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Richmond Times-Dispatch Guardianship Series

Sunday, Nov. 17, 2019

Dear Team Members,

A few weeks ago, the Richmond Times-Dispatch came to us with a lengthy list of questions regarding the health system’s guardianship practices. The reporter and editor were honest in their opinion that our management of these cases somehow reflected a conflict of interest. A small group of senior management sat down in good faith with them to discuss their misperceptions and were hopeful that the resulting report would be fair and accurate. We were sincerely disappointed.

The promotion of and the first in a series of reports that were published today are egregious in their lack of balance, context and journalistic ethics. The reports are based on a false premise that strikes at the very heart of our commitment to our mission.

We want you to know what was shared with the Times-Dispatch:

  • Similar to other health systems, VCU Health System pursues guardianship for hospitalized patients who are not capable of making health care decisions and who do not have a family member or friend who is able, available and willing to serve as the patient’s decision maker. 


  • The ultimate decision about guardianship, and who will act as the guardian, is made by the court – not our hospital. Guardians are court-appointed. VCU Health System has no role and has never participated in the process to determine who is appointed to be the patient’s guardian. The court orders the guardian’s responsibilities to their ward. Our health system’s court costs are dictated by statute.


  • Guardianship is a last resort and rarely pursued. Guardianship accounts for less than one-tenth of one percent of our patient discharges. For example, in FY 2019, out of 39,000 inpatient discharges, 34 were guardianship cases. This is a significantly low number given VCU Medical Center’s status as the largest safety net hospital in the Commonwealth.


  • As a licensed inpatient hospital, we must ensure that all of our patients are discharged from the hospital into a safe environment. VCU Medical Center expends significant human and financial resources for a variety of uses to ensure that every patient is safely discharged from our hospital without regard to their ability to pay. Depending on the situation, this can include skilled nursing facility contracts, home health visits, transportation, and durable medical equipment.


  • VCU Medical Center undertakes an exhaustive process that can take several weeks to several months to ensure a patient’s safe discharge. It involves the collective effort of the entire care team that includes doctors, nurses, psychiatrists, occupational and physical therapists, social workers, and more. Guardianship cases are the exception and occur when the discharge planning team cannot identify a designated decision-maker or other family member willing and able to serve for a patient who is clinically designated as incapacitated and no longer needs inpatient-level care. We see everything from decision-makers who are believed to lack capacity themselves to physical and/or mental abuse occurring in the home (Adult Protective Services often is aware of these cases). And sometimes incapacitated patients simply do not have anyone to be their decision-maker.


We especially regret that the Times-Dispatch included incomplete information or out-of-context stories and hearsay about health system employees and patients to make their case. The real story, fortunately, is told in the compassionate care you provide every day that saves and betters the lives of hundreds of thousands of people in the Richmond region and beyond. Thank you for your continued commitment and passion for our mission and the people we serve.


With high regard,


Marsha Rappley, M.D., Senior Vice President for Health Sciences and CEO, VCU Health System


Ron Clark, M.D., Interim CEO, VCU Hospitals and Clinic


(Note: This letter was sent to VCU Health System members.)


Update (Dec. 4, 2019): Laura Reitmeier, nurse clinician in the Medicine Division of the VCU Health System, gave permission to VCU to share her response (below) to the Times-Dispatch's series on guardianship. She originally posted the response to social media.


It took me several days to process the inaccuracies in the Richmond Times-Dispatch “Unguarded’ articles and formulate a response.  First and foremost, as a healthcare provider, my duty lies in protecting patients and families.  That protection includes guarding the privacy and confidentiality of those we serve.  As such, out of respect for my patients and my profession, I cannot share specific details regarding these cases.  What I can tell you though is that I was there and Ms. Balch and her editor are simply wrong in their portrayal of VCU Health’s role in the guardianship processes that occur in our system.

The most disturbing thing about this article is that she truly has all of the information and facts.  She spent a year researching these cases in detail, and links many sources and documents that she collected during that time.  Healthcare in America is complex and baffling.  It is a web of laws and rights and policies that often seem to make zero sense.  I would not expect someone not in this field to fully understand it (even after 15 years I do not) and if the author only had the superficial facts of these cases, then I would not fault her for drawing the conclusions that she did.

Unfortunately though, she did have many of the facts.  And the facts show that our system is broken.  There are deep, systemic injustices in our country that set people up to find themselves in these precarious and hopeless positions.  There is a lack of preventative care, a lack of education, the impossibility of health care costs, the unfathomable rules and caveats that come with coverage and yes, a huge disparity in care for our indigent and underserved populations.  She also had very specific facts about the patients of which she writes that she chose to leave out of her article.  I can assure you that there was no other safe discharge plan and every avenue was exhausted.  I can only assume the information was withheld because it does not match the intended narrative.  Instead of using the information she uncovered to shine a light on the deep fractures in American healthcare, she chose to set up an enemy in the very health system in this community that takes in these vulnerable patients.  VCUH is the largest safety net hospital in Virginia.  That means that no patient is turned away from care regardless of their insurance status. We do not turn them away. We do not remove people from hospital beds because they are poor.

I have the honor and privilege of working in the Medicine Division, which by its nature cares for many patients with complicated socio-economic and psycho social issues and specifically the patients discussed in the series.  I have seen the very system maligned in this article go above and beyond to find a safe discharge plan for the most helpless among us-over and over again.  Again, I am unable to share the details as I am bound to protect the privacy of our patients and families.

I encourage everyone to read these articles.  I also encourage you to read the supporting documentation and to determine if what you are reading matches the conclusions drawn here.  I challenge you to explain how anyone could say that guardianship is an “efficient” process to get people out of hospital beds.  It is an absolute last resort and only considered once every other option has been exhaustively explored and ruled out.  Even then, I have seen patients refused by every nursing home facility in the state of Virginia.  I would ask you to research what happens to patients when they stay in an acute care hospital setting after the issues that required hospitalization are resolved.  Learn about what the lack of mobility can do to their long-term prognosis, what the disturbance of the body’s natural day/night rhythms can do to their mental state.  Learn about these issues, learn how you can advocate for those that can’t, and be a part of the solution.   This is everyone’s problem. The mightiest ally we have is our ability to vote. 

And to my Social Work and Care Coordination colleagues, I see you.  I know what you do day in and day out for the patients in your care.  I hear you have the difficult conversations.  I see you hold someone’s hand as you deliver news they do not want to hear.  I see you graciously accept the role of enemy because sometimes vulnerable patients and families just need somewhere to direct their anger.  I know what you do and I appreciate you and am honored to walk this path with you.

Those that know me well know that I cringe at posts or memes extolling nurses and healthcare providers, or listing all of the difficult tasks we complete.  This is what we signed up for when we entered the profession.  I don’t want accolades or to be told our job is thankless.  It is not thankless.  It is full of difficult things, but it is also full of hope and joy and I am lucky that I get to meet so many people and be a small part of their lives.  What I do want is for you to pay attention to these issues and if you are so led to advocate for policies and lawmakers to work finally to fix the system.


Laura Reitmeier DNP, MS, RN, ACNS-BC

Nurse Clinician-Acute Care Medicine

VCU Health