Recap 2012: State builds mental health system from scratch

The entrance to Vermont State Hospital one month after Tropical Storm Irene. VTD/Josh Larkin

The entrance to Vermont State Hospital one month after Tropical Storm Irene. VTD/Josh Larkin

The Shumlin administration and lawmakers had to put the state’s psychiatric system back together after Tropical Storm Irene damaged the Vermont State Hospital in August 2011.

Rather than restoring the existing mental health infrastructure, Gov. Peter Shumlin decided to build from scratch.

At the beginning of the 2012 legislative session the administration called for a decentralized mental health system with acute care facilities in different regions of the state. This direction was a major shift from the previous system which centered on the Waterbury psychiatric hospital.

The landmark bill that set the groundwork for the new, regionalized mental health system was Act 79. The bill called for a 45-bed acute-care system to replace the state’s 54-bed psychiatric hospital.

Incoming commissioner Patrick Flood and newly appointed medical director Jay Batra were charged with overseeing the implementation of the mental health overhaul. Although Batra was concerned about the decentralized system, he agreed to sign on. Other leading medical professionals have also consistently voiced concern that Vermont doesn’t have adequate psychiatric resources to spread staff across regional facilities.

The 45 beds consist of a new 25-bed state hospital in Berlin, a new 14-bed acute-care facility at the Brattleboro Retreat and a six-bed unit at the Rutland Regional Medical Center. In addition to these facilities, Fletcher Allen Health Care and Central Vermont Medical Center have acute-care units. Act 79 also laid the foundation for a seven-bed secure residential facility in Middlesex, a temporary eight-bed acute-care facility in Morrisville and several other facilities across the state, including an eight-bed residential unit in Westford.

Rob Simpson, CEO of the Brattleboro Retreat. Photo by Randy Holhut/The Commons

Rob Simpson, CEO of the Brattleboro Retreat. Photo by Randy Holhut/The Commons

The Brattleboro Retreat, a private psychiatric hospital, is one of the lynchpins of the new system, but at one point funding for the facility was in question. While lawmakers deliberated on the details of spinning off treatment to local hospitals and several community care facilities, the Centers for Medicare and Medicaid and the Vermont Division of Licensing and Protection began an investigation into a drug overdose and death at the Retreat. Twenty-nine-year-old Jared Alexander Fitzpatrick of Middlebury was undergoing psychiatric treatment at the Retreat when he died of a drug overdose in January after he snatched methadone off a nurse’s cart at the facility. Fitzpatrick was not in state custody. When hospital executives testified before lawmakers they didn’t provide details about the death or the investigation. Nor did Shumlin administration officials who were also aware of the probe. The Legislature approved the Retreat’s participation in the psychiatric system without realizing that CMS had threatened to pull funding if the Retreat didn’t make significant changes to its procedures and staffing. The CEO of the Retreat publicly apologized to lawmakers in June and at the end of July federal regulators assured the Retreat that it had taken adequate steps to maintain Medicaid funding levels.

Leadership changes, facility delays

Toward the end of 2012, both Flood and Batra resigned. Flood moved into a bureaucratic role after Gov. Peter Shumlin was re-elected, and Batra took a post as the chief medical officer for the Vermont Health CO-OP, a member-run health insurance cooperative that is seeking state licensure. Former Deputy Commissioner of Mental Health Mary Moulton took over as acting commissioner.

All of the planned facilities were delayed due to permitting and construction difficulties.

The Department of Mental Health indicated in October that it’s on track to overshoot its fiscal year 2013 budget by $1.5 million. Such costs include the the entirety of the temporary facility in Morrisville and expanding the Middlesex facility to seven beds from five.

As 2012 comes to a close, the town of Berlin has indicated it is preparing the state’s conditional use permit to break ground on the new state hospital in early 2013. The state plans to open the hospital in January 2014.

The Brattleboro Retreat unit is slated to open in February and the Rutland acute-care center is scheduled to open in May.

Construction of the Middlesex temporary, secure seven-bed facility is well under way, and will be opened in the spring.

Morrisville’s acute-care center at Lamoille Community Connections is set to accept its first patients on Jan. 2. The Morrisville facility is expected to ease pressure on Vermont’s emergency departments, which have been inundated with severe psychiatric patients who have been unable to get proper treatment due to a dearth of beds.

According to numbers provided by the state, the average time these patients spent in an emergency department waiting for admission to an inpatient facility quadrupled from 10.7 hours in April to 42.4 hours in October. The average wait time dipped to 24.3 hours in November, but the longest period a patient had to wait for a placement shot up from 57 hours in April to 245 hours in November. That’s more than 10 days.

Vermont won’t see a substantial improvement in mental health care for patients suffering from acute mental illness until the new facilities open in the next year or two, Commissioner Moulton said.

The big question heading into 2013 — aside from whether the decentralized system will meet the state’s psychiatric needs — is how the overhaul will be funded.

120507_ShumlinWaterbury

When Act 79 was passed, the Shumlin administration was confident that the state would receive a 90 percent federal match for the new state hospital and other buildings from the Federal Emergency Management Agency’s public assistance program.

At the end of November, however, the state learned that it was ineligible for the 90 percent federal match because FEMA said repair costs for the damage didn’t exceed 50 percent of the cost of replacing the facility and “it is feasible to repair the facility.” In other words, the federal agency said the Vermont State Hospital was not destroyed.

Exactly how much of the new state hospital and other facilities FEMA will fund is currently unknown, but it will not be at levels as high as the administration originally thought when the plan was set in motion. The Shumlin administration said that despite the FEMA ruling, it will push on with its current plans.

In November, the departments of Mental Health and Buildings and General Services submitted a “worst-case scenario” financing plan to the Department of Financial Regulation. Without knowing how much insurance and FEMA dollars would be available, the departments’ plan B called for bonding the entirety of the new state hospital.

Bonding would put taxpayers on the hook for the hospital’s $28.5 million in construction costs and create another obstacle for the state as it tries to reel in a $50 million to $70 million budget gap projected for the following fiscal year.

Bonding would also bump up the overall cost of the project to roughly $38 million when interest and banking fees were taken into account — a very different fiscal situation than the state was hoping for.

The 90 percent federal match the administration was banking on at the beginning of 2012 would have left the state with a $2.85 million tab for the new facility.

The silver lining, however, is that for the first time in nearly a decade, the state is eligible to receive about $11 million in annual reimbursements for Medicaid patients. In 2003, the Vermont State Hospital was decertified and lost funding from CMS because of inadequate treatment and facilities. Now that the facility is closed, the state is receiving funds to pay for placements in the new regionalized system.

Stories

Shumlin proposes to decentralize treatment centers to replace Vermont State Hospital
http://vtdigger.org/2011/12/14/shumlin-proposes-to-decentralized-treatment-centers-to-replace-vermont-state-hospital/

House approves plan for 25-bed for new state hospital and more extensive community psychiatric care
http://vtdigger.org/2012/02/02/house-approves-plan-for-25-bed-for-new-state-hospital-and-more-extensive-community-psychiatric-care/

Shumlin administration to lay off 80 Vermont State Hospital workers
http://vtdigger.org/2012/02/24/shumlin-administration-to-lay-off-80-vermont-state-hospital-workers/

Senate approves 16-bed psychiatric facility to replace Vermont State Hospital
http://vtdigger.org/2012/02/29/senate-approves-16-bed-psychiatric-facility-to-replace-vermont-state-hospital/

Shumlin: Administration and lawmakers agree state workers will return to Waterbury, state hospital will be 25 beds
http://vtdigger.org/2012/03/15/shumlin-administration-and-lawmakers-agree-state-workers-will-return-to-waterbury-state-hospital-will-be-25-beds/

Berlin residents pan Shumlin administration proposal to locate state psychiatric hospital near elementary school
http://vtdigger.org/2012/05/31/berlin-residents-pan-shumlin-administration-proposal-to-locate-state-psychiatric-hospital-near-elementary-school/

Brattleboro Retreat faces regulatory violations over drug overdose as lawmakers approved plan for mental health system
http://vtdigger.org/2012/06/04/brattleboro-retreat-faced-regulatory-violations-over-drug-overdose-as-lawmakers-approved-plan-for-mental-health-system/

FEMA balks at price tag for Irene damage to state property
http://vtdigger.org/2012/07/20/fema-balks-at-price-tag-for-irene-damage-to-state-property/

The $80 million word: Shumlin administration contractor misread FEMA requirements
http://vtdigger.org/2012/08/03/the-80-million-word-shumlin-administration-contractor-misread-fema-requirements/

Administration tells lawmakers mental health overhaul, state office plans see both progress and delays
http://vtdigger.org/2012/08/14/administration-tells-lawmakers-mental-health-overhaul-state-offices-plans-see-both-progress-and-delays/

State officials say Department of Mental Health over budget, 8-bed Chittenden County mental health facility on hold
http://vtdigger.org/2012/10/19/state-officials-say-8-bed-chittenden-county-mental-heath-facility-on-hold/

New Vermont State Hospital could cost $38 million — $10 million more than originally proposed
http://vtdigger.org/2012/11/19/new-vermont-state-hospital-could-cost/

Mental Health Commissioner Patrick Flood’s departure lamented
http://vtdigger.org/2012/11/20/flood/

FEMA says Vermont State Hospital and other Waterbury buildings were not destroyed
http://vtdigger.org/2012/11/27/fema-says-vermont-state-hospital-and-other-waterbury-buildings-were-not-destroyed/

State moves ahead with Middlesex mental health facility

http://vtdigger.org/2012/11/29/state-moves-ahead-with-middlesex-mental-health-facility/

Cost of states new community mental health system to jump $20 million next year
http://vtdigger.org/2012/12/03/cost-of-states-new-community-mental-health-system-to-jump-20-million-next-year/

Q & A with Jay Batra: Outgoing medical director for the state’s mental health system
http://vtdigger.org/2012/12/10/q-a-with-jay-batra-former-medical-director-for-the-states-mental-health-system/

Medical professionals say ER treatment for psychiatric patients is woefully inadequate
http://vtdigger.org/2012/12/18/medical-professionals-say-er-treatment-for-psychiatric-patients-is-woefully-inadequate/

Morrisville mental health facility to open Jan. 2; Department of Mental Health hires Novas-Schmidt as interim medical director
http://vtdigger.org/2012/12/28/morrisville-mental-health-facility-to-open-jan-2/

Andrew Stein

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