Mental Health commissioner Patrick Flood testifying before the House Human Services Committee Thursday. VTD/Andrew Nemethy
MONTPELIER – The dollars and details are spilling out as the Shumlin administration scrambles to spell out a drastic revamp of mental health care in the wake of Tropical Storm Irene’s devastation.
A harried Mental Health Commissioner Patrick Flood appeared before the House Human Services Committee with the first detailed take on how the state plans to rebuild the mental health system after the flooding closure of the 54-bed Waterbury State Hospital.
Lawmakers on the panel, who convened this week for a new session, also listened to mental health providers who several times used the word “urgent” to describe the need to get moving on a plan to alleviate the crisis caused by the hospital’s closure. The providers praised Flood for visiting them and many of their facilities in the past two weeks since he took over as Mental Health commissioner in a job swap with Christine Oliver.
The panel got a front row seat on the central disagreement over the plan when they were told via speakerphone by the head of Fletcher Allen Health Care’s psychiatric unit, Dr. Robert Pierattini, that the state cannot get by without a 30-40 bed state hospital staffed to handle patients needing intensive mental health care.
The governor’s plan rejects the need for a central facility that size, and that issue is shaping up to be the major point of contention.
Flood made it clear he understands anxiety and stress remain in the mental health community since Irene hit four months ago.
“We are in a situation that is evolving as we speak. There is no way around that,” he said, acknowledging as he handed out version one of the detailed plan that there already is a version two. “I know this document will change by the end of the day.”
Flood said he was impressed by the cooperation and hard work of everyone in the field, though he warned “hard choices” lie ahead.
“Together we will come up with the best choices for Vermonters, I am sure,” he said.
The governor’s proposal, unveiled last month, includes 36 acute care beds to replace the state hospital, spread out at three facilities: 14 at the Brattleboro Retreat ready as early as July; six at the Rutland Regional Medical Center as early as fall; and a new 16-bed facility to be located near Central Vermont Medical Center in the future.
It also proposes to greatly expand community services, from emergency intervention, housing, crisis beds, so-called peer services and intensive local mental health outpatient and residential services that administration officials say will preempt the need for a larger state hospital.
Flood put some dollar signs and timelines on the plan for lawmakers on Thursday. The capital costs of the Retreat beds would be $4 million; the new ward at Rutland would be $6 million; and the state-run facility would cost $16 million, for $26 million total in capital costs, he said.
Flood said FEMA may cover some of those expenses since they were created by the flooding at the state hospital. Alternatively, the costs may be built into the rates charged by the facilities.
Importantly, he said the state is now eligible for an additional $20 million because all the new sites are eligible for Medicaid and Medicare reimbursements that the federal government previously denied the state because of quality of care issues at the Vermont State Hospital.
The funds from the Centers for Medicaid and Medicare will be used to strengthen community services, Flood said.
The proposal detailed Thursday includes $1 million for four new crisis beds; $600,000 for up to 100 housing vouchers since lack of housing often precipitates mental health crisis; $1 million for so-called “peer services”; and $5.6 million for new residential program beds such as those at Second Spring in Williamstown, which takes patients whose needs can be handled in a less than acute setting.
Joining Second Spring with “step-down” beds will be a new seven-bed facility in Westminster that is under development and expected to be ready in February and another one with 15 beds in northwestern Vermont that could be available in six months once it is approved by the Legislature, he said. Second Spring will add eight beds for a total of 22, he said. In all, the plan includes 30 new community based spots.
Flood said he anticipated additional staffing costs for his department to ensure that the expanded, decentralized system is well-integrated and a new web-based tracking system for patient needs is established. He said the state is still urgently seeking a solution for housing patients under court order, since they cannot continue to stay at the correctional center in Springfield.
Flood conceded the “fewer versus more” debate over state hospital acute care beds is key, but he also noted the central Vermont facility would not be ready for two to two and a half years.
Rep. Anne Pugh, D-Chittenden, chairwoman of the House Human Services Committee, addresses a standing room only crowd with Rep. Anne Donaghue, D-Northfield foreground. VTD/Andrew Nemethy
“I want to emphasize that point so we don’t get inordinately stuck on that one point,” he said.
At the same time Flood emphasized that the facility is being designed for “quick expansion” to 25 beds if needed.
Providers question plan
Pierattini told lawmakers on the panel that Fletcher Allen’s experience with taking patients who would have ended up at the state hospital before Irene has been dramatic and difficult. “We are doing our best,” he said, but “the mental health system is at the very edge of adequacy,” he said, telling stories of his own personal experiences working over New Year’s Eve.
“Our units were full, they were overcrowded, they were dangerous,” he said, and the hospital has also had to turn away patients who needed care. This was not the case before the state hospital closed, he said.
Pierattini said the state needed a “Level 1” intensive care mental health facility with 30 to 40 beds to replace the Waterbury State Hospital, and the facility absolutely needs to be in a medical center and provide the full range of medical care. He said mental health patients now at Fletcher Allen display a host of “extensive medical issues” from diabetes to suicide attempt wounds to seizures, renal failure and hypertension and drug addiction.
“These are very typical,” he said, adding that it was “inconceivable” to him that the system would try to treat the most acutely ill anywhere but with full hospital care.
“If we don’t do this people will die because we absolutely have to have these medical services,” he said, specifically excluding the idea of using a nearby hospital where response is “by vehicle.”
It is unclear in the governor’s plan how close the 16-bed Central Vermont facility will be to the Central Vermont Medical Center and what medical services it will have.
He also strongly backed the contention by the Vermont State Employees Association and Dr. Jay Batra, the head of the Vermont State Hospital, that a central facility with well-trained staff is best able to deal with patients in acute crisis, and he said the new state plan does not provide enough beds in the northern part of the state. He further raised issues of accountability when private institutions treat mental health patients under state care, an issue raised by the state employees association as well.
The state plan, he said, should be modified.
“We need a replacement hospital that is accountable to the commissioner of mental health and fully integrated into a medical center,” he said.
Ann Pugh, chair of House Human Services, pressed Pierattini on how he came to the conclusion that a 30- to 40-bed hospital is necessary, noting that Flood had testified that as many as half of the patients at the state hospital could have been served elsewhere if services and beds were available.
Pierattini said the 54 beds at the former state hospital were “not an arbitrary number” but based on trial and error and data over many years of experience. He cited a 2006 study that called for 30 to 40 beds.
Pugh replied that if the state built 100 or 200 beds they would fill up. She said overbuilding capacity was problematic. Rep. Anne Donahue, R-Northfield, said the key was finding the right balance.
But Pierattini stuck to his guns, insisting that the system has to plan for “for peaks in census (because) the averages can be misleading.” He urged the panel to talk to more practitioners in the field and not just administrators for their advice.
“I think it’s very important to get testimony from actual mental health clinicians,” he said.
That touchy subject was raised by Rep. Topper McFaun, R/D-Barre, who asked Flood whether state hospital employees on the frontlines had been consulted in drafting the plan. Flood conceded he didn’t know the answer to that question. Batra, the state hospital chief, has testified no one from the Agency of Human Services consulted him on the governor’s plan.
Rutland Regional Medical Center President Thomas Huebner and Brattleboro Retreat President and CEO Robert Simpson both stressed the urgency of the situation and they asked the panel to move quickly to approve funding for expanded acute care beds.
They agreed with Pierattini that the system is in extended crisis, treatment is suffering, and that stressed-out staff need to know the state is working quickly to resolve the issues.
“We’d like to get a yes as soon as possible” said Huebner of the proposed six-bed facility for his hospital, which has been accepting disruptive patients who previously might have been at the state hospital and forced to turn people away as well.
Citing the severity of the need and patients who can’t get or decline treatment because of the crowding at the hospital, he said, “There are moments we really don’t sleep well at night.”
Simpson agreed with Huebner.
“The system is very shaky,” he said.
The one blessing, he said, is that a real sense of teamwork has developed among all the providers since Irene, and the closure of the state hospital has provided “a wonderful opportunity to take a stab at stigma.”
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The obviously opinionated and highly prejudicial statement that “peer services” are merely “so-called” (i.e., paragraph 11: “so-called peer services”) would on the surface and at best appear to imply services provided by peers as well as peers themselves are not legitimate, nor credible and, as such, is an insult to peers (read: people with similar lived experiences in one form as well as to one degree or another), one which is taken with great offence even if it was not what was intended by its usage.
What other reason, rational or excuse would there be to employ the term “so-called” in this particular instance of editorial parlance other to relegate the persons referenced by such a term to a lessor state of value and importance compared to those found by those using it to be more legitimate as well as credible?
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Having just reread the above editorial er, article again, it should also be noted how in paragraph the usage of the same term in a similar context of again employed, this time with quote mark that merely serve to provide redundancy or otherwise some form of emphasis: i.e., so-called “peer services”.
Once was bad enough, however repeating the term clearly shows a pattern of what can only be assumed is an entrenched and blatant prejudicial attitude and therefore is one expected to be found among the editorial pages than within a news article.
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“I think it’s very important to get testimony from actual mental health clinicians,” he said.
That touchy subject was raised by Rep. Topper McFaun, D- Barre, who asked Flood whether state hospital employees on the frontlines had been consulted in drafting the plan. Flood conceded he didn’t know the answer to that question.
The staff at VSH have been ignored and marginalized, treated as if politicians have any idea about the needs of some of the most vulnerable Vermonters…the governor and his representatives have made it clear that they do not care what experienced mental health workers think.
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Point taken Morgan, but the use of “so-called” in journalism is not a derogatory term but one to describe a term that has no clear definition to the public, is colloquial or not well known, which is the case with peer services. Another example would be the so-called “nuclear option,” the term in the US Senate in the debate over filibusters. The House panel itself asked what the term peer services meant since they were not sure either. The second use of “so-called” I should have edited out since it was obviously redundant at that point. I would be happy to use a short phrase if anyone has one that can explain in a story to the lay reader what peer services are.
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The people who have historically been the most marginalized and ignored have been the mental health consumers. It’s about time someone listened to what they want; fewer institutions and more community programs.
By the 1970s, employees at public institutions in many states had become unionized. In response to initial stage of deinstitutionalization, some public employee unions became vociferous opponents of the movement of people from state institutions to privately operated community programs. (Taylor, S. J., & Searl S. J. (2001). Disability in America: A history of policies and trends.)
Unions have a history of letting the interests of workers trample the interests of people with disabilities. Unions would obstruct the right of people with disabilities to community living and participation in order to protect union jobs. In 1975, the American Federation of State, County, and Municipal Employees (AFSCME), a public employee union representing 250,000 mental health workers nationally, released a scathing report that blasted the policy of deinstitutionalization. The report, titled Out of Their Beds and into the Streets, presented deinstitutionalization as a plot to relieve state governments of the responsibility for caring for people with mental disabilities, the elderly, and other groups and to put money into the pockets of private profiteers. (Steven J. Taylor, Ph.D Co-Director of the Syracuse University Center on Human Policy, Law, and Disability Studies)
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Yes the State is eligible, but not assured of the additional $20 million, that the Commissioner thinks is an automatic for years to come. There are going to be major cuts in Washington and where will those come from first? Mental Health. There has also been the story given by the commish since the Douglas administration that you can have no more than 15 beds to get the funding. This is a BOLD FACE LIE! Just ask New Hampshire and Massachusetts who both built have built larger than 15 bed State of the Art CMS approved facilities and recieve Federal funding. Also, if this plan is to be cost effective then why is it going to cost the taxpayers $1.6 million more to fund this plan then it would to run the State Hospital? As a taxpayer this enrages me as now it will be more money out of my pocket and knowing that Vermont’s most vulnerable will not get the care they need and deserve. There is alot being hidden right now by the commish and the administration that if the people of Vermont knew what was happening would be outraged
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I would not cite what has happened in New Hampshire as something positive. The Department of Justice issued a scathing assessment of New Hampshire’s mental health system describing it as “broken” and “failing.” The report said the state was violating the Americans with Disabilities Act by unnecessarily institutionalizing mental health patients instead of spending money on less restrictive community care. Federal law requires that people with mental health disabilities be treated and housed in the least restrictive way possible.
This is what will happen in Vermont if we keep pouring money into a failed state run hospital.
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Dear Peter,
House Institutions and Corrections had a presentation on this plan Thursday afternoon. Human Services has policy jurisdiction, and we have some degree of oversight of the capital dollar costs involved. Below are my comments, if anyone is interested.
In general, I can probably support the $10 million for the additional acute care beds in Rutland and Brattleboro, but the rest of the “Plan” is less a plan than an intention, with substantial unanswered questions about how the needed services and treatment capacity will be provided.
Regional/community capacity?
This plan is touted as based on having treatment opportunities close to where people live. Yet it contains no state owned or dedicated acute care beds or services in the northwest corner of the state, where most of the people are. It seems to me that something needs to be worked out with Fletcher Allen for this claim to be fulfilled.
Depth of expertise?
Since this is based on capacity dedicated to state patients in regional facilities, will there be sufficient depth and variety of skill and expertise in each facility? Is it inefficient and duplicative to do that? If that highly skilled staffing is not available at each facility, will the appropriate treatment be available at each place? Will patients be transferred among facilities? For a patient in acute crisis, is it not more important to have the best treatment that to have treatment near their home?
Inefficient scale of new state facility?
The possible new 16 bed facility in central Vermont — isn’t this an economically inefficent scale for any kind of hospital/residential facility? Given the high fixed costs of the basic facility and staffing? Dr. Pierratini as quoted in the piece above may be correct that for basic treatment capacity we need 30 – 40 beds, but I would also like us to consider a larger facility with a flexible capacity that could be expanded and contracted or re-purposed depending on the needs of Vermonters. For instance, if we only needed 16 beds for acute mental illness treatment right now, we could have another wing with beds and treatments for inpatient substance abuse treatment and some capacity for sheltering public inebriates (drunk/drugged and picked up for safety). If over time our needs changed, the use of the facility could evolve. Since the details of the location, size, etc. of this facility are not known, I do not see how they can be adopted or endorsed as part of a bill. Would the adminstration then finalize the arrangements without further legislative action? I do not think I can agree to such a loss of oversight.
Improved and expanded community services?
I definitely support the endeavor to provide these services to those Vermonters who need support and counselling and treatment on an outpatient basis rather than hospitalization. But it is my impression that historially this approach is seldom funded on a sufficient basis, and we cannot now obligate future legislatures and governors to do so. I think that we should put several years worth of funding for this in some kind of endowment that will be drawn down over the next 3 to 5 years. This would not be a permanent guarantee, but it would be a concrete demonstration of commitment: literally putting our money where our mouth is.
Capital Money to private entity?
Although as I said above, I can probably support the $10m for the additional acute care capacity at Rutland and Brattleboro, I need to know more about the details of the long term contract. This would be state capital dollars being used to construct assets that will be controlled and owned by private entities. What if after 5 years, they said, this is not working, we do not want to renew the contract? We need to be sure to provide for all contingencies to protect the financial interests of Vermont taxpayers.
Rep. Cynthia Browning
Arlington
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Arizona had a new $80 million psych hospital built in 2003. Less than 2 years later it was already under fire from federal officials for inadequate care of patients.
(From an article in The Arizona Republic from Aug 6, 2004 titled :”FEDS THREATEN STATE HOSPITAL FUNDING AT RISK AFTER REVIEW FINDS PATIENTS MISTREATED”)
This is what could happen here in Vermont if the we build a new state run psychiatric hospital it is managed by the same corrupt and incompentent hospital adminisration.
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VSEA and all the providers need to endorse the plan to replace VSH with a more community based mental health system!!! Bigger isnt always better!!! All institutions for the mental health/ dd community must be closed IN America !
Community based services are best! Its also cheaper$$$
Smaller is best!!!