Committees briefed, at length, on mental health options

Psychiatrist Dan Fisher knows more than most about mental illness. He’s the been involved in the mental health field for 20 years and heads the National Empowerment Center in Lawrence, Mass., which advocates for patients’ healing and recovery.

He’s also been hospitalized several times and diagnosed as schizophrenic.

Wednesday, he provided a very personal and, at times, quite different view of how mental health care needs to be handled to a joint meeting of the Senate Committee on Health and Welfare and the House Committee on Human Services.

“You have an opportunity no other state really has,” he told lawmakers, who are facing complex decisions on how to reform the state’s mental health care with the closure of the 54-bed Vermont State Hospital after Tropical Storm Irene.

In Fisher’s mind, and in his experience, the state has the chance to bring about a historic shift, away from hospitalizations and what he said was rampant overuse of medication to a system of care that uses evidence-based alternatives that work.

“You all in Vermont have an excellent opportunity. You can lead the country in mental health services,” he told lawmakers.

His own hospitalizations “left me feeling I was no longer alive,” he said, but what saved him was people who let him be involved in his own treatment, which helped rescue him from the “traumatic experience” of being hospitalized.

“Hope is one of the most important ingredients to recovery,” he said. “Recovery is based on human relationships,” he explained, such as community support and support from peers who have experienced mental illness, as well as professional treatment under different community models.

Fisher was one of five psychiatric experts who testified Wednesday about the daunting and complex task of rebuilding the mental health system in Vermont after the loss of its main treatment facility for acute mental health care. The testimony comes a day after a draft bill was issued in the Statehouse by the Human Services Committee that puts some dollars and cents and programs and buildings together into a comprehensive, if still incomplete, package.

Fisher strongly advocated for a system that relies on community treatment and very little on involuntary hospitalization, saying “hospitalization may at times be necessary but it should be the absolute last resort.”

But other experts who testified Wednesday were more cautious about Vermont’s ability to reduce the number of acute care beds in the system, saying Vermont already has one of the lowest hospitalization rates in the nation and that some patients who are violent, aggressive and dangerous or in the criminal system will need a secure place to be treated.

“It’s important that Vermont recognize that it will be going someplace no state has gone before it,” said Dr. Jeff Geller of the UMass Medical School department of psychiatry, adding “it’s not a reason not to do it, or do it.” Vermont had the fifth lowest mental health hospitalization rate in the country and it will take “very great investments” in community treatment to replace the need for acute care beds, he said.

The issue of how many acute care beds are needed to replace the Waterbury State Hospital remains the elephant in the mental health room for lawmakers and advocates alike, and the experts danced around that question.

Dr. Howard Goldman, a professor of psychiatry at the University of Maryland, said evidence is “pretty strong” that community treatment models work and can reduce need for hospitalization. But as to how many state hospital replacement beds Vermont will end up needing, he said, “that’s an extremely difficult question.” The concern is that in an effort to reduce hospitalizations, the state can eventually end up not providing “a good quality of care,” he said.

“I think every community needs to have some acute resources,” he said.

Fisher estimated if Vermont’s proposed community system used all the newest treatment models, that number could be 20-25.

The administration’s proposal calls for 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. Acute care is now also being provided at Fletcher Allen in Burlington but that is not part of the long-term plan.

The proposal also calls for greatly expand community services, from emergency intervention, housing, crisis beds, peer services and intensive local mental health outpatient and residential services that administration officials say will preempt the need for more acute care beds.

Goldman told lawmakers that he comes from a civil liberties angle and has “long been concerned with the loss of liberty and sense of hopelessness” that hospitalization brings. He also said hospitals can inadvertently create long-term patients and bad outcomes, and they have a “historic tendency to overuse medication.”

But if an alternative system is to work, the “iron law” is that there needs to be a range of comprehensive services in the community that is stable and well funded, he said.

Dr. W. Gordon Frankle, chief of psychiatry at Rutland Regional Medical Center, said he experienced similar upheaval to Vermont’s when in Pittsburgh, Pa., when a state hospital with 221 patients was closed over an 18-month period. He said extensive on-call services, outreach and housing, crisis drop-in centers, peer services and a “high degree of oversight” were essential to make the downsizing work.

He said Vermont needs to make sure it has the oversight and state overview to make sure people are in the right treatment.

Geller, who was a department of justice monitor when the Vermont State Hospital was sanctioned in 2006, said the state will need to make statutory changes to commit involuntary patients to hospitals like Rutland under the new system and speed up the commitment process and appeals, which can take as long as two years.

A lynchpin in the administration’s plan is the 16-bed hospital proposed in central Vermont. Its size, expandable to 25 beds, has been criticized as being too small for adequate treatment, staff training and retaining and finding qualified mental health professionals. Minnesota Mental Health administrator Dave Hartford told lawmakers that his state’s experience with four similar 16-bed facilities has been problematic, admitting that “keeping staff has been challenging within those facilities.” He disputed assertions that the 16-bed hospitals were a “failure” as others had previously testified but said “right-sizing” for a “vibrant professional staff” was a “very complicated question,” especially in a rural setting.

Another issue for some lawmakers is that while northern Vermont has the state’s major populations centers, no acute hospital beds are proposed there. Hartford said there is no doubt that the state needs a “centralized intake process” to screen who should be treated where.

Testifying in the afternoon before the House Institutions Committee, a state buildings architect told lawmakers that his best guess is it will be 40 months before the new 16-bed facility is ready to open its doors, assuming a go-ahead is given by the Legislature in the spring.

Michael Kuhn, an architect with the Department of Buildings and General Services, said the state is using previous plans already designed for a 15-bed facility that was never approved and some $2.4 million set aside in the fiscal 2012 and 2013 to get through siting, permitting and land acquisition. Land acquisition talks are ongoing for two sites near Central Vermont Medical Center and both sites could provide the location for a hospital with up to 30 acute care beds, he said.

Figuring out the convoluted financing for the 16-bed hospital, which is estimated to cost around $16 million, and the proposed beds at the Rutland Hospital and Brattleboro Retreat caused some heartburn for the House Institutions panel Wednesday. Funding is tied into flood insurance settlement money and FEMA funds, whose amounts may not be known for months while FEMA expects any reconstruction to be done in 18 months – hardly within the timeline Kuhn’s presented the panel. However a FEMA official has told the state that it can ask for an extension.

The lawmakers confusion and frustration at trying to decipher its role in the complex mental health restructuring and the renovation of the Waterbury state office complex at the same time prompted Chairwoman Alice Emmons to give a pep talk at the end of the day.

“We’re going to be operating out of our comfort zone a lot in this committee,” she said, noting they had to have faith in FEMA and the administration and rely on their experience to get through the long process.

“We’ve been dealing with this (the state hospital) since 2005,” she reminded them.

Then she added it was time to call it a day: “I think we’ve about had the radish,” she said.