Health Care Thoughts – Public Policy Dilemma

Tom aka Rusty Rustbelt


Fifty years ago much mental illness treatment was done in-patient in state run facilities, and many of them were hellholes (One Flew Over the Cuckoos Nest was probably too positive compared to what I saw early in my career).

The de-institutional movement (starting in the late 60s) caused a build up of community based services, and in combination with better therapies has made a much better (although not perfect) system. In many areas the mental illness and substance abuse facilities are run through common governance, some areas not so.

But there are still people who need in-patient services, especially those who also have chronic physical health problems, and there are too few beds and too few payment paths to accommodate those patients.

So what to do?

Some are being dumped into geriatric nursing homes, and not surprisingly the results range from not very good to disastrous. Exact numbers are hard to come by, because the reporting mechanisms do not always separate those admissions. Generally we hear about these cases after something goes terribly wrong and hits the media.

Nursing homes are getting better equipped to deal with geri-psych issues, but younger and often agitated patients really do not fit. A few nursing homes have set up special units or dedicated the entire building to mental illness patients, but not many that I can find.

Nursing home regulatory protocols actually hinder aggressive psych treatments, as regulators and consumers are concerned about “chemical restraints,” the notion that nurses drug the residents into submission and then sit around doing their nails and reading magazines (no psych drugs can be administered without a physician’s order and a thorough care planning process).

So far no one has developed a really good response to this problem, either clicical or financial. The health care reform bill has not directly addressed this issue, although it creates an opening for the discussion.

(For anyone interested in some good reporting go to the Chicago Tribune website and put “nursing homes mental illness” in the search block. The Trib also does a lot of good work on nursing home problems in Illinois. A Google search will yield plenty of information. Also this MSNBC story

Tom aka Rusty Rustbelt