The nursing homes were often the worst

The former mental hospital workers I interviewed observed that few physicians had the time or experience to manage complicated mental health cases and that the fee-for-service model did not produce good patient care. And while community mental health teams that comprised nurses, social workers, and psychiatrists often worked well with families and family physicians, these teams were spread-thin, and their advice was not always welcomed. A common consequence was that a large number of patients cared for by general practitioners were badly over-medicated or placed on inappropriate drug regimens. The problem of over-medication was especially acute in nursing homes, where physicians acceded to the requests of staff who were ill-equipped to manage former mental hospital patients. Several former practitioners singled out nursing homes as sites of inadequate care, noting that former patients living in these facilities were far more likely to be subject to restraint B physical and chemical B and more apt to be over-medicated than they had been in their prior institutional settings.

When the MDs took over from the psychiatrists, a lot of them really blundered…. [They] had no idea what to do, so they just wrote prescriptions. Lots of guys were really over medicated, especially in the nursing homes. Sometimes we would get a doctor who would throw up his arms and say, “Here, you know what this guy needs. Do up a medication plan for me.” But most times they’d just blunder on.

The nursing homes were often the worst. They were full of what we used to call “hidden restraint.” When they didn’t know how to handle somebody, they just gave them a sedative and stuck them in an armchair or recliner so they couldn’t get up and wander around. Then these guys would get pneumonia, and it was the staff [that] as good as killed them.