Weekly Briefing

When the last resort becomes standard practice

Damning report show that North Carolina is still warehousing the mentally ill in rest homes

Every now and then, something comes to light in the world of public policy that makes you stop in your tracks and question the humanity of the society in which you live (and maybe even your own). Whether it's the shameful treatment of a group of innocent children, a case of ravenous corporate greed or perhaps some incident of intentional and remorseless poisoning of a formerly pristine piece of the environment, the questions flow in quick order:

Could things really be this bad? Is this really the best our community can do? Is our passionate aversion to taxes and regulation and love for the almighty dollar so powerful that we're really willing to allow this be an acceptable practice?  

Sometimes the horrific fact at issue also sparks a feeling of déjà vu – as in: Wait a minute – didn't this come to light years ago? You mean no one has done anything about it yet?!

The rest home scandal

Such moments ought to have been occurring for a lot of North Carolinians in recent days as a result of an investigative report released last month by the good folks at Disability Rights North Carolina (DRNC) entitled "Trapped in a Fractured System: People with Mental Illness in Adult Care Homes."

In case you missed it (and, sadly, mainstream media play was limited) the report details the hard fact that North Carolina is essentially warehousing thousands of mentally ill people of varying ages in so-called "adult care homes" and "family care homes" – modest facilities that were once commonly referred to as "rest homes" and that are designed to house and provide a relatively limited set of services to senior citizens in need of assistance.

Moreover, not only is the state warehousing these individuals in contravention of their rights under the Americans with Disabilities Act, it is, to use a bureaucratic term of art, frequently "co-locating" them in the very same facilities that house thousands of vulnerable seniors. The DRNC investigation documents at least four incidents in recent years in which residents of North Carolina adult care homes have died at the hands of other residents. 

Now, of course, the whole issue of the adequacy of adult and family care homes in doing what they were originally designed to do has long been an issue. For decades, advocacy groups have questioned the whole concept of corporations wringing profits out of the modest and inadequate Medicaid reimbursements provided by the federal government to house vulnerable seniors in modest – frequently grim – surroundings.  

The phenomenon of "co-location" however, adds another dimension to this problem that ought to cause all North Carolinians to feel a sense of shame and anger. This is an excerpt from the DRNC report:

"State law forbids Adult Care Homes from admitting residents for the ‘treatment of mental illness.'… According to information provided to an N.C. Institute of Medicine (IOM) Task Force in December 2009, North Carolina had 631 Family Care Homes with 3,533 beds and 627 Adult Care Homes with 36,564 beds…. A 2010 report to the IOM revealed that 6,432 persons with mental illness reside in Adult Care Homes and Family Care Homes.

Despite the prominent role Adult Care Homes play in the North Carolina mental health system, Adult Care Homes are not regulated as mental health facilities. They are ‘assisted living residences' licensed by N.C. DHHS under rules adopted by the state medical care commission. Staffing requirements and qualifications are not designed for care of residents with mental health needs. For example, during the first and second shifts, an Adult Care Home with 41 to 50 residents is legally required to have only three staff present (a 1:16.6 ratio). At night on third shift, only two staff need be present (1:25 ratio)….In mental health group homes the population is limited to six residents, a ratio of 1:6. Additionally, staff at a mental health group home are supervised by a MH/DD/SAS qualified professional."

According to North Carolina's Secretary of Health and Human Services, Lanier Cansler, the practice of co-locating mentally ill people in rest homes in contravention of their rights and the safety of others is a matter of the state turning to a last resort. Cansler told Raleigh's News & Observer in late July, "There is obviously an issue with having the resources to do all the things we need to do. We've not yet been given the authority to print money at DHHS. You can do everything you can to be efficient and effective with the way you use the available funds, but you can only stretch the dollars so far."

He might have put it more bluntly this way: "Look, I haven't got many choices here. We've already tried releasing mentally ill and disabled people to homeless shelters. Unless you want me to throw them in prison, this is about the only option I've got to keep people in out of the weather."

Of course, the sad and terrible truth of the matter is that keeping people in out of the rain is often about all these facilities are good for. This is from the report's description of one facility in which all 32 residents had a diagnosis that included a mental illness:

"Many residents have mobility issues….Other than smoking and watching television, there are few social activities available for the residents. Transportation is available only for doctor visits. The facility remains surrounded by a barbed wire fence.

The major issues reported by the residents were idleness and isolation. The facility director reported that most residents are at the facility merely because of an inability to manage their medication intake properly. Many residents agreed that this is their sole barrier to living in the community."

A better way?

As the DRNC report points, there are better ways (i.e. both humane and lawful) to deal with the challenge of housing and helping our mentally ill and disabled fellow citizens. There are, in fact, models for permanent supportive housing that can meet the requirements of the ADA and provide people with a path to happier and healthier lives. In the long run, such facilities can even provide a more cost effective option.

To effect such a shift away from the "business as usual" model of warehousing humans in for-profit rest homes and toward one that features smaller community-based (and typically nonprofit) providers, however, will take a lot of public money and political will. Not only will there be a need for new and significant public investments to jumpstart such a shift, state leaders will also need to muster the courage to take on the entrenched and well-connected rest home lobby.

One possible venue for advancing such a shift is a special effort of the North Carolina Institute of Medicine known as the Task Force on the Co-Location of Different Populations in Adult Care Homes. Commissioned in 2009 by the General Assembly, the Task Force has met several times this year and has shed a good deal of light on the problem. Let's hope it formulates a series of helpful recommendations.

Ultimately, however, task force recommendations probably won't be enough. As with so many other past episodes in which government has improperly institutionalized a politically powerless constituency, the final solution may rest in the judicial system.

In July, DRNC filed a complaint with the U.S. Department of Justice asking that it initiate an investigation and, if necessary, sue the state to obtain compliance with the ADA and its requirement of genuine community integration for these individuals. Let's hope this effort bears fruit sooner rather than later.

Let's also hope that it prompts even more people – civic leaders and average North Carolinians alike – to stop in their tracks, take a look in the mirror and demand an end to this outdated and unacceptable practice.