The entrance to Vermont State Hospital one month after Tropical Storm Irene. VTD/Josh Larkin
MONTPELIER – A major shift in Vermont’s mental health system toward vastly expanded community treatment was given near-unanimous backing by a key House panel Friday afternoon.
By a 9-1 vote, the House Human Services Committee approved plans by Gov. Peter Shumlin to overhaul the mental health system following the closure of the 54-bed Vermont State Hospital in Waterbury after it was flooded in tropical storm Irene.
However, the House panel diverged from Shumlin in one key aspect, recommending a new 25-bed state hospital be built in central Vermont instead of the 16-bed facility the governor proposed. The panel backed the rest of Shumlin’s replacement plan for the state hospital, which proposes a four-year contract for six acute-care beds at the Rutland Regional Medical Center and 14 at the Brattleboro Retreat, as well as five beds for those held in the department of corrections at a yet-to-be-determined site.
The fast-tracked bill is a response to the crisis in treatment created by the closure of the state hospital, which removed 54 acute-care beds from the system, creating a space squeeze for acute-care beds and severe disruption in private hospital psychiatric wards and treatment centers around the state.
But it also marks a pronounced shift – which many advocates say is long overdue – to more community oriented mental health care, with peer services, housing subsidies, early intervention, and three new intensive residential recovery facilities (one with 15 beds, two with eight) located in Northwestern, southeastern and either central or southwestern Vermont. Four short-term crisis beds in underserved areas and a five-bed residence for those seeking to avoid medication are also set out in the proposal.
The complex 36-page bill that emerged from the committee also sets up strong oversight and coordination for the new decentralized system, calls for monitoring reports, sets out legal protections for patients involuntarily committed and spells out the “no refusal” rules under which Rutland Hospital and the Retreat agree to treat acute care patients.
Separately Friday, Mental Health Commissioner Patrick Flood said the state is exploring use of the former Genesis Nursing Home in Morrisville to help ease the crunch in intensive psychiatric care on a temporary basis. The 90-bed facility shut down as a nursing home in 2007 but is being used as office space and already meets the state’s stringent safety needs.
Flood said it could provide from 6-8 beds to as many as 20, including a secure ward for patients under court-ordered evaluation or supervision, one of the state’s most severe needs now. However he cautioned that many other sites have been evaluated and fallen through since the state hospital closed, comparing the process to “pulling rabbits out of a very deep hat.”
The bill passed in committee Friday includes a last-minute provision that would permit a contract with an interim site like the Genesis facility.
The late afternoon vote came after several days of wading through both minutiae and large policy questions, not to mention a multitude of dollar figures which weren’t filled in until the last minute. Many lawmakers involved have described the process as unprecedented in scope and urgency.
Rep. Sandy Haas, P-Rochester, recalled for fellow committee members that the state has been trying to close the antiquated state hospital building in Waterbury and revamp care for nine years without success.
“Today I get to do that and I am very proud,” she said.
Topper McFaun, R-Barre Town, agreed, saying, “I feel very positive about we’re about to do for the people of the state of Vermont.”
Chairwoman Ann Pugh, D-South Burlington, noted the intense pressure on the panel to move a bill and find compromise on a host of complicated issues.
“The committee process is a darn messy process, but it sure beats any alternative,” she said, calling the bill a workable “middle ground.”
The lone dissenting vote was cast by Rep. Tom Burditt, R-West Rutland, who praised the committee’s work though he disagreed with its decision to bump the acute care beds from 16 to 25. Burditt said he was concerned that would mean a $10 million jump in operating costs for the new hospital, and also said based on testimony he was not convinced the extra beds were needed.
State building officials have said the new hospital, targeted for two potential sites near Central Vermont Medical Center in Berlin, will not be built for at least three or more years. Its cost is expected to be around $25 million. The state expects state insurance and FEMA funds to provide much of the funding for the three hospital facilities that comprise the new acute-care system. However there is considerable uncertainty about how much of its operating costs, estimated at $12.5 million, will have to be paid by the state under federal Medicaid regulations.
The bill now moves on to two other committees. House Appropriations will take a crack at the dollar figures and Institutions and Corrections will add its voice to the decisions on the new facilities proposed, both early next week. The bill is scheduled to be reported to the floor for debate by Thursday.
Rep. Anne Donaghue, R-Northfield, said the decision to increase the beds in the central Vermont acute care facility to 25 is a cautionary move that allows the state some flexibility. If the new community system reduces the need for intensive care beds, the psychiatric hospital’s size can be scaled back. Donaghue said she agreed with testimony from many mental health professionals who said a larger hospital was needed to meet Vermont’s needs and would also best serve the clinical needs of patients and staff.
She downplayed any conflict with the governor over the hospital’s size, saying “I believe he is, like most of us, mostly interested in a positive outcome” for Vermonters.
Donaghue, a strong advocate for mental health patients, said the pressure to vote out the bill preempted more detailed discussions and language on legal protections that she would have liked in the “ideal world.” But she said she felt confident patients were protected by language added to the bill requiring the mental health department to continue to work on the issue and report back to the panel.
“It’s a very early step. There’s a long way to go,” she said.
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If beds exist the mental health system will find ways to fill them. The extra $10 million that a 25 bed facility will require would be better spent on a non coercive method of treatment. Soteria houses are alternatives to the authoritarian psychiatric hospital system that is based on routine use of harmful antipsychotic drugs.
From The Journal of Nervous and Mental Disease 187, 1999:
Two random assignment studies of the Soteria model and its modification for long-term system clients reveal that roughly 85% to 90% of acute. and long-term clients deemed in need of acute hospitalization can be returned to the community without use of conventional hospital treatment. Soteria, designed as a drugfree treatment environment, was as successful as anti-psychotic drug treatment in reducing psychotic symptoms in 6 weeks. In its modified form, in facilities called Crossing Place and McAuliffe House where so-called long-term “frequent flyers” were treated, alternative-treated subjects were found to be as clinically improved as hospital-treated patients, at considerably lower cost. Taken as a body of scientific evidence, it is clear that alternatives to acute psychiatric hospitalization are as, or more, effective than traditional hospital care in short-term reduction of psychopathology and longer- social adjustment. Data from the original drug-free, home-like, nonprofessionally staffed Soteria Project and its Bern, Switzerland, replication indicate that persons without extensive hospitalizations (<30 days) are especially responsive to the positive therapeutic effects of the well-defined, replicable Soteria-type special social environments. Reviews of other studies of diversion of persons deemed in need of hospitalization to "alternative" programs have consistently shown equivalent or better program clinical results, at lower cost, from alternatives. Despite these clinical and cost data, alternatives to psychiatric hospitalization have not been widely implemented, indicative of a remarkable gap between available evidence and clinical practice.