Reference no: EM133116193

Case Activity:

For several decades, an important force in mental health programs has been "deinstitutionalization." Many people who were formerly patients in large state hospitals have been transferred to smaller, community-based facilities.

Window on the World (WOW) is one of the new agencies that arose in response to deinstitutionalization efforts. It was designed to act as a halfway house for people recently released from the nearby state hospital. Although the funding for WOW comes from a number of sources, the primary source involves third-party payments from the state vocational rehabilitation agency and the state and local departments of social service. Essentially, these agencies pay room, board, and fees on behalf of the clients they place in the halfway house.

The WOW facility is clean and well kept. Staff members have real concern for the clients, and efforts are made to keep the surroundings comfortable. Yet some of the staff members have begun to question the treatment plans for individual patients.

In one such recent situation, John Billings, a staff member, asked to see Harmon Fisk, the executive director, about one of the patients.

"I''d like to talk to you about Gail Drew," he began. "I''m positive she''s ready to get on her feet and start moving. If we could just cut back on her medication, I think we might really see an improvement in this case. She might even be ready to be placed in a part-time training program and come back here in the evenings. Maybe nothing really major at first, but if we could just give her a chance, just give it a try."

"Just what do you want me to do, John?"

"Well, I thought you might be able to check with Dr. Freund about whether he could change her medication. You know, the stuff she''s taking now is keeping her kind of knocked out, and...."

"Look, John. Carl Freund has been the consulting psychiatrist here since the word go. You come in here with a fresh master''s degree and want to tell him his business. Don''t you think he knows what he''s doing?"

"It''s not that, Mr. Fisk. Of course I think he knows what he''s doing. I''m just saying that I''m seeing a subtle change in this one patient, and I think she''s ready to move toward a less sheltered existence. We won''t know that unless we cut down on her medication. We can always change it back again if it doesn''t work out. What have we got to lose?"

"I''ll tell you what we''ve got to lose. We''ve got Gail Drew''s fees to lose. She''s a Social Service patient. They pay her way. But they pay her way only when she''s incapacitated. If she''s on her feet and out there being trained, the fees are cut to a quarter of what they are now, and we can''t support her on that. And if she''s out there working, her fees are cut to nothing. She can''t support herself on that. Now, what do you want me to do? Put this woman out there on her own in the cold? On your say-so?"

"Wait ... wait a minute, Mr. Fisk. We can''t just keep someone doped up because that''s the only way we can make money off her."

"No, now just you wait a minute. For one thing, you sound plenty noble, but I don''t see you turning down your paycheck on Fridays. Where do you think that money comes from?"

"I know, but...."

"I didn''t make this system. If you don''t like the way it works, talk to the government. The thing is, I don''t like seeing a patient like that lying around all day any more than you do. But believe me, we wouldn''t be doing her any favor cutting off her medication, getting her out there on the streets with her hopes up, and then having her lose the support that she''s got. Face it. These people are chronic. They''re not going anyplace. But at least here it''s clean, it''s comfortable. They''ve got a roof over their heads, and they''re not piled one on top of another in an institution like they were monkeys in a cage."

"But Mr. Fisk, Gail Drew should have a chance...."

"Have a chance for what? To starve out there on her own? Look, we need fees to run this agency. If we don''t get the fees, we don''t get to exist. Then what happens to Gail Drew and to the rest of the patients we''ve got in those beds upstairs? You think our going under is going to do them any good? Where do you think they''ll go except back to State, where they came from?"

What ethical considerations exist in this case? How would you address them?

Are there ways that differing funding patterns might be developed to make deinstitutionalization work more effectively?

If you were John Billings, what would you do now?

If you were Harmon Fisk, the director, would you be able to come up with any better answers?

Are there insurmountable differences between human service professionals and managers?