September 29 2009: Illinois Nursing Homes Mix Felons, Seniors

In this initial article, Jackson and Marx accurately present a significant problem in the State of Illinois.  In a nutshell, many mentally ill persons, including some with criminal records, are shuttled into nursing homes where they (a) place other residents at risk and (b) often do not receive adequate treatment and services.  As a result, tragedy predictably ensues.  They report several horrific instances of murder and rape documented in nursing homes.  They cast a wide net of apparent blame, criticizing the state, law enforcement and the nursing home industry.

They correctly identify several contributing factors.  First and foremost, though it receives surprisingly little focus in the article, they report that the state has no other place to put these people.  Other than court-ordered long-term hospitalization in a state psychiatric facility, such as Elgin, Illinois has no system in place to address the needs of psychiatric patients with a history or risk of violence.  There are few, if any, specialized facilities or programs.  Even for the non-violent mentally ill, community based services are poorly funded and inadequate in Illinois.  These people have to live somewhere, and that is the fundamental problem here.

The State of Illinois has systematically adopted long-term institutional care as its solution.  The reason for this is simple: it is federally subsidized through Medicaid shifting the cost burden significantly from the state to the federal government, a point not clearly articulated in this report.  The writers are critical of the state.  They accurately report that the screening and background checks meant to ostensibly avoid dangerous placements in nursing homes is poorly executed, though they fail to elaborate that process and how it fails. The Tribune writers appear to assume the problem lies in properly obtaining background checks and identifying those with a criminal history.  They sidestep the more basic question of what, exactly, the state should do with people who are correctly identified as dangerous.  They report that the state has no systems in place for tracking incidents of violence in nursing homes.  Nursing homes are required (and typically do) file incident reports with IDPH reporting episodes of violence and injury.  If I were one of these writers, I would certainly have asked someone why there is no tracking system in place.  This seems like a basic question of accountability for which someone needs to be held responsible. It would have been helpful had the Tribune identified who, really, should be accountable for this.

The writers also criticize the nursing home industry, at least segments of it, and the facilities themselves.  They are right to do this.  In fact, services are, more often than not, rather poor.  Illinois is warehousing the chronically mentally ill in nursing homes with minimal, sometimes no, rehabilitative services.  But again, they offer little analysis of the problem.  They point out that the reimbursement rate for long-term care of psychiatric patients in Illinois is one of the lowest in the nation, contributing directly to poor staffing.  They also point out that state investigative and enforcement personnel assigned to monitor nursing home care in Illinois is inadequate, resulting in poor oversight.  But they fail to supply the critical insight:  the quality of care provided in these facilities is systematic.  It does not arise as the consequence of rogue, morally bankrupt operators; rather, it arises directly as a result of a funding and regulatory system established by the State of Illinois.  The state can regulate staffing ratios, they can regulate the credentials and training required of staff, they can regulate the criteria by which individuals are deemed appropriate for what level care.  The network of facilities, the degree to which they provide or do not provide quality services, and the general population residing in them is cultivated by the State of Illinois through their policies, laws and funding.  The State of Illinois is ultimately culpable, but we are provided no information on the way in which the state itself has created this problem through poor policy planning and decisions.

Although this article overtly emphasizes the failure of the state to monitor and protect residents in nursing homes, rather than investigating more carefully why and how the state has failed, the writers subtly begin to vilify the facilities and operators.  Two examples:

“Nursing home operators say the number of violent incidents is minuscule considering the millions of hours of care they provide annually to a sometimes difficult population. The homes, they say, offer a vital public service by taking in destitute people when no one else can or will. And they describe themselves as besieged by plaintiffs’ attorneys, government inspectors and journalists.”

The double use of ‘they say’ invites the reader to view these claims with skepticism. The writers do not allow that there may be some truth to what is said.  What is the incidence of violence in prisons? In hospitals? In schools? In community-based psychiatric care? What other options, in fact, do these residents have? Though no one would suggest that we should shrug and accept some level of violence, the writers fail to consider the validity of the operators’ arguments but present them instead as simply self-serving.  An objective reporter would evaluate such claims and place them in the context of facts.  The Tribune does not do this; instead they write in such a way as to suggest that the operators claims are simply self-serving lies.

“The facilities had a financial motive for accepting them,” suggested Richard Dees, chief of the state public health department’s Bureau of Long-term Care. When “the number of seniors going into nursing homes began to decline, there were facilities with empty beds,” Dees said.

There are two problems with this.  First, it subtly implies that a financial motive is ignoble.  These facilities are businesses and financial motives are legitimate reasons for making decisions.  Second, and more importantly, it ignores the fact that the state had a financial motive for allowing these patients into these facilities.  The question is, once placed, what sort of care and services did they receive?  It would be nice if such facilities voluntarily stepped up and provided the services for the mentally ill that Illinois itself fails miserably to provide, but this is an unrealistic expectation.  These are businesses and the quality of services they provide, like any business or profession, will ultimately depend greatly upon state regulation.  It is ironic that the quote comes from the “chief of the state public health department’s Bureau of Long-term Care.”  It seems to me that Mr. Dees, not the financial motives of operators, should be under scrutiny regarding claims of inappropriate use of nursing home facilities.  Is not regulating long-term care facilities his primary responsibility as Chief?

Instead of identifying how the state is complicit, indeed responsible, for the problem they are bringing before the public, the Tribune writers subtly begin to turn the nursing home operators into villains, conveniently shifting focus from where it rightly belongs: on the way in which the State of Illinois has established the provision of treatment, services and care to the chronically mentally ill.

This is the first article.  It might be unreasonable to expect an insightful, nuanced and clear analysis of the problem initially.  The question becomes, how do they proceed to develop the story?  Do they increasingly focus on the real problem, provide documented, critical information, ask the right questions of the right people? Or do they build upon the subtle theme of shifting focus away from critical questions and investigation to creating villains that readers can rally against like an angry mob, ‘get the bad guys, get the bad guys,’ introducing distortion and emotionality in place of reason and analysis?  Sadly, they do the latter.

Notably, Somerset was not mentioned in this first article.  How did it eventually become the center of the storm? And as it shifts to center stage, what happens to the interests of the mentally ill in the State of Illinois? This is made clear in subsequent reports and events. It is not a pretty picture.

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