Review: The task force recommendations

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. . .

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