Category Archives: Ethics

The Deinstitutionalization of Acute Care Patients ?

An era of restricted revenue”

“The business case for lowering inpatient length of stay”

“As hospitals and healthcare systems pinch pennies”

“The number of avoidable days relative to a benchmark”

“Diagnosing efficiency benchmarks”

PiggyBank+StethoscopeimagesMuch of the healthcare sector is now focussed on reducing length of stay in hospitals. A key element of healthcare reform is both denying payment to and penalizing hospitals for “inappropriate readmissions.”

NursePatientInWheelchairimages-1This can be good for individual patients as well as for the economy. Hospitals can be very dangerous places to be. Robert Pearl, MD, highlights 4 key reasons for that.* It is the 4th that should raise a cautionary note about this trend: “Hospital stays sometimes result in problems after discharge.”

We’ve seen this potentially combustible mix before. It was then called “deinstitutionalization.”

StraitJacket-images-7By 1965, newspaper and movie horror stories had gained enough traction to push politicians to close state facilities and move psychiatric patients into nursing homes and community care. These moves were predicated on the development and provision of adequate community care.

Deinstitutionalization did improve the lot of millions living with “intellectual and developmental disabilities.” It allowed them to escape intolerable conditions in these hospitals and to live with proper support and without stigma. But it was a very different story for Americans suffering from severe mental illness.

mental-illnessCalifornia had taken the lead in aggressive deinstitutionalization.**

  • And California became “the first state to witness not only an increase in homelessness . . . but also an increase in incarceration and episodes of violence.”

  • In 1972, a “California prison psychiatrist . . . claimed to be ‘literally drowning in patients . . . who have serious mental problems.’”

  • A study of . . . patients discharged . . . between 1972 and 1975 found that 41% of them had been arrested [and] the majority . . . had received no aftercare following their hospital discharge.”

Nationally, by “the mid-1980s, 23% of nursing home residents . . . had a mental disorder.” There was no comparable increase in training or resources. It is estimated that 1/3 of the homeless and 16% of the total jail and prison population have schizophrenia or bipolar disorder.PrisonMentalIllnessimgres-1

In 1984, the New York Times reported, “The policy that led to the release of most of the nation’s mentally ill patients from the hospital to the community is now widely regarded as a major failure.”

Today’s healthcare reform is similarly predicated on the provision of appropriate aftercare. Hundreds, perhaps thousands, of apps, techniques and approaches are under development to improve home care and prevent the now-costly readmissions.

Again it is assumed that the market, our states and our communities will provide what hospitals up to now have not. As of Aug 28, 2014, 23 states – only 2 short of ½ – had not elected the Medicaid expansion under the ACA – a bad omen.

Not only was there a failure of will to provide adequate aftercare support for the seriously mentally ill. There was also what an author referred to as “one awkward reality”:

  • [T]he economic case for deinstitutionalization – highly appealing to both fiscal conservatives and civil libertarians – turned out to be almost entirely wrong. . . . Effective community-based supports are generally superior to institutional care. They aren’t necessarily cheaper; often the opposite is true.”***

So whither 21st century American healthcare reform?

* Robert Pearl, MD, “4 reasons why hospitals can be very dangerous places to be”

** E. Fuller Torrey, MD, “Ronald Reagan’s shameful legacy: Violence, the homeless, mental illness”

*** Harold Pollack, “What happened to U.S. mental health care after deinstitutionalization?”

How Do You Survive An Organization In Flux — And Flourish?

Imagine being a player, coach or employee of the Los Angeles Clippers these last few months. Everyone associated with the team felt not only a lack of leadership and uncertainty about their futures, but shame and humiliation.

How do you survive something like that?

491054373I think we can garner 3 lessons out of that extreme case of an organization in flux.


Doc Rivers, the LA Clippers coach: “My focus is completely on trying to figure out a way of eliminating the distractions. . . . This is a situation where we’re trying to go after something very important for us. . . . It does [have an impact], but you’ve got to move on. . . . That’s adversity that we didn’t want, but we have it, we’ll have to deal with it.”

To counter discouragement and even despair and keep their people moving forward productively, Alcoholics Anonymous has long urged its members to focus on what they can control and let go of what they cannot.

To use another sports metaphor, star baseball players say that when their offense is in a slump, they need to stay focused on playing good defense, keep at it on offense and wait for a better day to click in.


Doc Rivers again: the team “was pissed.” “This is not anything anybody wants to go through, and this is never good for anyone. . . . They’ll grow from it and they’ll be better people because of it.”

Referring to plans to run an off-ramp of an interstate highway through a low-income Latino neighborhood, a good friend of mine, many years ago, emphasized the importance of making a distinction imagesbetween “being pissed” and getting resentful. Anger is a natural reaction to a threat. Resentment is settling into a life-negating spiral of outrage that ends up corroding yourself.

“Anger is not one thing. It is many things, loosely organized by language into a whole. It is . . . not the feeling of anger per se that has caused harm. Rather, the cold soup of enacted or contemplated self-righteousness or the hot energy of attacking others can easily lead to actions with negative consequences. But these need not be the core features of anger.” (1)


“When the [NBA] commissioner [Adam Silver] put this to me [becoming emergency interim chief executive of the Clippers], I said, ‘Hey, I love basketball,’ ” Richard Parsons said. “I don’t like basketball. I love basketball. It represents all the best in teams sports, and character building and it’s fun. I love basketball. I always have.”

The atmosphere may be foul, the future gloomy, prospects fading by the hour. But if I can dig down into what I truly like and enjoy about my work – not necessarily my job, but my work – then that may see me through some very difficult times and may become what transforms raw talent into polished skill, like tempered steel.

I know this is hard to do, a lot harder than fancy words make it seem. But if you walk into a factory, an office or a home where worry and uneasiness seem to rule, isn’t it the one bright, smiling, centered person there whom you will remember when you leave? Stay focused on what you love, and that energy may make you special.


And that is the part of all this about “flourishing.” Human nature seems to have this propensity for getting sucked into the “Sturm und Drang” all around us. Those who rise above that will stand out for their resilience and will find value either in the new organization or the next organization.




(1) ACT On Life Not On Anger, George H Eifert, Ph.D.; Matthew McKay, Ph.D.; and John P. Forsyth, Ph.D. 2006: New Harbinger Publications.