The entrance to Vermont State Hospital one month after Tropical Storm Irene. VTD/Josh Larkin
MONTPELIER – They wandered all morning through the corridors of history, seeking a glimpse of the future.
All afternoon, they waded through the numbers, nuances, conflicting opinions and complex policies of Vermont’s mental health system.
By 5:30 p.m. when it was over, House Institutions Committee Chairwoman Alice Emmons of Springfield, looking tired, clearly spoke for her panel when she said, “Who knows where we’re going to go.”
She got sympathy from Rebecca Moore, a licensed psychiatric social worker who was the last to testify in a day that began with the panel getting a long guided tour of the vacated Waterbury State Hospital and the labyrinthine corridors of the rest of the office complex flooded by tropical storm Irene. The panel then looked at two possible state hospital sites being considered in Berlin.
“You poor people,” said Moore with a smile, agreeing the task before the Legislature in deciding how to reconstruct Vermont’s mental health system after Irene is anything but an easy one. As Rep. Cynthia Browning admitted – in a joking phrase heard often in the State House this year – they have a “Waterbury complex.”
House Institutions is one of a handful of key committees in the Legislature tackling a revamp of mental health in the state proposed by Gov. Peter Shumlin. His plan calls for a broad spectrum of beefed up community mental health services and three separate small intensive care facilities for those in acute mental health distress, replacing the acute care provided before Irene’s flooding solely in the 54-bed Vermont State Hospital in Waterbury. The governor’s proposal now calls for 36 acute care beds spread out at three facilities: 14 at the Brattleboro Retreat, six at the Rutland Regional Medical Center, and a new 16-bed facility to be located near Central Vermont Medical Center.
The governor’s plan has raised a raft of difficult issues that are financial, programmatic and even philosophical: Is a standalone 16-bed facility big enough to hire and keep staff and doctors for adequate treatment? Should the state privatize care of the state’s most mentally ill in facilities in Brattleboro and Rutland. What kind of legal and transparency issues does that raise in case of problems? What will the capital costs and operating costs be, considering the mix of federal and state money? What will happen to the 240 former VSH employees now working at sites around the state?
And perhaps underlying all this: Can the state maintain the elaborate expanded community services needed to underpin the governor’s plan and avoid building a new larger state hospital facility – especially in light of a history of cutbacks over the decades?
That issue was front and center for Moore, who since the hospital was flooded has been working at Burlington’s Fletcher Allen psychiatric ward since employees were displaced from Waterbury.
She said Vermont’s community mental health budgets were “decimated” in past years by cutbacks – and when that happens the state hospital is where untreated patients end up in more severe crisis.
“The state hospital does not exist in a vacuum,” she said. She said the patients she works with have numerous issues that are not easily resolved and many require extensive time in an acute care setting to get ready to go back into the real world.
She said in her opinion, the number of intensive-care beds in the governor’s proposal is “inadequate to meet the need.”
VSH Medical Director Jay Batra seconded her comments, comparing the shifting state policies and funding in mental health care as “playing the seesaw like whack-a-mole.” He said there is widespread agreement of the need and benefits of improved community mental health services outlined by the governor, calling them “long overdue.” At the same time he repeated his call for a centralized four-unit acute care facility with 12-15 beds in each unit, saying the governor’s plan doesn’t account for the actual “unmet need” in Vermont.
Batra said Vermont’s ratio of acute care mental health beds to population is already one of the lowest at nine per 100,000 people. New Hampshire’s ratio is three times as high and Massachusetts is 15 per 100,000, he said.
Batra also said the state of Minnesota tried similar sized 16-bed facilities to avoid a federal cap on funding eligibility as the governor has proposed and has decided that system has failed, noting that keeping and hiring staff for a facility that small is very costly.
“It simply does not work,” he said. “You can’t staff the place.” Training and treatment quality is also an issue. Staff, he said, learn from patients, from other staff and from extensive practice “over and over again” that teaches them how to deal with disruptive and difficult patients needing Level 1 care. A 16-bed facility simply doesn’t meet those criteria, he said.
He also vigorously argued before the panel that Vermont needs an “absolutely accountable, non-refusal facility” that will take involuntary admissions and those under care of the corrections department, which private facilities may not be able or willing to do.
“Having a place that simply cannot say no is essential to this,” he told the committee.
Batra’s opinion on the need for a larger replacement state hospital has been buttressed by the head of Fletcher Allen’s psychiatric unit, who testified last week that a central hospital with some 30-40 beds is needed. However some mental health advocates in Vermont want to see even fewer beds and more people treated in their communities.
Rep. Jason Lorber, D-Burlington, asked Batra what the Shumlin administration thinks of his opposition. After a pause, Batra joked, “Do I have the right to remain silent?”
Both he and Moore were asked if they were consulted on the governor’s state hospital plan and they said no. But Batra, who has been at the state hospital for five years, said he didn’t want the conflict over bed numbers to distract from the larger important debate on how best to formulate a good statewide care system, calling that debate a “false dichotomy.”
The chore facing the panel, which will have a say on any facilities built, is not just difficult but urgent. Rutland Regional Medical Center Thomas Huebner testified for the second time in a week that the crisis caused by the closing of the state hospital has created tremendous stress on his hospital, not only in dealing with difficult patients but because treating patients who would have formerly gone to the state hospital means others in the region are turned away.
“This cannot continue any longer than necessary,” he told the panel, urging them to approve something soon even if it is not “perfect.”
While he urged action on the governor’s proposal, he cautioned that there had to be a real financial commitment to whatever is passed. He said his “biggest fear” is that the community mental health system and places such as his hospital won’t be adequately funded, which means treatment will falter with more people facing more acute crisis.
“We have to be accountable for outcomes,” he said.
Peter Albert, a senior Vice President at the Brattleboro Retreat, also urged the committee to concentrate not on finding the perfect number of beds for mental health care but to focus on what would constitute the best system.
The committee’s lengthy day began with a sobering tour of the inside of the now-empty state hospital, the small Spartan rooms, dark corridors and thick doors putting a grim face on the oft-used word applied to the building, “antiquated.” The entire red-brick complex, parts of which date back to before 1900, once housed some 2,000 “insane” Vermonters, and when Irene hit, housed around 1,500 state office workers and 51 state hospital patients.
After its tour, the panel also visited a state parcel behind the regional library in Berlin, a possible site for the governor’s 16-bed state hospital facility, which the plan says could be expanded to 25 beds. Part of the 5-plus acre parcel, however, appeared to be frozen swamp and would require substantial backfill. It is also located about half a mile from Central Vermont Medical Center. Experts and advocates have said any new modern mental facility should be adjacent to a medical hospital.
The second site visited Wednesday is a substantially larger parcel owner by Henry Lague with two small houses on it that is at the corner of Paine Turnpike and Fisher Road, much closer to the medical center.
Construction of any new state-owned Level I mental health facility in Berlin is at least two years away, state officials have said.
Permalink |
I found a story published by the Milwaukee Journal Sentinel that described how Pennsylvania successfully closed its Mayview State hospital. Many in Milwaukee want to do the same thing there. Vermont should do this also:
” Mayview, the Pennsylvania state mental hospital, had 221 patients when state officials decided in 2006 to close it. These were some of the toughest cases in the state. One woman had been admitted in 1952. Another was prone to shoving hangers under the skin on her arms.
In the end, all but 19 – including those two women – were placed in housing in the community. Those patients, the most dangerous, were transferred to another state hospital. Today, just 10 remain.
For those needing acute care, Pennsylvania health care officials developed a 30-bed facility attached to the University of Pittsburgh’s Medical Center. Medicare, Medicaid and private insurance cover three-fourths of the cost with the county picking up a fourth.
In addition to less restrictive care, the approach is a money-saver for taxpayers. It also helped spawn more housing designed for people with mental illness. Pittsburgh mental health professionals say they can treat three people in the community for the overall cost for one patient in the now-closed state hospital….. Housing options ranged from a 16-bed facility for people needing highly skilled care to independent apartments.”
http://www.jsonline.com/watchdog/watchdogreports/107835219.html
Permalink |
Excellent find Curtis! Thank you! Your work and efforts in these and related regards are well appreciated, not only by me but also many others as well.
Beside the above excerpts of the article you mentioned however, what is also of interest in the above mentioned article includes the last section under the subheading of “Past similarities”, which mentions how a study that was done pretty much appeared to mirror a master plan written in 1993. It also mentions how the 1993 master plan was authored by Susan Besio, who at the time the article was published was quoted as stating how:
[...]
“I have no idea why they didn’t follow our recommendations,” said Susan Besio, who authored the document. “We believed it was a good road map for Milwaukee to change its mental health system.”
Besio is now director of Vermont’s Medicaid system. She said most communities around the country have either closed their government-run psychiatric hospitals or folded them in to larger systems.
[...]
——–
Sound familiar?
By the way, also of interest was a related article:
Mental health overhaul could nearly end inpatient care
Report calls for Milwaukee County to pursue outsourcing, community care:
http://www.jsonline.com/watchdog/watchdogreports/104414474.html
via Milwaukee Journal Sentinel; October 6, 2010
Here is the link to the report:
Human Services Research Institute report, sponsored by Public Policy Forum:
http://media.journalinteractive.com/documents/Mental+Health+Redesign+Report.10-5.pdf
Permalink |
Andrew Nemethy’s articles following this complex issue have been excellent, and these three quotes, from comments above, demonstrate some of the complexities.
The article on the closing of a state hospital and expansion of community services in Pennsylvania notes, “Those [remaining] patients, the most dangerous, were transferred to another state hospital.” In other words, Pennsylvania closed one state hospital, but not all of them, through increased community services. Vermont has had only one.
It continued, “For those needing acute care, Pennsylvania health care officials developed a 30-bed facility attached to the University of Pittsburgh’s Medical Center.” In addressing the issue of restructuring care for acute mental illness, this underscores the point that best practices require adjacency to a medical center. Anything less leaves those with mental illness as second class citizens compared to any others receiving hospital care, who always have access to all ranges of specialties that may prove to be necessary. Mental illness often includes complex medical issues. The current Vermont plan does not recognize that simple reality.
“Mental health overhaul could nearly end inpatient care” — the critical word here is “almost”. As a ratio to every other state, Vermont’s public system has already nearly ended inpatient care: we have one of the most extensive community support systems, and lowest number of inpatient beds per population.
Expanded outpatient support is essential for our system to be strong, but how much more it can replace inpatient “Level 1″ care is an unprecedented guess.
As one community provider testified: too few beds means premature discharges that could present a public danger [Level 1 care represents the tiny number of persons who may present a risk of violence]; too many beds means more people hospitalized longer than necessary, which is less helpful to recovery and more expensive.
Too few would extend the extreme crisis we are currently experiencing, which began pre-Irene, with Vermonters needing inpatient care being turned away and severely ill persons held for days in emergency rooms. Now persons who committed even petty crimes but urgently needing inpatient care being illegally held for days in prison, waiting for a bed to open up.
Too few would force the state to cut short hospital stays, not allowing for building a relationship with a doctor that can lead to preventing a court petition for the trauma of involuntary, forced medication. There will be greater economic pressure to change the law to expedite the legal process that protects persons’ rights in those situations.
Waiting to see if we need more, and then expanding, will create those scenarios before more beds can be added, even assuming momentum is every regained for the state to build them.
Building 30 rather than 15 now would allow other urgently needed uses, such as addictions treatment, in one or two wings if they were not needed for psychiatry.
Which side of the “gamble” on size makes more sense?
The governor often repeats the claim that the mix of locations in his plan “provides many Vermonters with in-patient options closer to home, which can be very important for their recovery and discharge planning.” Important? True. Supported by the governor’s plan? Not when two-thirds of the beds are located where only one-third of the population lives. Burlingto patients will be shipped to Brattleboro.
The governor commits to the Berlin unit being “state-of-the-art care.” To even think of separating it from general inpatient care violates that tenant. Ten years ago, Fletcher Allen CEO Bill Boettcher thought he could move inpatient psychiatric care away from the rest of inpatient care. That mistake in judgment about standards for psychiatric care was the start of the fall of the dominoes that landed him in fedral prison for two years.
When will we ever escape from the stigma evidenced in the plan; stigma, the single greatest barrier to people accessing mental health care?
Permalink |
The huge problem with all of this debate in general has been on how it is still to much focused on not only beds and then mainly those of the institutional, forced treatment medical model as well as how many there should be as well as where they should be located, but it is also too focused on the needs of the system, hospitals and service providers.
What should be focused on is what the actual need is of the populations are and then how best to meet them, including when it is far better to meet such needs without the ER’s and hospitals as well as other default locations or players being the catch all.
In this light, it seems that the Governor’s plan is attempting to do this and strikes a good balance and is a more sound approach.
Although, if a new facility ends up being built, it would be better to have it attached to as well as much more integrated with a general hospital medical facility than is being proposed, given the actual needs as well as the size of the state’s overall population in general and, save for a small forensic facility to be centrally located somewhere within the state, there are those including myself who believe there is no need to replace these type of beds and the needs can be better dealt with using other means and by providing more robust community-based services, including by providing additional housing options, than is already being planned.
That said, in my opinion, the Governor’s plan is certainly heading in the right direction.
Permalink |
Here is the link to an interesting article concerning these matters regarding how they are being addressed elsewhere:
New programs provide alternatives to hospital, jail (via NAMI-Washington state):
http://www.namiwa.org/content/new-programs-provide-alternatives-hospital-jail
Permalink |
I am hopeful lawmakers will see past this and go with Gov. Shumlin’s plan. My big concern is this no refusal policy.
What happens when we get that central hosp or level 1 facility?
My concern is it will be over used and abused! When VSH was in play it hovered at close at 54 people at any given time. It was described as “A safety net “in many reports
The problem with safety net is they will be used simply they are there. Gov. Shumlin’s plan takes us away from the old school thinking. It challenges everyone to do something different. To think about alternatives. In many reports this quote was used “VSH is a safety net when others refuse to take them.”
Why do others refuse?
I know the General hosp’s can refuse but I think if there are state dollars flowing there needs to be criteria, Instead of talking about one place that has to take anyone there needs to be a REAL discussion about this issue of why refusals happen. There needs to be some sort of collaborative here! One quote I remember from RRMC was “Well if we had to we could just expedite them to Waterbury before.”
Sometimes it is hard to adapt to a new way of thinking.
But it can be done.
As I write this I am reminded pain management. In one hosp policy it states “We will help you seek alternatives to Narcotics.
This is a historic opportunity. Vermont has been the leader in so many areas. Can we become a leader in a new approach to collaborative care for everyone who has a mental illness?
Permalink |
Anne Donahue’s reply still shows a total disconnect from some of the problems with the system:
“Now persons who committed even petty crimes but urgently needing inpatient care being illegally held for days in prison, waiting for a bed to open up.
Too few would force the state to cut short hospital stays, not allowing for building a relationship with a doctor that can lead to preventing a court petition for the trauma of involuntary, forced medication. There will be greater economic pressure to change the law to expedite the legal process that protects persons’ rights in those situations.”
It is not possible to build a theraputic relationship with a doctor who has you locked up against your will. Many people in VSH WANT to have the right to get a finite prison sentence rather than spend months or YEARS locked up in a psychiatric hospital. I have seen people charged with hitchhiking on the interstate locked up for over 6 months in VSH. Other people with misdemeanor charge have spent more then TWO YEARS locked up in VSH. The answer to eliminate these problems in not to build a bigger hospital- it is to ELIMINATE INVOLUNTARY TREATMENT.
Those people charged with petty crimes would not be in that situation if there were more community treatment programs to help them before they got into trouble with the law.
Then they get to VSH and hear the staff “joking” about how they have to insure their job security by keeping people locked up for long periods of time. Then they get to VSH and hear the staff “joking” about how they have to insure their job security by keeping people locked up for long periods of time. The patients would be better off serving a finite sentence of a weekend in jail – which is what most people get for those types of charges- and then be given the option of voluntary treatment.
Then many people spend weeks, months or even years at VSH only because there is no other place for them to go. I knew someone who was locked up for the last FOUR YEARS of his life because he could not find placement. The solution for that is MORE COMMUNITY TREATMENT and not more beds in a psychiatric hospital. Especially not a psychiatric hospital that has failed certification over and over for almost a decade.
VT is a MUCH smaller state than Pennsylvania. If they can shut down a 200 bed hospital and find places for most in the community than VT should be able to move from a 54 bed hospital down to a 16 bed hospital.