and from the neighboring community. . . .

Here are comments from Somerset’s neighbors from the Uptown Update blog:

on the shutdown

on the possible shutdown

on city council hearings

on the federal survey

Residents and business owners in the area are encouraged to submit.  Again, all points of view are welcome.  The intent is to engage in dialogue and to sort out fact from fiction.  The neighborhood has much to say and deserves to be heard as well.

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7 Comments

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7 responses to “and from the neighboring community. . . .

  1. Ed Farmilant

    I was the owner and sometimes administrator of Somerset House from 1975 until I sold the facility in 1999 to the current owners. I started providing services for former state hospital patients in 1962, so I was there through most, if not all of the saga of community care for the mentally ill.
    A bit of this history to put the present into perspective: In the early sixties, the Department of Mental Health was caught up in the freedom movement; normalization could only occur in the community, so the plan was to discharge large numbers of patients to the community. In the older, less affluent areas of Chicago, like Uptown, there were a number of buildings that lent themselves to institutional use, and were very much for sale, since the hotel business in poverty areas was not thriving.
    Unlike other states, where the mass discharge fad led to people living in the streets or in small, fairly unsupervised places, because half filled, large nursing homes were available, IDMH created a program that placed elderly patients, primarily from the farm ward, (they actually grew much of the vegetables they ate) into them, and then people began to buy and convert buildings specifically for this population. The patients, now called residents, were out of the hospital on Conditional Discharge. That meant that the staff of this program could bring someone back to Chicago State Hospital if they so much as looked sideways without going through the formal admission procedure.
    The community, the press and the politicians had minimal problems with this process. In the beginning, these were elderly people, many of whom had been institutionalized for thirty plus years. Since they weren’t taught by hospital staff what proper community etiquette was, the major complaints had to do with urinating on the grass, or not knowing how to use a zipper. Many had not used a fork or knife in decades. Yes, they stood outside and watched the passing parade, but there were no incidents that involved life or limb.
    In the early years of this program, the facilities were paid by the Mental Health Department to provide room and board. For this we received a daily rate of $4.10. DMH outreach staff provided the social and therapeutic services. There was no way a small, not for profit facility could survive on $4.10 a day; they could not afford a standby cook, for example, to call in an emergency. The large size of these places provided an economy of scale that made this experiment doable.
    There were no regulations covering these ten or so facilities like Somerset (which was to be converted from a hot sheet place years later) that existed in Chicago at that time, other than the Chicago Health Department kitchen inspections. The various levels of care were what were licensed. Nursing Homes could provide nursing care (hands on services) while the Homes for The Aged could not, and it was illegal to admit someone who needed care at a higher level than the facility was licensed for. Most of these former state hospital patients did not need nursing care, and the rate was too low (Nursing Homes were getting $8.50 a day), so the licensed facilities could not afford to admit them. The ten, or so, homes formed an association and lobbied the City and State to provide a separate license category covering the services we gave, and the Residential Care Facility license was created. As well as giving us some stability, permanence and recognition, this kept the fly by night operators out of this segment of care.
    At some point, someone figured out that the Federal Government would pay for half the care, if somehow these folks could be made eligible for Public Assistance, and the entire cost of their care could be eliminated from the Mental Health Department’s budget, which was 100% state money.
    Eligibility meant several things; everyone had to have an Absolute Discharge, (so courts were set up in all the hospitals to accommodate this need), and to stay or be placed in a facility that the Public Aid department would reimburse, the resident had to have a medical diagnosis, otherwise the Feds would not pay their share. Needless to say, facility doctors and those in the state hospital system became very creative in diagnosing a medical need on paper, where none existed in reality. The consequence of all this is that facilities had to apply and qualify for a Nursing Home license, as their Residential Care license was now worthless. Never mind that the residents of these facilities needed the services that were authorized under Residential Care, and did not need those of a Nursing Home; in fact, this development was so counter therapeutic, that it brought harm to everyone involved. One consequence was the mixing of the elderly, infirm medical need resident with the young and robust mentally ill one.
    Needless to say that it didn’t take long for IDMH to dissolve their outreach program and remove their staff from the homes leaving the facilities with the new, added responsibility of providing the care planning and provision of the called for services. Practically overnight, these places had to create Nursing, activity and social service staff, and the policies that guided them. The beguine neglect by DMH created a void that the Department of Public Aid filled. IDPA created its own long term care section and rules; their main interest was in cost containment, and they developed an instrument that purported to set the time it took to provide a service, what level of staff was to perform the service, and how much they would pay for each element of care. By totaling the value of all the elements called for in a care plan, they arrived at a daily rate. When IDPA created its reimbursement system, the director of the project is reported to have met frequently with regulation writers from the Department of Public Health with the understanding that DPH would not require services that DPA would not pay for. This project’s director was quoted in the papers as saying that his system would find the lowest reimbursement that did not trigger serious violations. They then developed a line item cost report that each facility filled out yearly and was used to compute the facility rate for the following year, which was further tweaked by a paying a percentage of an area percentile average. The problem was that DPA created the line items of those costs they were willing to reimburse. Notably absent was a line item for staff training, and remember, DPH was not going to require anything DPA would not pay for. Yes, a facility could provide training anyway, but the effect of that was to lower the reimbursement rate for the following year. If you were a shareholder in one of these facilities, would you be happy with an administrator that spent more than s/he was required to, and lowered the reimbursement rate to boot? Talking about reimbursement, it is my understanding that the state has not paid Medicaid homes for a number of months. It seems obligations are a one way street.
    When Medicaid was created and began paying for long term care, that cemented the requirement that all reimbursable facilities had to have a nursing home license. The dilemma was that, out of necessity, the regulations had to follow a medical model; one aimed at insuring care for the medical chronically ill. The medical model, based on the hospital model, assumes that the patient has a curable, or at least symptom relief prognosis and will need care for a relatively short time. In such a setting, staff can be interchangeable parts, a broken leg or recovery from open heart surgery will be treated about the same way in hospitals across the country, and from shift to shift in the same hospital. If a patient’s relative dies, the emotional response is not the concern of an acute care staff. If the food is lousy, well the patient will be here only a few days. If the patient has no usable clothing, well give them a bed gown. What is the significance of a resident smiling or feeling depressed that day?
    When the recipient of care has a chronic illness and needs to be in a long term care facility, the anticipated stay can be measured in years, and everyday issues take on a greater meaning. In the chronic care model, it is the relationship between residents and staff that is of prime importance.
    Around this time, due to some bad publicity about a nursing home depositing an incorrigible patient on her daughter’s door step, the legislature passed a bill that prohibited a long term care facility from discharging a patient except to a hospital (and must accept that person back) or for nonpayment of the bill. No other reasons. It didn’t take long for the young, street smart resident to figure out that they didn’t have to do anything and the facility was powerless to respond. To make matters worse, the state legislature passed a bill that established ratios for nurses and nurse aides to numbers of residents. This might seem reasonable, and should have produced better care except for the nursing shortage. Now that an unfilled nurse position was a violation punishable by fine, the nurse registry industry blossomed, and Registered and Licensed Practical Nurses began working for them, willing to give up benefits for higher immediate pay, and the freedom to choose where and when they were going to work. The unintended consequence was, and probably still is, that theoretically there could be seven different nurses working on a shift in the course of a week. Forget any continuity of care or any semblance of a nurse getting to know her patients, let alone the established procedure in a facility. They rented their license for a shift and tended to be indifferent to helping resolve any serious situation. And all this for about fifty percent more that the facility paid to the registry than they paid to the nurse when she was an employee. Of course the nursing shortage affects hospitals too, but they have the ability to raise their daily rates, so they can and do outbid long term care facilities for registry nurses.
    Well, finally getting to the point; the mentally ill person needs to be in a facility, the facility needs to have a nursing home license, the license calls for compliance with specific minimum standards, one of which is that a resident cannot be forced to take medication, or follow the dictates of a care plan, or stay in the facility at two in the morning.
    In the early days, administering facilities that served the mentally ill, the work was rewarding; we strove to help each resident reach his or her highest potential, and in the main we were successful. Eventually the discharge to community rate was not the goal; rather it was the resident’s comfort and stability each day. The facilities sought best practices and main tool we had to do this, was the ability to say to a resident ‘you have the right not to take your medication, or you have the right not to attend your group session, but that means you have to leave here. This program is too expensive and the staff too qualified for you to ignore it, and someone more serious about their future needs your bed’. We had a uniformed guard at Somerset by the front door to be sure that the people who came in had legitimate business, and to prevent the vulnerable from leaving at two in the morning.
    Once Medicaid became the payer, all this was a violation of the resident’s civil rights. Around this time, we began to see substance abuse show up frequently in the chart of people being referred, and the average age dropped from 60 when I started in the field, to the late 20s. The result was a great deal of frustration of the part of staff, a waste of their time and education, and those that could left.
    Much of this happened so long ago that I’m not sure of the sequence of some of it. At one point I had an idea of a way to finesse the civil rights issue and begin to provide again the care our residents needed. My idea was to have the Illinois legislature pass a bill that for anyone in a long term facility that had a secondary diagnosis of mental illness or substance abuse, (everyone’s primary diagnosis was medical) had to abide by the reasonable provisions of his or her care plan, and the refusal to do so, could be grounds for the discharge of that person. There were built in safeguards as to what reasonable meant, and a means of providing an outside, independent arbitration process to settle any dispute. The resident’s civil rights are protected; they can refuse to participate in their care, but there would be consequences that would protect the facility’s program integrity. If facilities like Somerset are expected to provide a therapeutic or secure atmosphere for its residents, then it must be given the leverage to do so. One ironic note; we had prospective residents sign an agreement to abide by their care plan and an understanding that they would be asked to leave if they didn’t. Public Health lawyers told us that such an agreement was unenforceable; the signer was mentally ill, and not competent.
    Needless to say, my idea went nowhere. I first went to the legislator who was most visible about the problems of long term care facilities. I thought that her introducing the bill give assurance to the others. Even though top officials of the Mental Health Department supported it, she just knew that if a for profit nursing home owner was pushing it, there had to be a hidden catch and wouldn’t touch it. I then went to the Representative for my district who introduced the bill, but before the House could deal with it, he amended it by gutting all the content relating to my idea and inserting in its place something having to do with added reimbursement for Kosher meals in Jewish Federation Homes for the Aged.
    This was no longer just not fun; it was overwhelmingly frustrating and stupid. The competing needs of three state agencies, the neighborhood, the press and the politicians at all levels made any attempt to be anything other than an impotent caretaker futile. I had spent almost 25 years of my life living and breathing Somerset, and I have some wonderful memories, but for the sake of my mental health and that of my wife, I decided to sell the place.
    I have been retired for 10 years, so much of what I have written here about the system may be out of date, but I doubt it; in Illinois nothing succeeds like inertia. I don’t begrudge the people I sold Somerset to for making so much money; that is clearly what the system is telling them to do; shut up, go through the motions, play the game, and take the dough. I worked in long term care, as an owner and or administrator for almost 45 years and I have seen a great many scandals in all that time. The media are interested in going only one or two layers deep about a problem that has many more; they don’t want to make things too difficult for their readers. The politicians come to this issue without any background in it other than their ability to grab center stage. Time and time again a facility was made the example; a public hanging and everyone thought the problem was solved now that there were greater punishments for violations. Of course none of it ever worked.
    This is not an attempt to justify the behavior of any owner or administrator, and I firmly believe that many are in the wrong business; they should be working for Goldman Sachs. But, I think that no administrator of a primarily Medicaid reimbursed facility can be expected to provide optimal service until the all the system components that conflict and contradict each other are reconfigured, and that is not going to happen anytime soon because no single government agency has the power to insure that all the elements of care enhance each other, and none would volunteer for the job anyway. It seems to me that only a Non Government Organization, without an axe to grind, begins to research, analyze, develop and publish a comprehensive blue print of what each agency has to do and which laws have to be modified so the whole system can be put into a workable condition.
    Does anyone really think that any owner or administrator gets up each morning and says ‘let’s see, how can I screw over my residents today?’

  2. Thank you Ed. That sort of historical perspective is invaluable and, it seems to me, precisely what is lacking in this entire episode. Thanks again,
    Jeff Beeler

  3. Edward

    Since I have been kept abreast of the “Saga of Somerset” by a person who is directly involved in the daily running of, and treatment of patients therein, I found the history presented by Mr. Farmilant most enlightening. Especially when viewed in context with the State of Illinois, the Federal Government, and the media’s unbalanced and incomplete reporting of what the owner(s) and staff of Somerset are dealing with.

    I know of NO business that exists to lose money- save that of Federal Government agencies, and they don’t mind because its not THEIR money that is being lost. However, private businesses exist to make a profit IF they are a profit-making entity. Should they not profit they cease to exist. The other, the non-profit organization, need only maintain itself, and generally does so because they operate under a different regimen.

    Somerset was set up, as noted above, to provide care to patients. It was the State, either Federal and/or State, that created the untenable position that Somerset now finds itself in, and should be punished accordingly. Of course that would not be an imposition on them, after all, it is YOUR money they would use to pay the sanctioning with.
    Perhaps it would be more appropriate to enact legislation that would require personal monies to be used to pay for cases lost due to inappropriate use of legislative or judicial powers. Malfeasance in office should also be a basis for immediate dismissal and loss of future benefits. The loss of same might give bureaucrats pause BEFORE they act.
    But then, Washington is not known for being aboveboard and transparent in it’s actions. Nor, for that matter, is the city of Chicago or the State of Illinois. When corrupt people are running things it is inevitable that corruption is what will result. With Washington and Illinois government involved it is no wonder that Somerset finds itself where it is.
    It would be great if the Tribune had the gonads to publish Mr. Farmilant’s comments in entirety, and for those officials and legislators in a position to influence policy/law were required to read and publically respond to it- especially to the family and friends of Somerset’s “clients”, but don’t hold your breath. Acting in the best interests of their constituents is rather rare- unless you are a part of their circle.

    It seems that NOTHING new has been presented here, nor will NOTHING new come of all the words and concerns raised by those directly involved: the clients, the staff, and all those others who are affected by the prosecution, no, make that PERSECUTION, of Somerset.

  4. Ed Farmilant

    There were few places for the infirm elderly to receive care before the Second World War. During the war, with all new residential building stopped, people who moved to Chicago to work in defense related jobs tended to live in boarding homes. The building of new housing took time to complete as the people in the boarding homes, now many without work, began to age and develope the chronic illnesses that come with age. With no where to go, but with social security money and The Chicago Department of Public Aid putting these folks on their rolls, many just stayed in the boarding homes, which were soon forced to provide some TLC as well as food and board.

    There had been Homes for the Aged, all run under religious or fraternal auspices, and all were not-for profit. Their source of income was the up front life savings that each resident gave to the facility in return for a promise of life time care. I think there had to be a minimum of $10,000 given over. These places refused to admit anyone needing nursing care, the actuaries said that would cost too much.

    The actuaries hadn’t taken the medical breakthroughs that the war caused to be developed, and people were living longer, which meant that until that group of residents died, these homes had to cherry pick those least in need of care – to care for.

    This situation created a need for the nursing home, and since the not for profit sector wouldn’t be bothered with folks who needed to be fed or given a bath, those folks were relegated to the for profit sector.

    By the early 1950’s, entraprenures were buying and converting three flats and mansions, anything with multiple rooms that beds could be tucked into. The demand became so great that the Chicago Department of Public Aid created a section to place and pay for folks in these new facilities.

    The rest you know.

  5. I responded on Mary Ann Smith’s blog site, but have not had a problem with residents of the Somerset in the 30 years I have lived in the neighborhood. Nor have I seen the residents engaged in any negative acts other than the mute who panhandles and I am not sure even if he is a resident of your facility. The neighborhood has been changing and improving, but as you will see in the community blog, I have no greivance. I also knew the facility better when Ed Farmilant was in charge. He was a terrific manager.

    • Steven Voss

      I worked at Somerset House in 1978 & 1979. I worked for Ed Farmilant & knew him & Barbara very well. I was a maintenance man there. Mr. Farmilant was a great person to work for & he truly cared for all of the residents at Somerset House & worked hard to make it a great place for us to work & a very nice place for the residents to live. I have only great memories of my time working there & the people I worked with. Mr. Farmilant wanted all residents to receive the respect they deserved & he made sure that the people that was hired wanted to show respect to all the residents.

  6. Thank you for your comment. Though yours is positive regarding Somerset, I am equally open to posting all views from the community. Please spread the word about this blog. I hope to achieve here what seems so lacking elsewhere: a more intelligent and informed discussion about the problems of the mentally ill in Illinois. And Uptown. Thanks again.
    jeff

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