Monthly Archives: March 2010
Resident X is deaf and dumb and does not communicate via writing anymore. She does sign. After many hours of work, staff found her a placement in a facility with a deaf community, including a deaf doctor, several other deaf residents and a full-time social worker fluent in sign language. Resident X was all set to go- info faxed, accepted, on the list to go, ALL SET. Where did she go? The state of Illinois sent the woman to Park House! WHY?!?!?!?! To my knowledge, Park House does not have a full time staff member fluent in sign language. How is that a good placement for her and what was wrong with the placement we found?
Resident Y set to go to Arbour. Again, a great placement. Smaller facility, more nursing care oriented (skilled) as Resident Y has some issues with mobility… his family was involved in the placement, toured the place and liked it… He was accepted, and ALL SET to go. Where did he go? The state of illinois sent Resident Y to Margaret Manor Central! Resident Y is gonna get flattened… Why??? The family’s response: “Total bullshit”.
Here is how the state could have managed the closing of Somerset more competently:
- Take the facility into receivership. Locate, hire and install one of the best administrators available with a demonstrable history of success in managing facilities with a severely disturbed mentally ill population. Provide that administrator with expert consultants and resources. Then, bring the facility into ‘substantial compliance’ and ensure quality services. As the state expected the facility to develop a plan in 24 hours and correct the problems in a couple of weeks, presumably a top-notch administrator could have things fixed in short order.
- Consult with experts and develop the new pass screening instrument that includes a risk assessment (as recommended by the task force) and begin to re-screen Somerset residents with the new instrument.
- Develop the ‘special certificate’ care and services for high-risk individuals, as the task force recommended. Presumably, this would be at another facility, though with the expertise now installed at Somerset, a unit could be devoted to developing this program; after all, the state, not the owners, are now in charge.
- Comprehensively assess available community services, housing options and the degree of acuity that these current resources are able to manage. As the task-force recommended, begin to develop and augment these community based services. They are currently inadequate in relation to need, as everyone agrees.
- Comprehensively assess how many of what types of placements are needed (ie., how many for high risk, special care, how many for community care, etc.). Compare this need to the available placements and develop additional placements where needed. For example, additional funding many need to be allocated to excellent current community agencies to expand their programming in order to accommodate increased demand and possibly the need for more intensive services.
- Systematically move residents into the now developed services according to an assessment based on the newly developed pass screening tool.
- Negotiate with the owner on the disposition of the property.
The advantages of such an approach are obvious and numerous:
- The receivership management will immediately resolve the ‘hell-hole’ situation and establish safety and quality care, removing the ‘immediate jeopardy’ situation that is the state’s basis for action. This would also immediately resolve the concerns of the community as the place would now be under competent management (ie., in contrast to the assertion it currently is not).
- The task-force recommendations, which are critical to addressing the underlying problems for which Somerset is merely a symptom, can begin to be implemented, tested and given public scrutiny.
- The state would develop a working model of how to make the transition from primarily institutional-based care to largely community-based services. In the long run, they are going to have to empty out most of these facilities in order to fully implement the task-force recommendations.
- Residents would be ensured better placements as well as time to cope and adjust to this dramatic change in their lives. Dangerous offenders would be placed where they could be managed and treated securely and residents would be more likely to obtain the level of community-based care and services they require.
- Staff would have time to find new jobs, decreasing the impact on unemployment and local businesses would have time to adjust to a loss of revenue as the large facility—staff and employees—are no longer customers.
So why did the state not do this? Simple: they would have failed, for several reasons:
- Cronyism. Had the state taken receivership, they would not have sought out the best and brightest to take on a challenging situation. Instead, without doubt, they would have installed some poorly qualified, mediocre muckety-muck currently in the department that has, for the past ten years, been demonstrably ineffective at accomplishing any significant change in the first place.
- Accountability. Had the state taken this approach, they would have had the same problems the administration of Somerset had. If they attempted to prevent residents from loitering, they could not restrict them to the building (a violation of their rights). Nor can they prohibit anyone, resident or not, from standing on a public sidewalk. And like Somerset, they would find the police refuse to enforce laws against loitering, begging and public nuisance against residents but instead say ‘it’s your problem, manage it.’ The list goes on. The state, like staff, would have found it very difficult to engage residents in programming without meaningful incentive or means of compelling participation. And like Somerset, with some irony, they would have found that community based services had been cut as a result of state budget cuts.
- Visibility. It is easy for the state to say they are going to develop an instrument to screen for risk, easy to say they are going to develop special services for high-risk individuals, easy to say they are going to substantially increase community based services. Actually doing it is an entirely different matter. To have the actual implementation of these services in the spotlight during the closing of Somerset, though logical, is the last thing the state wants.
As a result, they charge in and allow only 30 days to re-locate 300+ extremely difficult to place people. The available community services are limited and those that exist, though in many cases of high caliber, are not necessarily prepared to deal with the severity of illness among Somerset residents. There are no special services for high-risk residents, nor any specialized tool for determining who those people are. The whole thing is poorly planned and haphazard and amounts to essentially shuffling people around. Why did they do this? I’m not sure whether to attribute it to general incompetence or, more cynically, to strategic effort to play public relations rather than do the hard work to truly address the needs of the people they are purportedly rushing in to help. The result is the same.
There is a fascinating BBC produced documentary by Adam Curtis entitled ‘Century of the Self’ in which he details the rise of ‘public relations’ in the 20c. Founded by Edward Bernays, ‘public relations’ was the term he coined for propaganda. The essential discovery was that you could control the public by appealing to their emotions rather than their rationality. The impact of this cannot be underestimated.
The Tribune ‘reporting’ illustrates this so well one might imagine Bernays sitting behind Marx and Jackson saying ‘no, no, scratch that, put this in instead.’ I will illustrate this point with their most recent article.
Clearly, the issue at hand, one would think, is the disposition of the residents to new homes. Are they going to better facilities? How are they being treated in the process? Where are they going? Most importantly, where are the identified offenders—those dangerous felons the Tribune has reported on endlessly—where are they being placed?
Instead, the article is comprised of two key elements:
- a discussion of the profit and financial transactions of the owner, implying that he is a schmuck and,
- bland assertions that the state is handling everything just fine.
Here is why this constitutes propaganda rather than reporting:
The effect of the article is to make readers angry at Mr. Rothner, implying that he has raked in millions and engages in disreputable financial dealings while running a one-flew-over-the-cuckoos-nest style facility. This is followed up by unsupported, vague and bland assertions that the state is in there making everything right. So the public works up a righteous ire against the owner and rallies to the state.
What’s wrong with this? Set emotion aside for a moment and ask yourself the following questions:
- The state has been inspecting Somerset, under the current owner, for 10 years. Why now do they decide to close the ‘hell hole?’ How did the place pass inspections for the last 10 years? Did the state stand idly by for 10 years? Was the facility operating fine for 10 years; if so, how did it plummet so fast? By asking these questions, the Tribune would introduce rationality and put the spotlight on the real problem: (a) the state has been complicit with the poor care in (all) these facilities all along (b) Somerset is not really the hell-hole the state is conveniently deciding it is now. This would lead to a critical question: what’s the state up to? (or for that matter, what is Ald. Smith really up to?)
- The Tribune reports that Somerset earned a profit of 21 million over 8 years, which means 2.6 million per year. The implication is that this profit is shameful. Why is that? How much profit do other nursing homes make? How much profit does a hospital make? How much profit does your bank make when it lets you take your own money from an ATM? Is the Tribune implying that the state is overpaying for these services? If so, they should say that. Or is the problem that the owners have made any profit and not provided the services expected. If so, then profit is irrelevant: the issue is the quality of care provided, which takes us back to question #1. If Rothner has been milking an unethical cash cow for years, the state has been feeding and fattening the cow the whole time. But the Tribune includes this information to get you mad and make you stop thinking rationally. In the process, like any good propaganda, diverting your attention from the state’s role in all this, past, present and future.
- The entire Tribune series focuses on dangerous felons being inappropriately housed in nursing homes, citing specifically 67 in Somerset. Again, the Tribune fails to inform us what, exactly, the state has done with these 67 individuals that, according to the Tribune, are highly dangerous. That is because they do not want you to know the answer: they have simply moved them to other facilities very similar to Somerset or, I believe in at least one instance, placed them in community living arrangements. These dangerous offenders are, according to the Tribune reports, the heart of the story. Where are they now? Funny, no one asks.
- This article reports that 43 residents have been screened for community living (though some of these opted to remain in an institutional setting). That leaves nearly 300 residents unaccounted for? Where did they go? To other similar facilities? What is the track record of those other facilities? How many were able to go where they wanted? How far were they displaced?
The real story here is that the State of Illinois has for decades neglected their responsibility to provide care for the chronically mentally ill and have simply dumped these people into nursing homes, which they paid more poorly than most other states, and for which they provided extremely poor oversight eventually creating the mess the Tribune is, in its own sophomoric way, reporting on. And now the state wants to avoid court interference in its autonomy as a result of two pending lawsuits and, during this budget crunch, wants to rake in matching federal dollars provided for community based care. So suddenly, they want residents out of these facilities. But instead of first developing the services—both the intensive treatment programs for high risk patients as well as the community based services—and then rationally transitioning current nursing home residents into these new services, the state is, in a remarkable show of stupidity, putting the cart before the horse and starting to clear out the nursing homes first. If Marx and Jackson were responsible reporters, they might ask questions about this instead of accepting as fact every bland assurance fed to them by the state. Instead, like good propagandists, they whip the public into a sense of outrage against the bad guy owners. In this way, the state gets cheered as it goes about making an even bigger mess of things and no one stops to ask any rational questions which might, just might, make the state slightly uncomfortable. The state couldn’t hire better propagan. . .uh, I mean, public relations services.
A candlelight vigil was held this evening for the residents of Somerset by the Organization of the Northeast. It received considerable media coverage, which I hope will bring attention to the plight of the mentally ill in Illinois. I believe the organization that coordinated this vigil shares my concern that the events at Somerset are not isolated, but reflect a larger pattern of irresponsible behavior on the part of the state. If we do not, as citizens, watch the state and hold it accountable, tragedy is sadly predictable. The vigil brings about public awareness of what is going on. And hopefully from public awareness accountability and responsible decision-making will be more likely. Here are some pics.
The full task force report is here and a link to their website is here. The effort and subsequent report is laudable. The appendix provides an excellent history of the problem. If the state adequately implements the plan outlined, care of the mentally ill in Illinois would improve dramatically. However, we have been here before. Illinois has a history of recognizing it has a mess on its hands in mental health, then investigating, initiating recommendations and enacting legislation only to have things remain pretty much the same.
To its credit, this round appears more comprehensive than ever before and the need to obtain federal money through community based care and the need to avoid nasty outcomes in the pending Olsmstead lawsuits provide significant incentive for the state to pursue real change. That said, success in implementing the task force recommendations depends entirely upon the competence and integrity of the state agencies involved, particularly HFS and IDPH. Observing their behavior at the closing of Somerset does not make one particularly optimistic.
The task force recommendations fall into 3 broad categories: (a) improve screening and background check procedures, (b) improve quality of care at nursing homes (c) increase community based care. All three goals are commendable, but the latter two deserve further comments.
Improve quality of care at nursing homes. The focus of this entire section is punitive and antagonistic with an implicit assumption that nursing home operators will not provide quality care unless forced to do so. There are several problems with this.
First, if operators provide substandard care, it is most likely the result of attempting to maximize profit, like any business (regardless of how short-sighted their strategy may ultimately be), or simply not having sufficient expertise to provide better care. The state sets the parameters by which this industry operates, including staffing ratios and qualifications. Thus, the task-force recommendations of increasing staffing ratio, training requirements (ie., specific certification for CNAs working in mental health and certification for PRSCs) is good. Their recommendation to tie a facility’s per diem reimbursement rate to accreditation by a national accrediting organization is essential. That is, set the standards and provide incentives. In addition, they propose establishing a technical unit that functions to provide non-regulatory expertise and assistance to facilities in establishing programs and services. Again, on target. It is rational to assume that operators are not malevolently providing bad care but are operating within the system of incentives and requirements provided by the state. If results are poor, it is incumbent upon the state to change those incentives and requirements, which this report recommends.
However, there is still great emphasis on oversight and punitive strategies in maintaining the quality of care. The problem with this is that the state surveyors themselves often lack the competence and credentials necessary to meaningfully carry out their oversight responsibilities. I have repeatedly witnessed survey teams where many of the surveyors have no background, experience or training with a mentally ill population. A surveyor once said, ‘You mean you let these people have sex?’ As a consequence, surveys often focus on paper compliance. The very first item in the task-force recommendations is that every individual have a care plan detailing the services they receive and goals/plans. This already exists. The problem is the quality of the care plans and the quality of the services detailed in them. Similarly, the task force commented on yo-yo facilities that go in and out of compliance. This phenomenon arises, at least partially, because the ‘plans of correction’ the state accepts are equally paper compliance bullshit. The very first item in the recommendations regarding improved oversight, then, should be as follows:
State employees charged with oversight and regulation of facilities providing mental health services by special certificate will be qualified, licensed professionals with minimally the same years of experience required of comparable professionals employed by the facilities they are monitoring. The employees will, like most professionals licensed in Illinois, be required to accrue relevant clinical continuing education to maintain their employment.
Second, to avoid dumb-ass plans of correction that are really no more than paper trails that show both the state and facility are doing something, though both are complicit in actually doing very little, I suggest the following addition:
When a facility is found to be in non-compliance with significant scope or severity, they will be referred to the technical support unit to jointly develop a plan of correction to bring the facility into compliance.
The purpose of this is to provide a mechanism by which the state and private operators can work together to solve problems and improve care, eliminating the antagonistic ethos that benefits no one. This is critical because, even the best regulations can devolve into mere paper compliance.
Finally, the task force does not discuss the role that reimbursement rates in Illinois may play in the quality of care provided. They recommend increasing staffing and training and propose a ‘bed tax’ but fail to note that the average per diem rate in Illinois is one of the lowest in the country. A bed tax is tantamount to reducing reimbursement while at the same time requiring an increase in services focusing more exclusively on the more difficult and dangerous patients. What is needed is a financial analysis to determine the feasibility of increasing services and decreasing payment. And since this ‘bed tax’ is going to fund more oversight, that oversight should (a) be qualified and (b) provide resources and expertise to assist facilities in improving services rather than simply monitoring paper compliance and generating fines.
Increase community-based services. Lord knows, this has been sorely needed since, say, 1963. It is essential because in the absence of appropriate and sufficient community services and living options, the state basically debilitates its psychiatric population overall. However, this idealistic (and commendable) idea merits two critical caveats:
First, if the state finds it difficult to regulate nursing homes (or IMDs, of which there are only 26), it is remarkable that no one has discussed how it is they will provide oversight and regulation to hundreds, possibly thousands, of small, diverse and local community based services. The presumption throughout both the Tribune articles and the task-force hearings seems to be that community-based care does not require oversight. This is unrealistic. In fact, incompetence, cost-cutting, errors, poor administration and tragic events are just as likely, perhaps more likely, in community-based treatment, which though admittedly better is significantly more challenging in many ways. I don’t recall a single word devoted to ensuring the quality of community-based services, nor to how safety of patients or the community will be monitored and ensured.
Second, though clearly many persons currently in facilities could be appropriately treated and maintained in the community, this is not the case across the board. And, unlike what is implied in the report, those not appropriate are not always identified offenders (and conversely, some identified offenders would be appropriate for community care). Although it is somewhat implied in their recommendations, what is essential is a continuum of care, from the most restrictive (even locked) setting to independent living. By not explicitly detailing this continuum, the task-force fails to address what is the most vexing challenge of mental health services: ensuring smooth integration across agencies, settings and levels of service. Only the state can achieve this. What is critical here, is that they fail to identify what agency would take this birds-eye view and have the authority to integrate services and care across a continuum. Consequently, it is virtually guaranteed to remain fragmented and ineffective. What is needed is a single agency that directly manages all services to the mentally ill (not really feasible) or a permanent authority that coordinates various state agencies to provide a coherent system of service provision to the mentally ill in Illinois and reports directly to the governor and state legislators. In its absence, chaos is likely, especially during transition.
Finally, as an aside, though the task-force listened to testimony from scores of different stakeholders, what is notably absent is much in the way of hard, empirical data. It might be valuable if they had identified areas in which competent studies carried out be experienced researchers might be funded and provide much needed data rather than basing plans for an entire system of care on people’s opinions, no matter how experienced they might be. Just saying. . .
Immediately after the facility staff was informed that Resident X , (previous offense of double murder) had been approved for community living they informed the state of their clinical assessment, which was that this resident was at high risk for offending again if not placed in a supervised setting where licensed staff could monitor/manage his clinical condition and medication compliance. This resident has a past history of medication non-compliance and substance abuse when not supervised to take his meds. This is what led to his offense of double murder. They must have not taken the staff seriously because he has been assigned an apartment in the uptown community, and I believe he has already moved into it.