After years of frustration, authorities and advocates believed this spring represented their last and best opportunity to reform Illinois's troubled nursing homes.
Still, it took tense negotiations and an eleventh-hour deal to strike a historic bill that aims to undo a half-century of failed policies and end a legacy of violence in which nursing home residents were raped, assaulted and murdered.
Both sides had come so far that only moments after the 159-page bill sailed over its first hurdle and passed the House with a 118-to-0 vote late Thursday night, Gov. Pat Quinn's top health care advisor, Michael Gelder, was hugged by both the industry's top lobbyist and one of the industry's toughest critics.
The reform bill's overwhelming support in the General Assembly "reflects a change of direction for the state," said an exhausted Gelder, who helped shepherd the negotiations. "It sends a very clear message that nursing homes are going to provide high-quality care, and they're not going to be dominated by individuals who have put profit ahead of the care and needs of their residents."
The overhaul effort was sparked by a series of Tribune investigations last year exposing chronic violence inside a subset of facilities that house younger psychiatric patients and convicted felons alongside geriatric residents.
The bill, which passed the Senate Friday and now goes to Quinn's desk, contains an array of measures to stem the brutality inside those facilities.
It would tighten existing criminal background checks and psychological screenings of incoming nursing home residents, and place the relatively small number of dangerous patients into separate, secure therapeutic wards.
It also would require nursing homes to significantly increase staffing levels and to meet more stringent safety and treatment standards as a condition of admitting any resident who has a serious mental illness or who presents a danger to others.
The most ambitious measures are designed to divert thousands of mentally disabled people from nursing homes and into an array of smaller, residential programs that provide intensive therapy and supervision for those who require it, but greater independence for those who don't.
While celebrating the bill's passage, Gelder and lawmakers said it will be a huge task to implement its many provisions, and that much difficult work remains. "It is a watershed day," said Chicago Democratic Rep. Sara Feigenholtz. But, she added, "I see this as a first step."
Even at a time when the state is nearly broke, officials and lawmakers say they are confident they can find a cost-neutral method to roughly double the number of state safety inspectors to more than 350 over the next three years, significantly increase staffing at the homes and expand Illinois' community mental health programs.
One way they plan on doing it is by redirecting state funds away from nursing homes and into community-based care programs. Officials also plan on raising tens of millions of new dollars annually by raising fees from nursing home providers and matching that money with federal Medicaid payments.
A significant portion of that money would then be returned to the facilities to pay for the additional staffing and other needs. State officials would use the rest to hire the new inspectors and to fund community-based mental health programs, according to participants in the talks.
The details of that funding plan must be hammered out by government authorities, the industry and advocates, and be submitted to the General Assembly no later than Nov. 1, the bill says.
"It's in everybody's interest to get it passed," said Chicago Democratic state Sen. Heather Steans, who sponsored the bill in the Senate. "I really think this is a great victory for residents of nursing homes and ultimately for folks who want a route out."
Illinois' nursing home problems reach back to the 1960s, when the state joined a nationwide deinstitutionalization movement and began to empty government-run psychiatric hospitals that once housed more than 50,000 patients but now hold about 1,500.
With few alternatives, many of the discharged psychiatric patients cycled from the streets to jail cells and emergency rooms. Thousands landed in a subset of nursing homes that were eager to fill their beds with indigent Medicaid recipients, even if those people had violent criminal records and were decades younger than their geriatric housemates.
Although mentally ill people are no more likely than others to be dangerous or to commit crimes if given proper treatment, many facilities provided substandard care and monitoring, the Tribune found.
The violent cases chronicled by the newspaper included the rape last year of a 69-year-old woman by a 21-year-old mentally ill felon at Elgin's Maplewood Care. Attacker Christopher Shelton's background screening had been improperly handled by the nursing home, and the facility failed to act adequately on warnings of his behavior, records show.
Though the state offers an array of community mental health programs, including congregate homes that offer 24/7 clinical supervision, the system is stretched to its limits. It could take several years to expand services and housing enough to handle the thousands of new clients envisioned in the bill.
"Most of these [programs] are at full capacity at this point, and we're going into a budget crisis," said Ed Stellon of the Heartland Alliance. "It is doable, but it will take some time."
Gelder said state authorities are already redrawing budget lines to provide the needed resources without increasing payments from the General Revenue Fund. "We don't want to empty our nursing homes and leave people on the streets," he said.
Among the bill's other key provisions is a mandate that nursing homes admitting people with serious mental illness obtain a new certification demonstrating that they can effectively monitor and treat those residents.
The new standards for those homes, which must be written in the next eight months, would require the homes to have sufficient staff, including psychiatric professionals, on a 24-hour basis; training of staff on "managing aggression and crisis prevention"; and substance abuse programs.
People with serious mental illness must be re-evaluated periodically by independent experts to assess whether they need to remain in these nursing homes.
Those who present "a high risk of aggression" would be housed and treated in separate, "self-contained units within existing nursing homes," according to the bill.
The legislation does not specify how the "behavioral management units" would be secured. But state authorities would be required by January 2011 to draft specific rules on staffing levels and training, "strategies to avoid physical harm" and use of "containment techniques."
Periodic independent re-evaluations also must be conducted for those placed in these units to ensure that only those who require intensive supervision are housed in them.
The bill also would establish a database that would track violent incidents inside the homes. It would add safeguards to ensure the informed consent of residents administered psychotropic drugs. And it would expand the state's ability to deny operators permits to open new homes if they run facilities that have repeatedly violated safety standards.
At the last minute, nursing homes agreed to increase nursing staff levels in the next four years to 3.8 hours of daily nursing care for each resident who needs skilled care, up from the current minimum of 2.5 hours. Quinn's task force had recommended 4.1 hours.
Terry Sullivan, regulatory director of the Health Care Council of Illinois, the state's largest nursing home trade association, said the legislation would create a tougher regulatory and financial environment for the industry, but he welcomed what he called "sweeping ... genuine reform."
Tribune reporter Monique Garcia contributed to this report.