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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

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Nursing Home Regulatory Fiasco – PART I

by Tom aka Rusty


Nursing homes are subject to a two part interactive regulatory system (plus several others) used to calculate certain reimbursement levels.

The Minimum Data Set 2.0 (MDS) is a clinical reporting system that is supposed to improve care by having nurses do more paperwork (more on this in Part II).

Resource Utilization Groups III categorizes residents into 44 acuity groups. The two systems interact to calculate facility acuity levels (very oversimplified explanation).

On October 1, 2010 MDS 3.0 and RUGs IV are supposed to be put into place. Problem is, MDS 3.0 is ready for roll out, but RUGs IV is not. If no solution is found soon, the feds will have to rig some sort of half-assed patch to keep the system working. RUGs IV should be done in another year.

The feds now face writing tens of thousands of pages of regulations to implement Obamacare, yet cannot finish work started with several years of lead time. Ugly, very ugly.

Rdan: The major question is: Does Rusty still have any hair left?

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