Buildings at the Waterbury State Office complex. Photo by Don Shall.
Tropical Storm Irene’s abrupt flooding and the subsequent emergency evacuation of 51 patients from the century-old Vermont State Hospital has finally put the hospital’s replacement front and center after years of debate.
But more than two months after Irene flooded the Waterbury facility, a vigorous push and pull continues over how the state should deliver care for severely mentally ill patients in Vermont. Though advocates have long fought over the fate of the hospital, this time the tug-of-war is between the state workers union and the Shumlin administration.
Now that the state hospital, a lynch pin in the community mental health system, is closed, Gov. Peter Shumlin is moving away from a centralized hospital toward more dispersed services as part of an interim plan.
Shumlin recently said the Waterbury facility will be closed for good, and his staff is considering a proposal to build a smaller “acute” care facility with 15 to 20 beds. The rest of the approximately 50 patients who at any given time need specialized care would receive home-based treatment, would be placed in several yet-to-be identified “step down” facilities like Second Spring in Williamstown, or be sent to several regional hospitals, including the Brattleboro Retreat, a nationally regarded mental health facility. The governor’s plan, which is still evolving, needs legislative approval.
The Vermont State Employees Association is worried that this interim plan will become permanent. The union, which represents about 240 workers who were displaced by the flood, is calling for a full-fledged replacement of the hospital in a central location as part of the state’s new plan for providing acute care to patients.
Conor Casey, legislative director for the association that represents state employees, said the state hospital should be replaced as quickly as possible. A centralized facility with the same number of patients — 50 on average — would be the best model for both effective psychiatric treatment and experienced care, he said.
“We’re advocating to expedite plans to build a new state-owned and operated facility in central Vermont, “ said Casey.
Patrick Flood, deputy commissioner of the Agency of Human Services, said there is no doubt the shape of any future system is “very much up in the air.” He said building a new state hospital, which officials have said is several years off, is “still actively under consideration.”
The VSEA’s push comes as plans for a future state hospital and the crisis created by its closure are up for discussion at a daylong meeting of the Vermont Legislature’s Mental Health Oversight Committee on Wednesday at the Statehouse. The session, which begins at 9:30 a.m., will include testimony from different partners in the mental health system, such as regional hospitals.
Casey has closely followed the state’s long-simmering effort to replace the state hospital, which has been debated and planned for more than eight years without much progress.
But within the mental health community there is considerable divergence of opinion about whether even a downsized state hospital is needed, or whether other psychiatric models with a variety of intensive treatment options can provide equally effective results.
Casey said he was worried that the interim solutions announced by state officials two weeks ago are going to lead to a de facto elimination of a central state hospital as the key psychiatric unit for acute mental illness. He noted nearly every state in the nation relies on a centralized hospital that provides treatment for any patient that is in acute mental distress.
If lawmakers and the Shumlin administration restructure the mental health care system without a central facility, Vermont would join Rhode Island as the only other state without a taxpayer-subsidized psychiatric hospital, according to a national expert on mental health treatment models.
Interim solutions
On Oct. 20, Gov. Peter Shumlin announced his administration had decided to permanently shutter the antiquated facility and provide treatment for patients through a continuum of services.
For patients who need a high level of care, the Brattleboro Retreat will maintain 14 beds. Shumlin said the state was looking for another location for an additional 15 acute-care beds, he said. The state would also step up community mental health services and continue to use psychiatric wards at major hospitals, such as Fletcher Allen Health Care in Burlington and Rutland Regional Medical Center, or facilities such as Second Spring in Williamstown.
Casey said he understands the need for interim solutions but “it’s absolutely the wrong policy” to rely on private facilities or hospitals for treatment of severely mentally ill patients. He said the state’s potential reliance on private facilities raises legal and jurisdictional issues, such as questions about access to public information.
The number of people served in state hospitals declined from around 500,000 in the 1950s to well under 50,000 to 40,000 today. We’ve seen every state significantly downsize their state hospital population.”
- Ted Lutterman
The state also has a need for a “forensic psychiatric facility” for patients under court evaluation or in the judicial system, he said.
Casey stressed that the 240 employees who staffed the Waterbury facility are an important human resource. The workers have been sent to care for patients at locations around the state.
“This is a workforce that has experience and practice in treating that population. In terms of continuity, it makes a lot of sense,” he said. “They’re in the most difficult situation in state government right now. There needs to be a light at the end of the tunnel for both patients and staff.”
Sharp drops in inmate populations
Ted Lutterman, director of research and analysis for the National Association of State Mental Health Program Directors in Alexandria, Va., said models for mental health care systems vary greatly by state and the roles of state hospitals are shifting around the United States.
Mississippi, for example, shut down all its acute care units and transferred treatment to community facilities, he said, and the state hospital now concentrates on services for patients who require long-term care. Other states use the state hospitals for mostly short-term acute care, he said. Ninety percent of clients in California’s state hospitals are placed in the facilities under court order.
Nationwide, states have seen a dramatic decline in state hospital populations as mental health treatment has been deinstitutionalized and modernized. Psychiatric care has shifted to regional and community care programs, he said. New drugs for treatment have also impacted care models, Lutterman said.
He said state mental health systems serve about 6.9 million people across the nation, and just 2 percent of patients end up in state hospitals.
“The number of people served in state hospitals declined from around 500,000 in the 1950s to well under 50,000 to 40,000 today,” he said.
“We’ve seen every state significantly downsize their state hospital population,” he said.
However, while numbers have dramatically declined, the cost to treat that smaller population is about 29 percent of the total mental health dollars states spend, he said.
During the last legislative session, state officials said it would cost $50 million to $60 million to fund a replacement hospital. However, those estimates were based on creating a larger facility than the approximately 20-bed to 30- bed facility that has been discussed since Irene.
Possible new sites
State officials have said they are looking at the possibility of creating a facility on property near Central Vermont Medical Center in Berlin, which would allow close affiliation with a medical facility, another issue roiling the waters. Many mental health advocates strongly feel that any new state hospital must be closely linked with a medical hospital.
That’s the view taken by Robert Pierattini, chair of psychiatry at Fletcher Allen Health Care, who has worked at the psychiatric unit in Burlington since 1982. Pierattini also agrees with the VSEA that Vermont needs a replacement state hospital for those in need of acute care.
“The Vermont State Hospital has done an excellent job,” he said. “We have an opportunity to look at our system here with care, and I hope that specialized (state hospital) capacity is part of it,” he said.
The Burlington-based hospital has been called on to care for some of the patients who would have been treated at the state hospital and at times has struggled to cope. The hospital has a 16-bed secure unit and 12-bed open unit, but the dorm-like setting is not suitable for behaviorally hard-to-control patients, he said, noting the units have become “more disruptive, and more chaotic and more noisy,” which does not help effective care.
Since the state hospital closed, length of patient stay has also grown from 9-11 days average to about 16 days, meaning the hospital has had to turn away more patients.
The VSEA’s Casey admitted the state is in a “difficult situation” as it struggles to adjust to the state hospital’s closure. “But this is obviously an opportunity to take a look at the mental health care system,” he added.
“What happens in the next year or two shouldn’t dictate what happens in the next 50 years, “ he declared.
Editor’s note: The lead of this story was clarified at 5:30 a.m. Nov. 9. The original posting did not point out that the governor’s plan is an interim proposal.
