In 2024, there was a major change in Massachusetts’ awareness of the need for a public guardian for the most vulnerable individuals. That year, advocacy by members of the Massachusetts Guardianship Policy Institute (the Institute), especially Wynn A. Gerhard, Esq., John J. Ford, Esq., and Paul J. Lanzikos, helped persuade the Legislature to commission two studies that energized the call for help. The Report of the Transitions from Acute Care to Post-Acute Care (TACPAC) Task Force, released on July 31, 2025, recognized incapacity as a significant reason patients remain stuck in acute-care hospitals long after being cleared for discharge. It recommended expanded support and funding for a public guardian to address this contributor to the state’s growing hospital bed shortage.
That same legislation also ordered the Department of Public Health (DPH) to study public guardianship directly — examining methods, management, costs, and funding options. Due concurrently with the TACPAC Task Force report, the DPH study has been completed but remains under internal review. We are optimistic that the report will affirm that Massachusetts needs a public guardian and, ideally, that it will offer concrete guidance on how that goal can be achieved.
How the Reform Effort Took Shape
For the past thirty years, the two most persistent problems with guardianship in Massachusetts have been: (1) that it’s often too easy to impose guardianship without adequate examination of whether it is truly needed; and (2) that when a person does need a guardian (particularly if they’re homeless, indigent, friendless, or estranged from family), there are too few qualified third-party professionals available to step in. Neither the courts nor the appropriate social service agencies have had sufficient funding or personnel to meet the state’s growing need for guardians.
Throughout this period, Massachusetts has largely squeaked by on an informal network of pro bono lawyers and social workers willing to accept appointments for respondents who lack the resources to pay for professional services. As one observer puts it, lawyers who happened to be in the courtroom when a pro bono guardian was needed would be “voluntold” by the judge to take the appointment. This was—and largely remains—a system built on goodwill rather than infrastructure. With an aging population and shrinking state budgets for mental health and community-based services, the old system has reached a breaking point.
The Consequences of a Broken System
One consequence is that hundreds of individuals in need of guardianship remain stuck in hospitals, awaiting the appointment of someone authorized to sign discharge and transition paperwork. This is not only inhumane; it’s costly. Hospitals and health insurers—including the Medicaid program—are estimated to spend between $100 million and $200 million each year on unnecessary acute-care days, while shortages of available beds delay care for new patients.
The challenge, then, is to develop solutions that increase access to guardians where they are most needed, while also strengthening legal safeguards and expanding alternatives for individuals who require less intensive decisional support. For the past decade, the Institute has wrestled with this quandary. Not to trivialize the problem, but this dilemma calls to mind the troubles of Ulysses’ in The Odyssey, when he sailed between twin dangers, Scylla and Charybdis: the course he took to avoid the whirlpool on the left drove him into the jaws of the monster on the right.
A real-world example of the problem is, unfortunately, the widely hailed enactment of the Massachusetts Uniform Probate Code (the MUPC) in 2009. This reform introduced heightened representation requirements and procedural safeguards to reduce the risk of unwarranted and ill-considered guardianships. However, it did not increase the availability of professional guardians for indigent individuals. In fact, compliance with the MUPC has driven up the cost of obtaining guardianship, thereby reducing the number of qualified guardians willing or able to accept appointments.
Different Models of Guardianship
The problem of mutually adverse pressures for reform does not have a simple or obvious solution. One answer may lie in recognizing that not all guardianships are alike. Individuals with more severe limitations and fewer social supports face significantly higher risks of harm, both to themselves and others, than those with fewer limitations and more social and financial resources.
Heightened risk requires a higher standard of involvement by a guardian. The Institute’s Report on Public Guardianship: Ten Year Review and Recommendations (the “Ten-Year Report”) shows that models of guardianship that require a heightened level of involvement already have been developed, and that these models have produced positive outcomes over the past decade in public guardianship programs in Connecticut, New York, and Massachusetts.
According to the Report, a clear divide exists between two dominant models of guardianship. One is an intensive level of professional care, often described as “wraparound,” “care-coordinated,” or “social work model” guardianship. In this model, a guardian actively oversees daily care, medical treatment, housing stability, social engagement, and other core aspects of an individual’s life. This approach contrasts sharply with a “decisions-only” model, in which a guardian’s role may be limited to authorizing decisions that are otherwise implemented by hospitals, nursing homes, social service agencies, residential managers, nonprofits, and other community providers who have care or custody of the individual.
In practice, decisions-only guardians may involve an average of just two hours per month of the guardian’s time — a limitation not unfamiliar to professionals who accept these appointments, who often are compensated for no more than 24 hours of work with the case per year. By contrast, the expectation in a social-work model of guardianship is that the guardian will devote an average of 100 hours or more per year to each individual served.
Outcomes
Another key finding highlighted in the Ten-Year Report is that the social-work model of guardianship reduces the rates of hospitalization, incarceration, reliance on shelters and food banks, housing court involvement, and other public and private emergency services each year. These findings were established in a peer-reviewed study conducted in Connecticut and subsequently replicated in New York. The reduction in public cost is drastic. The savings associated with social-work model guardianship are estimated to be five to ten times the cost of providing professional guardianship. While the annual cost of this model of guardianship averages between $10,000 and $12,000 per individual, the public and private costs that were eliminated for participants in the two studies ranged from approximately $60,000 to $83,000 per year.
By contrast, there is no empirical evidence that a decisions-only model of guardianship has a deterrent effect on public costs for emergency care, public safety, or any of the other outsized expenses that are incurred by at-risk individuals on their own. While it may be a reasonable assumption that decisions-only guardianship offers some benefit, available data suggest that its impact on systemic cost reduction is limited. At the same time, guardianship models are not absolute. There are gradations of involvement by guardians, and some who essentially volunteer so much of their time that they make an enormous difference in an individual’s well-being, at essentially no cost to society.
Looking Ahead
The impact of mutually adverse pressures to reform guardianship law and policy is not likely to disappear anytime soon. However, the findings of the Ten-Year Report point to progress in identifying how protecting the most at-risk, unrepresented individuals is both ethically sound and financially prudent. There are other indications that Massachusetts may be ready for a more complete set of reforms over the next couple of years, which may include possibilities identified in the Institute’s Ten-Year Report and the TACPAC Task Force report. With heightened public attention and a clearer understanding of what effective guardianship can—and should—look like, 2026 has the potential to be a watershed year for effective public guardianship policy in Massachusetts. Stay tuned.