Senate President Pro-Tem John Campbell. VTD/Josh Larkin

Editor’s note: Inside the Golden Bubble is an occasional column about the legislative process.

The Shumlin administration has been pressing the Legislature to pass a bill ASAP that will set the stage for the reconfiguration of the mental health system. Gov. Peter Shumlin wanted the legislation on his desk by Feb. 17. When that deadline blew by, Town Meeting Day was the new deadline.

But the former senator from Windham County must have forgotten the phenomenon known as legislative time. The fast paced, smooth sailing that can easily lead to the torpor of the doldrums when legislation hits stormy seas, that is, when senators or representatives ask questions, propose amendments and generally deviate off the course of fast passage.

Such was the case last Thursday, when Senate President John Campbell suspended the usual rules of the Green Room and attempted to put H.630, the mental health system bill that includes a provision for the Vermont State Hospital replacement facility, through all stages of passage — a neat trick whereby, if all parties agree, i.e., the GOP and the Dems, the Senate can go through the second and third readings of a bill in one sitting.

Senate President Pro Tem John Campbell struck a deal with his GOP colleagues. In order to get the rules suspended for fast passage, he needed approval from three-quarters of the senators. In other words, he needed Republicans and his fellow Dems to go along with the idea. He made his pitch: There would be no politics, only substance on this issue.

“I have a very good relationship based on trust, and I asked them if they would go along with voting to suspend the rules and make sure no one would be hanging out there without treatment,” Campbell said. “I promised there’d be no politics, and they agreed (to suspend the rules).

Lo and behold, politics did emerge — from a corner the president pro tem least expected.

Passage looked possible there for a while, until Sens. Vince Illuzzi and Joe Benning, both Republicans, and others effectively routed the proceeding. There were questions about whether Act 250 would be circumvented (there’s a passage about expediting construction), whether a provision to protect state workers was strong enough, and finally whether the legislation would give the state the flexibility to build more than 16 beds if need be.

Questions in the real world sometimes lead to answers; in the Legislature answers come in the form of amendments, political rhetoric and votes.

Hence, the all stages-of-passage agreement hit a wall in a hurry. A flurry of amendments ensued. Delay was inevitable and the Town Meeting Day deadline slipped away.

Later that evening, however, the delay was compounded by new news: Information had been leaked. The Shumlin administration was about to announce the layoffs of 80 state workers from the defunct Vermont State Hospital.

Though the move was anticipated, the timing was unexpected. The news flash took nearly everyone in the Senate by surprise — including Campbell. Suddenly, the fast track passage of H.630 was seen by some in a different light, and Campbell was worried about the perception that he knew about the reductions in force in advance and was trying to push through the legislation on behalf of the Shumlin administration before state employees were notified of the layoffs.

“Not only would I think that was a pretty lousy thing to do, also it was hard to go back and explain to Republican colleagues that this wasn’t about politics,” Campbell said. “I apologized to everyone as soon as I found out. None of them thought I was aware of this when I asked to suspend the rules.”

The senator felt slighted by the administration’s handling of the Senate vote, particularly given his loyal support of the key issue — Campbell has said he supports a 16-bed state psychiatric facility over the 25-bed proposal that came over from the House.

“The administration put me in a very bad place in the sense that I’m push something for what I believe is for the right reasons and of course the administration wants it pushed,” Campbell said.

The plan was to get the bill out on Friday, but the layoffs threw the Green Room into a tizzy and a vote was put off until this week.

Jeb Spaulding, the secretary of the Agency of Administration, blamed the Vermont State Employees Association for the timing. He said the union wanted to “roil the waters and get concessions.”

“Personally, it’s very disappointing that Vermont State Hospital employees who were affected had to hear about this on the news because the VSEA leaked it on their own members,” Spaulding said.

He said the layoffs had nothing to do with the bill in the Senate. “The reason we were pushing bill was because the governor asked for it to be on his desk by Feb.17,” Spaulding said.

“We were on a course to do that,” Spaulding said. “We said look there are things in bill including the budget adjustment act for fiscal year 2012 in this bill. The Budget Adjustment Act is now passed. We can’t we get this done by town meeting, we concluded, unless the bill passed last week — that was the rush.”

That course was detoured. An H.630 bill signing before Town Meeting Day is not going to happen. Senate committees will give the three amendments in the offing a once-over on Tuesday before the bill goes to the floor again on Wednesday. Then the legislation has to go to conference committee. A celebratory gubernatorial signing is at least two weeks away.

And it would likely only be celebratory if the governor got his way — that is if a 16-bed facility is approved. The House bill — and the three Senate amendments in play — all press for more beds.

Sens. Philip Baruth and Tim Ashe, both of Chittenden County, are proposing a 25-bed psychiatric facility; Benning’s legislation gives the state the option of signing up for 25, if needed; and Sen. Vince Illuzzi, R/D-Essex-Orleans, is demanding up to 50 beds. The proposals were reviewed by Senate Health and Welfare on Friday, and they go to the Institutions and Appropriations committees on Tuesday.

Download a copy of H.630 Benning amendment

Benning and Illuzzi are both concerned that the administration has rejected an offer from Fletcher Allen Health Care to take over the responsibility for the hospital and, as Benning put it, “nullify worry about whether Medicaid will cover” operating costs.

The Shumlin administration has said it would not build a larger psychiatric facility because of Medicaid rules that could kick in that would limit the number of beds to no more than 16 that the state would be reimbursed for at a 60/40 match level. Institutes for Mental Disease, under Centers for Medicaid and Medicare rules, cannot be larger than that and receive federal funding without a waiver. Vermont has long had a waiver that enabled the state to operate the old Vermont State Hospital, which had 54 beds. The state’s current waiver expires on Dec. 31, 2013. If a teaching hospital is associated with an institute, no waiver is needed because the rules allow CMS to reimburse the state — regardless of the size of the facility.

The governor has rejected exploratory proposals from Fletcher Allen and has said he doesn’t want the hospitals to control the state psychiatric facility.

H.630 Illuzzi amendment

The administration has proposed a community-based mental health system for severe psychiatric patients that includes the state-run facility, several regional hospitals, a small secure facility for patients with forensic psychiatric issues and a number of step-down facilities. Officials have said this network of supports could serve 80 patients in all.

Benning says the new system would not provide enough in-patient care for patients in northern Vermont. According to a map he obtained from the state, 68 percent of the patients live in “home counties” north of Middlebury and Randolph.

Download a copy of the 2008 map of patient locations. (Please note: the map contains an error, it should indicate 14 beds at the Brattleboro Retreat, not 15.)

Benning and Illuzzi each said in separate interviews that they are worried that the administration has decided not to retain people who are skilled at handling patients with severe psychiatric problems.

Illuzzi’s amendment cites a 1996 agreement between the VSEA and the Department of Corrections regarding a private-public partnership. The deal allowed state employees to continue to work with a contractor that provided mental health services to prisoners. Illuzzi wants to make sure state employees can stay on at private hospitals. His bill also requires the secretary of the Agency of Administration to contract with Central Vermont Medical Center and Fletcher Allen Health Care. The bill also requires private facilities to report bodily harm incidents and death. Illuzzi said the legislation includes statewide standards for involuntary medication, restraint and seclusion.

VTDigger

Some mental health advocates and psychiatrists testified in hearings that it would be difficult for the state to create a therapeutic environment with 16 patients.

The federal government doesn’t like to fund institutions of mental disease, or residential psychiatric treatment programs that are larger than 16 beds. Though Vermont has a special waiver through 2013 that allows the state to operate a so-called IMD with 17 or more beds, if the government doesn’t renew the waiver operating costs associated with nine additional beds could be appreciable. A 25-bed facility under this scenario could be significantly more costly.

The political ramifications of House Dems backing a change to the bill that the governor, also a Democrat, appeared to be borne out in House Appropriations late Wednesday afternoon. The majority of members of the budget-writing committee grudgingly supported the bill with the caveat that they preferred a 16-bed option with room to expand if needed. Lawmakers said they were worried about the long-term budget impacts of a larger hospital.

Rep. Mitzi Johnson, vice chair of House Appropriations, said she preferred a 16-bed facility. The Democrat from Grand Isle said she is comfortable with the idea of going from a total of 54 beds (the capacity of the now-defunct Vermont State Hospital) to 41, including placements at regional hospitals. Under the new system, the state would create an additional 40 placements at other residential facilities that she said would help to take pressure off the institutional, acute care system.

“I’m frustrated that we have a plan we know is going to cost a chunk more money as soon as the doors open,” Johnson said.

Rep. Kitty Toll, also a Democrat and a member of House Appropriations, said she wanted a larger psychiatric facility. “For me, I’m committed to taking money within our budget,” Toll said. “We have to look across state government and have priorities.”

Other lawmakers worried that a larger hospital and accompanying costs would pull money away from the community mental health system, which they also view as crucial.

Anxiety over whether lawmakers were making an ideal decision under emergency circumstances in the wake of Tropical Storm Irene, were overridden, however, by a sense of relief that at least they were moving on after years of wrangling over what to do with the Vermont State Hospital, which given its difficult history had long been a source of angst for the Legislature.

“I think it’s high time we moved on this thing,” said Rep. Bob Helm, R-Fair Haven, and a member of House Appropriations. “If we don’t get the FEMA money we’ll be the first to know. I’m not afraid. I’m glad we’re finally getting this thing off the shelf.”

Conor Casey of the Vermont State Employees Association said a 25 bed facility is a step in the right direction and “it’s an improvement from the governor’s plan.”

“What’s regrettable is this debate is about community mental health versus in-patient beds, when really we need to fund both properly for an effective mental health system,” Casey said.

The bill, H.630, passed House Appropriations on a 10-1 vote. Rep. Philip Winters, R-Williamstown, was the sole dissenter. The bill has already advanced through the Corrections and House Human Services Committees, and the GOP has agreed to suspend the rules. The House will take up the bill on Thursday.

Editor’s note: This story was updated at 6:38 a.m. and again at 7:20 a.m. Feb. 2.

VTDigger

Adding machine. Photo by Charles Tilford.

When the Vermont State Hospital was abruptly closed on Aug. 28 after Tropical Storm Irene floodwaters inundated Waterbury, workers quickly evacuated the facility and state officials found emergency placements at local hospitals and small private mental health institutions for the 50-plus patients who were suddenly displaced.

Since the storm hit, the scrambling hasn’t stopped. For the last five months, Shumlin administration officials, lawmakers and providers have been weighing options for replacing the hospital. In the short term — until lawmakers and the Shumlin administration can cement an interim plan — Vermonters who need intensive psychiatric care are being treated at Fletcher Allen Health Care in Burlington, Rutland Regional Medical Center, Brattleboro Retreat and several small residential mental health care facilities.

Long term, the state suddenly has an opportunity to reimagine what the system might look like after nearly a decade of intense debate over what to do with the old facility, which was decertified by the Centers for Medicaid and Medicare Services in 2005 and was no longer eligible for Medicaid funding.

The Shumlin administration is betting on a decentralized system that relies more on community and peer services, and less on institutional care. Under the governor’s plan, about 41 patients would receive care in intensive institutional settings and an additional 40 patients would be treated in community based residential programs. The state would plow new money — about $9 million a year — into local support services.

Making the new system work financially is difficult because much of what the state wants to do is tied to complex rules and formulas for federal funding. It’s possible, for example, that the Federal Emergency Management Agency will largely back the construction of a new facility with a 90 percent federal, 10 percent state match, after the state’s insurer pays its share of the cost.

Though federal funding will likely be available for the structure, it’s possible the Centers for Medicaid and Medicare could drop funding for annual operating costs if the state builds a facility with more than 16 patients, according to lawmakers and Shumlin administration officials.

On Friday, legislators in the House Human Services Committee agreed in a 9-1 vote to approve plans for a 25-bed facility in Central Vermont that would take the place of the Vermont State Hospital. The measure includes the outline for a complex system of decentralized care that would include 13 additional programs or facilities proposed by the Shumlin administration.

House Appropriations will examine the budget impacts of the proposal on Monday; House Corrections and Institutions will consider the financial implications of the proposal on the capital bill Tuesday.

Gov. Peter Shumlin wants a plan for a 16-bed facility from lawmakers on his desk by Feb. 17, and he made it clear in his press conference last week that he won’t budge on the number of beds he has specified.

The number 16 has particular financial significance. If a global commitment waiver provision for the state hospital set to expire in 2014 isn’t reauthorized by the federal government, operating costs at “institutions for mental disease,” or standalone psychiatric facilities, won’t be eligible for Medicaid reimbursements unless they have 16 or fewer patients or have an affiliation with a medical hospital.

The difference between operating the 16-bed facility and a 30-bed hospital, which many in the medical community feel is needed, could be as much as $15 million in state money under the worst case scenarios. Privately, some lawmakers have suggested the operating cost figures are a rough ballpark guess at best in any case and don’t factor in economies of scale. Though the new facility would likely to be located near the Central Vermont Medical Center, there is no formal affiliation between the state and the center.

The Shumlin administration has pitched a 16-bed facility because officials say more institutional beds aren’t necessary. According to statistics from the Department of Mental Health, nearly half of the 54 patients at the Vermont State Hospital didn’t need to stay at the hospital because they were ready to be discharged or moved to other facilities.

A 16-bed facility also happens to be the threshold for match rate eligibility (currently 57 percent federal funds, 43 percent state monies) for operating costs — even if the global commitment waiver isn’t approved. Projections from the Joint Fiscal Office show the state’s share would be $3.37 million of the annual estimated operating cost; Medicaid reimbursements would be about $4.7 million.

The Vermont State Hospital wasn’t eligible for federal match money after it was decertified by the Centers for Medicaid and Medicare in 2003 for a number of safety problems. (It regained certification in November 2004 for 60 days but lost it again in Februrary 2005.) When the facility in Waterbury was closed because of the flood, the federal government began matching the state’s costs for qualified patients who are placed in hospitals and small psychiatric facilities with 16 or fewer beds.

The total amount the state expects to receive for acute psychiatric patients in fiscal year 2012 is about $11 million.

Rep. Alice Emmons, D-Springfield, said the state has been struggling to figure out how to develop a long-term plan for a replacement facility based on the federal criteria.

“The federal government considers 17 beds on up, if not affiliated with a hospital, they consider that an institution for mental disease and that has been what we’ve been struggling with since 2005 as we’ve tried figure out how to replace the state hospital,” Emmons said. “That’s a fundamental piece all the way through this.”

Emmons said the state will be negotiating the global commitment waiver with the feds through 2013 before it expires in January 2014. “The question then becomes will be able to continue with that waiver provision and we don’t know,” she said.

Patrick Flood, the commissioner of the Department of Mental Health, said going beyond the 16-bed threshold means that “we (the state) would go back into the world we were in when we were not certified.”

The Brattleboro Retreat, which is classified as an institution for mental disease, would cost $7.5 million a year to operate and would not be eligible for a federal match should the global commitment waiver change, according to a spreadsheet from the Joint Fiscal Office. The pricetag for Windsor would be $2 million without federal support.

Payments for treatment at Rutland Regional would be matched, Flood said. Other facilities, including the secure treatment center at the Windsor Correctional Facility and five other “step down” residential care programs would be Medicaid reimbursed as well, according to JFO data.

The cost to rebuild

Emmons and others on the committee said the new psychiatric hospital is expected to take at least 3.5 years to build, which offers some leeway on the complex issue.

The capital costs for a new facility are roughly $1 million per bed. The cost of retrofitting the Brattleboro Retreat is $4 million; Rutland is $6 million and Windsor would run $1.8 million.

The state’s match would be 10 percent. At this point, the total cost is estimated at $27.8 million for all four facilities. The state’s match, after insurance estimates is $2.58 million.

Emmons suggested a reasonable course of action considering “so much uncertainty” was to pass out a bill authorizing state buildings officials to proceed with a certain facility size, knowing lawmakers had time to revisit the issue next session.

By then, she said, the state would know how much Irene insurance and federal FEMA funds had come in to pay for building the facility and the state would have a better handle on costs and how a raft of new community mental health programs the administration has proposed are working – which might reduce pressure for acute care psychiatric beds.

“As people have said, It’s very fluid,” she said.

Emmons also reminded her panel to consider that a larger psychiatric hospital that costs more to run would reduce funds available for community programs. “They’re interconnected,” she said.

Total expenditures would go up

Under the plans now under consideration, patients who need acute care would no longer be sent to one main psychiatric facility. Instead they would be sent to Brattleboro, Windsor, Rutland or the facility to be built in central Vermont.

Lawmakers and the Shumlin administration appear to have a similar take on the regional services, but there are three different scenarios for the central Vermont psychiatric hospital. Each scenario comes with a different pricetag.

The total cost of intensive institutional care, which would provide 41 beds (including the 16-bed facility in central Vermont), would be $20.5 million. That number bumps up to $25 million with a 25-bed facility (50 beds in all) and $27.5 million for a 30-bed plan (55 beds total). The Vermont State Hospital cost about $23 million a year.

Without a global commitment waiver to use institutions for mental disease, the state’s share goes up considerably for the central Vermont, Rutland and the secure Windsor beds. The state could have to pay the full $7.5 million a year for Rutland and $2 million a year for Windsor. Depending on the size of central Vermont facility, the state’s share ranges from $3.371 million to $15 million.

In addition, patients would receive treatment through geographically distributed peer services, emergency services and small residential facilities in southern and northern Vermont. The state would spend about $9 million a year on community based services and sub acute care.

The total cost of community based mental health care, including the regional designated agencies or nonprofits that provide outpatient and crisis services, is projected to be $130 million. The state’s share of that total is $52.9 million.

The grand total for the cost of Vermont’s mental health system, including the designated agency expenditures, was $153 million before Irene, and the state’s share was $72.8 million.

All three of the new proposals leverage more federal dollars and increase the overall cost of the system. The governor’s plan, the most conservative of the three, costs the state $76 million (without the global commitment match). With federal dollars, the total is $171 million. The 25-bed option with no global commitment matches for the new state hospital, Rutland or Windsor costs the state a total of $85.7 million. The total cost, including federal match, is $176 million. The most expensive option, including the 30-bed facility, Rutland and Windsor, comes in at $178 million total, with federal money, and a $88 million match from the state.

Editor’s Note: Andrew Nemethy contributed to this report. An update of this report was posted at 6:15 a.m. Jan. 30. A second update was posted at 10:30 a.m. Jan. 30.

VTDigger

The mental health care bill is still in draft form before the House Committee on Human Services. Draft 1.3 can be viewed at the legislature’s website: http://www.leg.state.vt.us/misc/HHSDraftMentalHealth.pdf. Additional information regarding the draft bill and Vermont’s mental health system can be found on the Joint Fiscal Office’s website: http://www.leg.state.vt.us/jfo/vsh_replacement_plan.aspx.

Witnesses will have two to three minutes to testify and can sign up at the door starting
at 4:00 pm on the night of the hearing. For information about this event or to submit written testimony, call the Senate Committee on Health and Welfare at (802) 828-2279 or e-mail Agatha Kessler at akessler@leg.state.vt.us
VT LEG 275060.1


VTDigger

Tropical Storm Irene created both short-term upheaval and long-term transformation in Vermont’s mental health system, leading individuals, peers, designated community mental health agencies, hospitals and state government to navigate new challenges and opportunities.

The first phase involved the immediate evacuation of the Vermont State Hospital in Waterbury. Patients endured being transferred to both hospitals and residential programs run by the designated community mental health centers. At one community mental health agency, they were greeted with flowers. At Second Spring Recovery Center, they were welcomed into a community residence that offered a different type of healing environment with more space and both staff and peer supports.

There is no one answer to what is the best environment for recovery from mental health crisis. The forced closure of the state hospital provided confirmation that, for some people who were thought to require inpatient care, the community placements were equally or even more beneficial.

The Vermont Council of Developmental and Mental Health Services applauds the initial plan developed by the Shumlin Administration to address the loss of the Vermont State Hospital. It allows for a variety of community-based, peer-run and hospital services as an interim system of care for people experiencing acute and intensive mental health conditions. It will be years before a new state hospital can be up and running, so the interim plan is critical for Vermonters both now and into the near future.

One of the key elements of the administration’s plan is the development of individual wraparound services for people who would otherwise be at Vermont State Hospital. These wraparound services are as varied as the individuals who use them. Generally, individuals will have staff support in their homes or another residential setting, and the specific therapy and supports they need to recover and get their lives back on track.

Designated mental health agencies are also developing small-scale residential services to assist people with recovery. These programs will enable some people to avoid hospitalization and will allow others to shorten their hospital stays as a transition back to independent living.

Enhancing the ability of mental health centers to provide emergency outreach and support to individuals in the community is another part of the plan. Budget cuts over the last few years had whittled down these services in many communities. Now the Shumlin Administration recognizes the importance of improving crisis services in community settings. The result will be decreases in emergency room utilization, inpatient care and incarcerations.

Our long-term plan will be informed by what we learn from these interim actions, and we will be better able to quantify the need for inpatient capacity. This has been a time of hardship, but also a time for learning.

VTDigger

Katina Cummings fires up the crowd. Photo by Josh Larkin. View gallery.

Editor’s note: Click on the first image in this story and you’ll find a cool photo gallery from the Mental Health Advocacy Day rally.

Nearly a thousand advocates for the mentally ill and developmentally disabled thronged the Statehouse Wednesday to deliver a straightforward message to their legislators: Don’t cut services.

“Treatment works,” observed Katina Cummings, the executive director of National Alliance on Mental Illness-VT, “but only if you can get it.”  More than 23,000 Vermont adults and 6,000 children, not counting those with developmental disabilities, Cummings said, have a serious mental illness.

Advocates and “consumers,” the Vermonters, who rely on nonprofit service providers around the state, oppose the significant budget cuts to mental health and developmentally disabled adults proposed by Gov. Peter Shumlin.

Mental Health Advocacy Day was organized by the Vermont chapter of the NAMI and the Vermont Association for Mental Health. The 19 co-sponsors included advocacy groups for people with mental illness, developmental disabilities and addictions.

At a joint meeting of the House Human Services and Senate Health and Welfare committees, legislators heard from a suicidal mother whose life had been saved by quick access to care, from a doctor whose mentally ill child was failed by a fragmented system, from providers who are struggling to meet the need and from the default responders to mental health crises — a police chief and emergency room director.

Their statements had a common theme: Cutting mental health services is penny wise and pound foolish.

Margaret Joyal, the director of outpatient services for Washington County Mental Health Services, noted that 120 outpatients would lose services if 5 percent of the agency’s budget is cut. The outpatient program provides care for 7,000 people a year. As a result of last year’s cuts, she said, WCMHS’s waiting list is now longer than at any time in her 20-year tenure. More cuts would mean eliminating services for homebound elders, and there wouldn’t be time to do planning for Supplemental Security Income clients coming out of corrections.

Joyal compared caring for people with mental illness to maintaining a home.  “(It’s) a constant obligation. It doesn’t go away because you fixed the roof one year or you get the house painted the next year. It’s always something.

“We are the mental health home for many of our clients,” she said, noting that 15-20 percent of her agency’s clients have no health insurance, and 80 percent have so little income they are at the bottom of the sliding fee scale.

“If we don’t maintain the system, it will crack and crumble — it will become unsafe for the people that rely on it. And in some ways, it’s already happening,” she declared. “A waiting list of other 50 people is not safe.”

Tim Bombardier, Barre City’s chief of police, fire and ambulance services, said he has worked in most of the counties in Vermont in his 30 years in law enforcement, and the situation is the same everywhere:  “If we were to lose mental health services, the burden gets shifted to police and EMS.”

Bombardier said his department relies on WCMHS as the emergency responder for people with mental health and substance abuse issues.

The only other alternative for dealing with people who are intoxicated or have a mental health crisis is for officers to take them into custody and accompany them to the hospital. That shifts the burden (and cost) of care to the hospital. Moreover, it takes an officer off the street. Recently an officer had to wait with someone for five hours at the hospital.

Recently, Bombardier said, he has been looking at how to get more mental health help at the street level to relieve the burden on the police and emergency personnel. “The people in our community with treatment needs, if there’s not somebody on the streets, we’re not going to know they need help until there’s a crisis,” he explained.

David DiLego, a mental health consumer from Burlington and NAMI member, told the committee that he has a disorder that makes it impossible to distinguish delusions from reality. Five years ago, he said, he was lying on the floor screaming to God to make the voices stop. His choices were to commit suicide in order to find relief from his symptoms or to go where he wouldn’t be allowed to commit suicide. He went to the hospital and has been in psychiatric care ever since, seeing a therapist every week and a psychiatrist once a month. He takes five medications a day to manage his illness.

“If these programs continue to be cut,” he said, “there is a very clear consequence. People will die. People will commit suicide, and God forbid, may harm someone else.” He pleaded with the committee to recognize through his testimony that mental health care is essential.

“Today I’m in a much better position than I was five years ago, but my mental health remains fragile,” he said. “People who suffer from mental illness are the most vulnerable people in our society, and I believe that our culture has a responsibility to take care of those who need them most and can advocate for themselves the least.”

Dr. Mark Depman, the director of the emergency department at Central Vermont Medical Center, said of the 30,000 patients the hospital sees a year, thousands have mental health issues. Every emergency room doctor “has the same recurring terror,” he said, of sending someone home who will commit suicide or of sending someone back to a college campus who will take a gun and shoot others.

Save services, no cuts. Photo by Josh Larkin.

Washington County has a great system that works, he observed, and told the committee, “You shouldn’t tinker with it.” Washington County Mental Health staff  are “on the phone speaking to clients around the clock, compassionately, with a sense of humor, looking for ways for people to keep their lives going” — elderly people who are homebound, veterans with PTSD, seasonal workers suffering from depression because of the long winter.

Depman called the committee’s attention to Atul Gawande’s January article in the New Yorker, “The Hot Spotters.” In it, Gawande describes a program for providing excellent medical care at a reasonable cost — “exactly the issue we’re working on in Vermont,” Depman observed.

Gawande recommended a strategy of assigning relatively low-cost resources at the community level to solve problems that could result in expensive hospital admissions. “You have that system here in Vermont for mental health. It should be the model for your medical system that you’re looking forward to,” Depman said.

After the hearing, the advocates walked over to the auditorium in the Pavilion Office Building to organize for a noontime rally.

Cummings reviewed points set forth in the coalition’s legislative agenda that the advocates could make when visiting their legislators.

(In a few meetings, the 19 coalition groups had agreed on a set of common goals. The one that attracted the most support was to integrate mental health, primary care and addiction services as a means of controlling healthcare expenditures and improving outcomes.)

Other priorities included:

• Increasing funding for community mental health services and Designated Agencies
• Replacing Vermont State Hospital, supporting the expansion of community residential services and funding comprehensive, intensive outpatient services as components of a continuum of care
• Providing early screening, assessment and intervention for youth, as well as a continuum of home, school, community and crisis services for them, and respite care for their families
• Strengthening and expanding the mental health and addictions workforces
• Providing jobs and safe, affordable housing for people with mental illness
• Educating the public about mental health and eradicating stigma.

Then Cummings asked what the results would be from cutting mental health budgets. “Homelessness,” one person shouted. “Police,” yelled another. “Exhausted and aging families,” added a third.

Busloads of advocates began arriving from around the state and poured into the auditorium while the early arrivals rehearsed. “There is NO health without mental health,” they chanted. “One, two, three, four, mental health budget cuts out the door!” “How about, ‘No axes — raise taxes!’” suggested Floyd Nease, the executive director of the Vermont Association for Mental Health.

As the advocates practiced their chants, Christine Oliver, the Commissioner of the Department of Mental Health, walked in from a house appropriations committee meeting, where the budget was being discussed.

She congratulated the crowd for making their voices heard.  “I’d like to think that I speak for you all as well, and I am doing my best, but this is a long road,” she said.

“I just want to assure people that I do understand the impact of these cuts. Nobody’s happy about them, but we’re just trying to do the best we can. We are not turning our back on the most vulnerable Vermonters. We really are trying to come together and work with all of you and all of our partners, the Designated Agencies … to kind of piece together what we can piece together to ensure that people do not fall through the cracks.

“When we talk about spreading the cuts widely, it’s really to make sure that no one person really falls through the cracks,” she said. “We’re all having to do things a little differently. Maybe some services to some degree will be lessened … It really is about all of us working together, continuing to have the conversations about how do we do things, how do we help each other… I’m open to any suggestions folks have about how to do it.”

A man’s voice, high and urgent, rose from the back of the auditorium. “If you cut services, we’re just going to end up in jail or back out on the street. Do you guys want to pay taxpayer dollars to put people in jail?”

Oliver said she shared his concern about people not being able to access services and about the impacts that cuts could have on other parts of the system:  “There are initiatives going on right now with the Department of Corrections, and it’s our partners in the Designated Agencies that are trying to work with that population as well so we have better transitions, but we don’t want people to get there in the first place.”

“I’ve been in jail once, and I don’t want to go back to jail or to Waterbury State Hospital!” the voice rang out.

VTDigger

* * FOR IMMEDIATE RELEASE * *

Monday, November 8, 2010 On behalf of the Vermont Association for Mental Health, the Board of Directors announced today that they have hired Floyd Nease, of Johnson, as their new Executive Director. Nease will follow Ken Libertoff, who served in that role for 30 years.

Peter Albert, President of the Board said this of Nease’s hiring: “The Board and members of VAMH are extremely excited by Floyd’s willingness to serve in this capacity. His combination of experience as a clinician, administrator and legislative leader are ideally suited to lead this organization to a bright future.” Nease recently won re-election to his seat in the Legislature, where he has served for eight years, six of which were in leadership roles. He is currently Majority Leader in the Vermont House, and works as a senior manager at Washington County Mental Health Services. Nease served as Executive Director of Laraway Youth and Family Services in Johnson for ten years. Prior to that, he served as Director of Child, Youth and Family Services at Lamoille County Mental Health.

“I am humbled and honored even to be asked,” Nease said. “The Vermont Association for Mental Health’s advocacy has made historic gains for the parity of mental health with physical health. On that issue alone, VAMH’s leadership has been recognized nationally. VAMH’s programs like Friends of Recovery Vermont and Camp Daybreak, which was the first camp in Vermont for children with special needs, are serving Vermonters in ways that change lives.”

“There has not been a time in Vermont’s history when the issues facing the mental health and substance abuse systems have been more critical to the future of Vermont’s citizens. The need for VAMH’s voice to be heard loud and clear has never been greater.” Nease continued. “The future of Vermont State Hospital is still way up in the air. Designated Agencies have been cut more than ten percent over the past three years. They are being asked to do much more with much less. People who need addictions and mental health services are being sent to jail, where effective treatment is unavailable. Homelessness among people and families with addictions and mental illness is way up in Vermont. Public policy issues like forced medication, shackling practices, Vermont’s abandonment of transition aged youth, remain unresolved. There is the ongoing struggle to achieve real parity. A parallel challenge is the importance of integrating substance abuse services into every facet of our health care system. Finally, and perhaps most important, there is real work to be done about the stigma that mental illness and addiction disorders still carry. I look forward to working on all of these things and more.”

Nease’s first appearance in this role will be at Washington County Mental Health’s annual meeting this (Monday) afternoon.

VTDigger

Advocates, employees and former patients are outraged by Douglas administration’s decision to close the Canteen at the Vermont State Hospital. They say it’s the only place left for patients to get a break from the hospital’s locked down wards. In order of appearance: Malcolm Sawyer, former VSH patient; Joe Yoder, a psychiatric technician for VSH; Sarah Lunderville, executive director of the Vermont Center for Independent Living; Curtis Sinclair, Canteen coordinator; and Michael Sabourin, a patient advocate.

VTDigger

Vermont State Hospital

Letter-writer: Make judicious cuts without eliminating entire programs

Editor’s note: This open letter to Agency of Human Resources Sec. Robert Hofmann is from Curtis Sinclair, the coordinator for the canteen at the Vermont State Hospital. It was also sent to Gov. James Douglas.

Hello Secretary Hofmann,

I am writing to you and the Governor’s office directly because an important program at the Vermont State Hospital is being cut for no good reason. I run this program, the hospital’s Canteen. After I took over the running of the Canteen in 2002 I was able to cut costs and increase revenues to the point where it broke even. That is important to know. This canteen can be a totally self sustaining operation that does not cost the taxpayers of Vermont any money while providing a valuable service to the patients at VSH.

I realize the philosophy at this time seems to be cuts to positions, but I don’t see how you can take something away from Vermont’s most needy and sick people. The patients at VSH have lost their library and gym over the years. They also lost another area they called the “hideaway” where they could meet in the evening to socialize and even play pool. Now there are losing the last common meeting area where they can relax and socialize.

I can speak from my own personal experience with being a patient at VSH. Time spent in the Canteen feels like freedom. It is the one place a patient can go and not feel like he is locked up in a restrictive psychiatric facility. Patients at VSH should not be treated like prisoners. They deserve and need time to relax.

The Canteen is also an invaluable vocational rehabilitation and occupational therapy tool, especially for those who are stuck in VSH for a long period. I was in that situation years ago, fighting for my right not to be medicated. I was allowed to work in the Canteen as a patient for most of my two year incarceration. That did more to help me that anything else. It also allowed me to prove that I could function without being medicated. In the end I was able to win that battle and get discharged without being drugged against my will. If it had not been for the Canteen program I might be on disability. We have had other VSH patients in the years since then who have benefited greatly from working at the Canteen. Please don’t take this program away from them.

If you need to cut positions it is possible to make judicious cuts without eliminating entire programs. The Canteen could easily function with one less full time worker. Why cut three positions and lose a valuable asset when you can cut one and save that asset? I’m sure two cuts can be found in other areas without eliminating services for Vermont’s most vulnerable people.

Sincerely,

Curtis Sinclair
Canteen coordinator

VTDigger

Read more in this series

‘We just don’t have the people’

‘This is bankrupting our state’

Prison, a tough environment for mentally ill

Many of Vermont’s prisoners have been diagnosed with psychiatric disorders, and the majority of them are eventually released into the community. But they often fail to receive the support in the community that they need to keep from reoffending, a legislative committee found. Consequently, many end up back in prison where treatment services for people with mental illness are limited.

For the individual who is punished as a consequence of not receiving the structure, supervision and mental health care he needs to stay out of jail, this cycle represents a cruel Catch-22. For the taxpayers who fund the various parts of the cycle, it represents a costly and wasteful systems failure.

Advocates for people with mental illness charge that recent budget cuts have strained local agencies’ ability to provide services, and they anticipate that as a result more former prisoners with mental illnesses will end up back in prison.

That’s because reintegrating prisoners with mental illnesses into their communities depends on the capacity of local mental health agencies to deliver well-coordinated, comprehensive services. Whether these organizations have the required capacity is an open question.

“Many communities have not been given the resources that will enable them to provide the services needed,” said the Joint Legislative Corrections Oversight Committee in its 2008 report. Sometimes services to newly released prisoners aren’t provided promptly, according to the report. Sometimes they aren’t comprehensive enough. “Even the courts that are aware that many mentally ill offenders could be better served in the community are frustrated at the lack of community services available,” the committee said.

The report also cited wide discrepancies in the quality of services: Some communities “do not provide the needed services, some are reluctant to provide services to a person who may be violent, and some do not have the capacity to take on new patients and therefore have long waiting lists. A lack of community services means that more mentally ill people are likely to be placed in the prisons,” the committee wrote.

Budget cuts haven’t helped

Some advocates maintain that cuts in community mental health centers’ staff and budgets have left the agencies ill-equipped to maintain their earlier level of services, let alone provide more care.

Michael Hartman, Commissioner of the Department of Mental Health, acknowledges that the budget reductions have had some impact on the agencies but maintains that so far the cuts have affected the staff more than services.

Mental health, substance abuse and developmental disabilities services are provided by “designated agencies,” that is, private, nonprofit organizations around the state, funded primarily by the Department of Mental Health. This year, state budget cuts led to a 6 percent staff reduction at the designated agencies.

The 2009 budget reductions eliminated 178 of more than 3,600 full-time-equivalents who were employed in the designated agencies in November 2008, said Julie Tessler, executive director of the Vermont Council of Developmental and Mental Health Services. (Hartman noted that more than 300 people were laid off at the Agency of Human Services, which had some 3,000 employees.)

How dire were the agencies’ budget cuts? It depends on your point of view.

The issue topped the 2009 advocacy agenda of the National Alliance on Mental Illness-Vermont, which states “given current demands and cost pressures, these agencies need a minimum 8.5% annual increase over 2008 state general fund budget just to keep pace with their current caseload … Further state cuts are likely to wreak havoc in the ability of these agencies’ staff to support individuals in recovery.”

Funding to the designated agencies was reduced by about 3.75 percent this year, Hartman said, but he noted that the reduction came after three consecutive years of 7 percent increases: “Because of that, there was some ability to absorb a 3 percent decrease.” He said that a number of the designated agencies were able to restore some of the positions they had cut, and three of the 10 agencies proposed salary increases for their staffs.

“We fund per capita mental health services at a higher rate than almost any other state in the country,” Hartman said. “We’re always in the top 10 – sometimes in the top five. We have a very high penetration rate of services to severely mentally ill adults, and the second highest in the country to children. We are funding the best we can with what we have to work with.”

Increased demand stresses system

Nevertheless, he acknowledged that there’s a limit to the agencies’ ability to absorb cuts.

“I don’t want to give the image that everything’s hunky-dory, that everybody’s fine. I think the reality of it is that, like other parts of the country, we’re seeing more people come in the door looking for services and we have less staff able to provide those services.”

The increased demand, he said, is coming from “the person on the street who has lost their job, their housing is unstable and they’ve maybe always had some mental health issues but could hold them together as long as everything else is okay. Now everything else is not okay.”

Tessler disputes Hartman’s claim that the designated agencies have not reduced services, and she offers a dark view of the effects she foresees ultimately rippling out to the criminal justice system.

Tessler notes that eligibility guidelines have been tightened, so some clients no longer qualify for services. Clients who do qualify get fewer hours of therapy or receive group therapy instead of individualized therapy. There are fewer staff members to help people find jobs and support them in carrying out job responsibilities. (“Nothing is as therapeutic as work,” Tessler observed.) And with fewer resources, it’s harder for the agencies to provide psychiatric assessment and treatment.

“Every time we provide those services, we lose money because the state reimburses us at such a low rate,” Tessler declared. “That can also affect (psychiatric) medications and medication management.” If a medication doesn’t work or there are side effects or a dose needs adjusting, patients need to be able to get in touch with their providers easily. “It’s so critical,” Tessler stressed.

As a result of the reduction in access to mental health care, more people are showing up in emergency rooms, Tessler said. She added, “The census at the Vermont State Hospital has been quite high all summer.” She attributes this to people of modest means not seeking help until their symptoms become acute.

Based on what she is seeing, Tessler says, “We do believe that more people will end up with interventions from police and public safety, and more people will end up in correctional facilities.”

Systems failure?

Elaine Alfano, deputy policy director of the Bazelon Center for Mental Health Law and a former state representative for Calais, argues that the heightened risk of Vermonters with mental illness for involvement with the criminal justice system represents a systems failure. (Alfano served for six years on the House Health and Welfare Committee.)

“Accepting such scenarios without seeing them as system failures that urgently need to be addressed continues a pattern of unacceptable consequences, belying the availability of effective mental health treatment and community supports that allow people with serious mental illness to lead stable and productive lives in the community,” she said in an e-mail.

“While Vermont has a tradition of good laws and policies, it has trouble … with implementation and sustaining promising programs. Translating polices into effective practices takes strong leadership, on-going use of science about what works, organizational behavior and performance improvement, accountability and a thoughtful approach to systematization,” she wrote.

Alfaro sees adopting performance improvement programs as a way to ensure that policies get implemented.

“Performance improvement programs are ubiquitous in business and in health care,” she noted, “and there is growing recognition that these efforts should be applied to whole systems and governmental endeavors.”

VTDigger