visit patients on site, as do behavioral specialists and physical therapists.  The goal, as outlined by the administrator, would be to manage Maria’s behaviors and reduce or remove the psychiatric medications she was likely overusing.  Further, Maria would:

  • Shower daily
  • Be out of bed, dressed and ready for the day by 8:00 a.m.
  • Be among residents close to her age and of similar ability levels
  • Participate in group outings twice monthly
  • Enroll in a day program that encourages skill development and independence
  • Have access to daily activities and meals with other residents

These may not sound like noteworthy amenities, but Maria was living without these fundamental offerings and had been for some time.  A daily shower was perhaps the most exciting idea Maria had entertained in months.  She was eager to move in and preparations were made to accomplish the transfer.

It cannot be emphasized enough that Maria’s new facility was inclined to accept her due, in large part, to the ongoing involvement of Lifecare Innovations.  They were aware and reassured by the fact that our clinical team would continue to identify and solve problems, work with the medical team and Maria herself to increase stability and cooperation without also increasing her medication intake, and head off small issues before they erupted into major upheavals.   We are available to facility staff, the treating physicians and Maria 24 hours per day and visit on site at least once weekly.

The expertise and interventions of a clinical professional can make the difference between a failed placement and a successful one.  Identifying appropriate options, working with medical professionals to complete assessments and documentation that supports the patient’s placement goals, coordinating myriad details and resolving potential issues before they de-rail the plan are all specific ways Lifecare Managers can strengthen the odds for success and relieve families of the onerous task of finding appropriate options and making them last over time.

Maria and her mother had just about resigned themselves to the idea that life at the former facility was all it would ever be for Maria.

Today, from her motorized wheelchair or Hoyer lift, from her seat on the bus or from her place at the dinner table, the freshly-showered Maria would tell you otherwise.

©Lifecare Innovations, Inc.