Vermont State Hospital. VTD/Josh Larkin

The state is exploring whether a modular high-security facility could be built in Waterbury to house mental health patients who are required to be held securely under court order.

That news and several other developments in the state’s comprehensive mental health overhaul passed by the Legislature in April emerged from a meeting where Mental Health Commissioner Patrick Flood and mental health stakeholders met at National Life in Montpelier Monday.

Flood said the opening of an eight-bed temporary mental health acute-care facility in Morrisville is now likely to be a month later than the hoped-for Aug. 1 date. Renovations are ongoing at the site of the Lamoille Community Connections regional mental health agency building in the village.

Flood also announced that he has approved an eight-bed “step-down” intensive residential recovery facility in Westminster.

The facility is one of three – two eight-bed and one 15-bed units – called for under the state’s new mental health bill passed by the Legislature this April. The sweeping bill shifts  treatment focus more to community based care and disperses acute care among three replacement hospitals, a new 25-bed hospital to be built in Berlin and a 14-bed unit at the Brattleboro Retreat and six beds at the Rutland Regional Medical Center.

Meanwhile, the site of the Berlin hospital may be the subject of an emerging tussle between the Shumlin administration and some mental health advocates and lawmakers, based on comments made at Monday’s meeting by Rep. Anne Donahue, R-Northfield.

Regarding the department’s long-running effort to find secure housing for mental health patients, the state is now focusing on the 10-acre Waterbury flea market site on Route 2 north of the village, Flood said. The state had previously looked at several other possible sites, including a building the state owns at the Southeast Correctional Facility in Windsor.

Flood said the Waterbury location was proposed by a staffer as a possibility about a month ago and his department is considering whether a modular seven-bed unit is feasible for the purpose.

The state has been struggling since Tropical Storm Irene to find secure housing for mental health patients formerly housed at the Vermont State Hospital in Waterbury. The 54 beds at the state hospital, which was flooded out last August, included a locked unit.

Since then, the state has housed secure patients – five currently – at the Southern Vermont Correctional Center in Springfield. But Flood and other mental health officials have consistently said the prison setting is inadequate for the purpose and have searched high and low for another option as the state has revamped its mental health treatment model in the wake of Irene.

“It’s just not acceptable. We have to get out of there,” he said. Flood credited former state hospital staffers who are working in Springfield “for making that situation work as well as it has.”

He said state officials looked at a modular solution after Irene hit and decided it wouldn’t work but have since taken another look at the possibilities.

Putting the secure patients in a standalone locale is not ideal, since it is more expensive to staff a small facility, but he said that might be warranted if the modular facility works out.

Flood said he’s convinced a small facility is feasible and the owner of the flea market site so far seems open to the idea. The idea is preliminary at this point and permit issues are among the possible obstacles, he said. The site is zoned industrial and it’s uncertain how a modular state hospital unit fits in, he noted.

“This is really a one-of-a-kind facility,” he said.  “It’s residential but also a treatment facility with people coming and going.”

The issue of where the new Berlin state hospital location should be emerged from a question raised by Rep. Anne Donahue, R-Northfield, a strong mental health advocate and one of the key players in the mental health overhaul bill that passed this session.

Donahue cited an email she received from Secretary of Administration Jeb Spaulding saying that he favored the site near the regional library, which is considerably farther away from Central Vermont Medical Center than the other site under consideration adjacent to the hospital.

She asked Flood whether he supported that position, and Flood replied that “my view is the closer to the hospital the better.” In response to a question from Donahue, he said he “will make that point clear to the administration.”

Donahue said siting the new state hospital away from the medical center goes against all the testimony her Human Services Committee heard about the strong need to locate a state hospital within or next to a medical hospital. She said the more distant site would once again segregate those with mental health issues from the general population and continue the “stigma” that goes with mental health care.

For the administration to promote the more remote site, she said, “was just a slap in the face.”

She said all models today advocate integrating mental health and physical health care together when it comes to acute mental health care.

“These things are only going to get closer,” she said, noting the state should remember that it is designing a facility “for 50 years out into the future.”

However, Spaulding Tuesday said the administration is “listening carefully to the residents of Berlin and the mental health community” as it decides which of the two sites is the best option.

He said he indicated his preference because he wanted to be open and transparent in response to a question on what his view was on the two sites.

Spaulding argued that the site by the regional library had many advantages, noting it is “brighter, bigger and quieter” and also flatter and doesn’t have power lines running through it. “It’s a much nicer piece of property, he said.

But he added that numerous factors will go into the choice, saying the process is not going to cater to any one person’s views, a reference to Rep. Donahue.

“I’m in the process of trying to listen to as many people as possible and make a recommendation to the governor,” he said, adding that the department of mental health’s position “will count very heavily” in the decision.

Spaulding said he expected a choice would be likely sometime early in June.

Editor’s note: This story was updated with comments from Spaulding at 11:24 p.m. May 22.

VTDigger

Gov. Peter Shumlin and Michael Obuchowski, commissioner of the Department of Buildings and General Services, in Waterbury. Photo by Taylor Dobbs

Less than 48 hours after the lawmakers ended the legislative session, Gov. Peter Shumlin brought a thick stack of their work – the Capital Bill – to Waterbury and signed it where he hopes it will make an impact: at the state office complex.

This year’s capital bill is an update to legislation from last year, which went into effect before the devastation of Tropical Storm Irene. The new bill re-allocates $12 million for renovation projects to the Waterbury complex, $5 million for a new state hospital facility and dedicates the first $15 million of any budget surplus in the fiscal year 2012 to rebuilding efforts.

The Waterbury campus, which housed 1,500 workers with the Agency of Human Services, the Agency Natural Resources, the Department of Public Safety and Vermont State Hospital, was hit hard by Irene.

The funds will bolster incoming money from the Federal Emergency Management Agency as well as insurance claims still due to the state.

“I said when Irene hit that it was our opportunity to rebuild Vermont better than the way Irene found us,” Shumlin said, “and there is no better example than what is going to happen right here in Waterbury, or for that matter, downtown Barre, as we bring our state workforce to green, clean, energy efficient workspace that will allow them to be efficient for Vermonters into the 21st century.”

Part of the problem now facing the state is funding. Despite promises of money both from insurance and FEMA, the administration still doesn’t know how much they can count on for the project, which originally would have provided workspace for 1,024 workers at an estimated cost of $135 million. Shumlin called for the plans to be reconfigured to cut costs and to accommodate about 900 workers, but the project will likely be at least $100 million.

Jeb Spaulding, secretary of the Agency of Administration, said the state would probably have to invest at least $50 million in the project.

“We’re still looking at after insurance and after FEMA – it’s still a ballpark figure – but it could be $50 to $80 million over multiple years,” Spaulding said.

The historic buildings at the front of the complex will be remodeled and some of the buildings closer to the river will be demolished. Shumlin said it would include at least one all-new building. The offices should be set to reopen within three years, the governor said.

“We’ll be tearing down a number of the buildings that, frankly, we wish we didn’t have in the first place,” he said. “We’ll be rebuilding the historic infrastructure … so that we’ll have energy efficient built-in space, and we’ll be building a new state-of-the-art building right in back of these historic buildings that will provide quality workspace for the future.”

The office complex isn’t the only thing in Waterbury left in rough shape by the storm. While some downtown businesses closed in the immediate aftermath of the flood, Shumlin said he is worried about the slow bleed of business losses accumulating while the state offices are closed.

“There are businesspeople here, and I don’t want to single them out, who will tell you that their restaurants and other businesses are suffering because the state employees aren’t here to buy the services that they always bought in Waterbury,” Shumlin said. “So the challenge is, now that we’ve made the decision to come back: How do we move faster than the skeptics have said to ensure that we don’t lose more business in Waterbury between now and when we bring the state employees back?”

VTDigger

Vermont State Employees’ Association Applauds And Welcomes Shumlin Administration’s New Position
To Build A New 25-Bed Acute Mental Health Hospital In Central Vermont

The Vermont State Employees’ Association (VSEA) is applauding the announcement by Governor Shumlin that the State will be approving the construction of a new, 25-bed, acute mental health hospital in central Vermont. Until this morning, the Administration had been rigid on its vow to build only a 16-bed hospital to replace many of the acute beds formally located at the heavily Irene-damaged Vermont State Hospital. Shumlin told reporters his new view is based on recent discussions his team has been having with the federal Centers for and Medicare and Medicaid Services (CMS) and him personally with federal DHS Secretary Kathryn Sibelius, who assured the Governor that Vermont would continue to receive Medicaid reimbursement through September 2013, even with construction of a 25-bed hospital. Earlier in the legislative session—after taking weeks of testimony from a host of mental health professionals, private hospital officials and current State Hospital caregivers—the Vermont House overwhelmingly passed legislation calling for 25 acute beds in central Vermont.

“VSEA and its VSH caregivers thank the Governor for listening to the House and to the sound, professional advice he was getting from doctors, nurses and all the other mental health experts,” said VSEA President John Reese. “The decision to raise the number of new acute mental health beds in central Vermont from 16 to 25 was the right call for the Governor to make here. This is especially true when you consider that the bulk of Vermonters in mental health crisis reside in the central and northern parts of our state. Today’s decision to build a 25-bed hospital will help relieve some of the pressure our State Hospital caregivers warned would occur if the State was to build just 16 beds in this region.”

VTDigger

Gov. Peter Shumlin. VTD/Josh Larkin

State workers will move back to Waterbury and the replacement facility for the Vermont State Hospital will be 25 beds.

Gov. Peter Shumlin announced the double-whammy decisions today at a hastily called press conference with a phalanx of Democratic leaders and members of key committees standing behind him. In remarks, Lt. Gov. Phil Scott, a Republican, lauded the plan.

Shumlin said lawmakers and his administration have agreed to replace the state office complex that was damaged by Tropical Storm Irene with “Plan B,” the option presented by the architectural firm Freeman French Freeman last Friday that calls for restoration of the historic buildings on the Waterbury campus and construction of a new “state of the art” facility.

The Waterbury compound offices had been home base for about 1,500 workers from a handful of agencies. The new state offices would accommodate 900 employees, all from the Agency of Human Services. About 100 Department of Health employees would remain at offices in the Burlington area and 300 workers with the Agency of Natural Resources would be moved to the National Life office complex in Montpelier. About 200 AHS and Department of Public Safety employees have already returned to buildings in Waterbury.

The original pricetag for Plan B was roughly $135 million. Shumlin said he would be asking architects to go back to the drawing board and design a smaller “state of the art” facility that could be constructed at a much less cost. He declined to name a target figure for the project, except to say it would be greatly reduced.

The state’s insurance company has offered $15 million to $20 million for replacement and renovation costs. FEMA reimbursements would be similar. That could leave the state with $40 million to $50 million in out-of-pocket costs, depending on construction estimates.

Shumlin told reporters: “I want it to be as cheap as possible.”

“We’re going to push as hard as we can with Freeman French Freeman to lower the costs that came forward,” he said.

The House is working on a capital bill that is supposed to be voted out of committee in the next week. Shumlin said the administration will work as aggressively as possible to nail down costs this legislative session.

“I do want to suggest it’s quite possible we won’t have all numbers we need before the Legislature adjourns,” Shumlin said. He said legislative leaders need to find a way to work together to approve figures after adjournment.

The governor wants renovations to start immediately and he hopes to start construction in the fall. He said the construction will be phased, starting with renovations, and moving forward with razing damaged buildings.

The governor had pushed for a 16-bed psychiatric facility to replace the Vermont State Hospital, which was located on the Waterbury state office complex campus and was also ruined by floodwaters. He maintained that the federal government would only provide operating funds for a 16-bed facility.

Lawmakers have been wrestling on the right size for the hospital, which under federal law is an institute for mental disease. The administration has said the state would not be eligible under Centers for Medicare and Medicaid rules for operating funds for a facility larger than 16 beds. The House voted for a 25-bed facility; the Senate and the administration wanted 16 beds.

At the press conference, Shumlin announced he had negotiated an agreement with Kathleen Sebelius, the secretary of the federal Department of Human Services, at 4 p.m. on Wednesday that will allow the state to continue to receive federal reimbursements through 2013.

“We have an agreement from CMS that we will be unaffected by any reimbursement issues, should we build a 25-bed facility until that global commitment waiver expires 2013,” Shumlin said.

After that, he said CMS will allow the state to pull its license for 25 beds if the federal agency decides against a waiver for a 16-bed facility.

The administration is looking at sites in Berlin near the Central Vermont Medical Center. FEMA would pay for 90 percent of the cost of the replacement facility for the Vermont State Hospital.

VTDigger

Beth Pearce, state treasurer

The transformation of Vermont’s mental health system and the continuing fallout of the closure of the Vermont State Hospital by Tropical Storm Irene brought news on several fronts Tuesday in a busy day inside and outside the Vermont Statehouse.

Anne Noonan, commissioner at the Department of Labor, Vermont State Treasurer Beth Pearce and Human Resources Commissioner Kate Duffy detailed for lawmakers an array of efforts, including plans for a retirement incentive, to ease the situation for former state hospital employees facing layoffs and an uncertain future.

Meanwhile, three lawmakers each from the House and Senate began working out differences on a complex bill that dramatically shifts mental health treatment in the state to a more community based model while downsizing and partially privatizing the number of acute care hospital beds.

In Morrisville, Lamoille Community Connections has given a preliminary green light to a temporary plan by the state to house and treat eight acute care patients in space at their headquarters, which is the regional mental health agency. The decision offers hope for an interim solution to a severe crisis in acute care in the state.

And based on testimony by Mental Health Commissioner Patrick Flood Tuesday afternoon, it appears likely the state will settle on a 10-room building in Windsor at the Southeast State Correctional Facility as a secure site for five to 10 “forensic” patients who have been ordered held by the courts. The state has been evaluating numerous locales for patients sent into the system by the courts.

Those developments highlight the state’s continuing struggle to deal with the flooding closure of the state hospital in Waterbury, whose 54 intensive care beds were a critical piece of mental health treatment despite an antiquated building and loss of federal funding nearly a decade ago.

The discussions about the layoffs of state hospital workers and the news that the Lamoille facility may go along with a controversial plan to house eight patients at its headquarters in the former Genesis nursing home illustrates the yin and yang of intertwined issues that has beset the state since Irene hit Aug. 28.

Anne Noonan, commissioner of the Department of Labor, told lawmakers that the state has several million dollars in different funding pools that can be used to assist former state hospital workers in job searches, retraining and education or to boost their certification for jobs in the new mental health system so they are “more marketable and employable.”

Noonan assured lawmakers that state workers who take another job outside state government will remain eligible to get a first crack at state jobs as the new mental health treatment system is built if they keep the state informed of their interest.

Lawmakers asked Pearce, the state treasurer and Duffy to provide fiscal information that will enable lawmakers to add a voluntary retirement incentive in the mental health bill. With the 960 state employees cutback in 2009, the incentive was available to employees 55 or older with 20 years in service, according to Pearce.

According to figures given to the committee, 20 VSH employees have over 25 years of service, and many have five or less.

Sen. Peg Flory, R-Rutland, said she was concerned that when the state finally opens its new mental health hospital in Berlin, many highly qualified state workers will have left the field and staffing will be an issue.

“I think we’ll do what we have to do to make sure that facility is properly staffed,” said Duffy.

Lamoille Community Connections Board President Ed French Jr. said the board unanimously agreed Monday night to consider the state’s proposal, subject to reaching an agreement that addresses a number of concerns raised by the community. The board will meet again next Wednesday in a public hearing to discuss the plans, he said.

The state has been desperately searching for more beds for Level I intensive care and run into numerous dead ends before the Morrisville facility came on the horizon. Last month a standing-room only crowd debated the merits of the proposal with heated arguments on both sides. Eventually as many as 15 patients could be treated at the site under the state’s plan to lease two wings of the building.

Vermonters needing intensive mental health care are currently crowding wards at major hospitals around the state, creating a cascading shortage of beds for many levels of treatment and wreaking havoc in facilities not set up to deal with acute care patients.

If a portion of the Lamoille facility eventually is renovated and opened, it will provide some good news for former state hospital employees by providing them job opportunities – as many as 70 jobs may be created at the facility for 24-hour care.

Appearing before the Senate Government Operations Committee in the afternoon, Duffy, the state’s human resources commissioner, said of the roughly 240 state hospital employees working when Irene hit, 195 were on the payroll in December of last year, working at a number of replacement facilities. Now, 74 of those have formally been notified they face a RIF (reduction in force) and will lose their jobs at the end of March, she said.

That number is slightly less than originally announced a couple of weeks ago. If their qualifications fit other state jobs they may be able to “bump” other employees with less seniority, she said. She said the majority of those former VSH employees are at Brattleboro Retreat, the state correctional facility at Springfield and a few other locations.

She said a potentially bigger layoff is possible in April with former VSH employees who are working at Fletcher Allen Health Care in Burlington.

She called the situation for the former state hospital workers “very fluid.”

“They still have anxiety and concern about what’s going to happen,” she said, noting it will be months before the state can “retrofit” the Morrisville facility and at least several years before a replacement state hospital being proposed in Berlin near Central Vermont Medical Center is built.

House and Senate conferees began work Tuesday to reach agreement on the mental health transformation bill passed by both chambers. The size of the Berlin facility is a main bone of contention, with the House proposing 25 beds and the Senate 16, which is the number favored by Gov. Peter Shumlin’s administration.

Duffy said officials have been “very clear” in discussions with mental health workers about uncertainty with the jobs in the new hospital facility. But she said one thing is clear: “There’s certainly not going to be the same level of staffing that we have right now,” she said.

However, Duffy said private hospitals that are targeted to become part of the new mental health system “have expressed clearly to us” they are interested in the former VSH employees. But she said a number of factors such as the location of the jobs and pay and the individual’s training will impact how many sign on.

VTDigger

Recently I was introduced to the inner world of politics versus common sense. Some would prefer to believe this nonsense couldn’t exist in a small state like Vermont. But it does exist and Vermonters should never allow it to become entrenched as acceptable behavior. Before turning to the issue, an explanation of how the Legislature works is in order.

Every bill starts in either the House or the Senate. Senators are assigned to two committees; House members to only one. In this design House members generally have more time available to listen to testimony than their Senate counterparts on any given issue. When a deeply complicated issue arises, an ad hoc committee featuring members from both bodies may be assembled to examine it more closely.

That brings us to the issue of redesigning our state’s mental health system. According to the director of the old Vermont State Hospital (VSH), approximately 530 people per year are involuntarily admitted for “serious mental illness,” a condition that leaves them functionally impaired and in need of “acute bed space.” Approximately 169 such beds are needed every day. Two-thirds of those patients come from the northern part of the state, the bulk being from Chittenden County.

This past fall an ad hoc committee called Mental Health Oversight developed concepts for a new system design. These were incorporated into House Bill 630. They featured a new state hospital with 25 acute care beds in Berlin, five at the Springfield jail, and private contracts for 14 in Brattleboro and six in Rutland. Although featuring less acute beds than pre-Irene, a community support system of less intensive beds would also be developed throughout the state. The House voted 124 to 3 to support this plan.

But then the bill arrived in the Senate. Mysteriously, and with little testimony, 25 beds suddenly became 16 and the bill was put on a fast track for passage. The change shifted available acute bed space south, away from the patient base. Initial building funds were also threatened because FEMA would not fund a later expansion. Recognizing the need for 25 beds in Berlin, I joined other senators objecting to a rules suspension so the bill could not get passed out Thursday. This brought debate to a halt.

On Feb. 24, we learned, much to everyone’s surprise, that the governor had ordered RIF notices to 80 former VSH workers. This caused general consternation, because a critical component of the new system included maintaining that skilled work force. Now we knew why the bill was put on the fast track for passage: The administration didn’t want us to know about the layoffs.

The cynic in me believes the governor is facing the reality that his campaign promises cannot be fulfilled without mass layoffs or dramatic tax increases. Whatever the cause of this political gamesmanship, it flies in the face of common sense. We shouldn’t build less space than we need and miss the opportunity for federal funding in the process. We shouldn’t build infrastructure weighted toward the southern part of the state when the need is in the north. We shouldn’t jettison those most skilled in handling our most vulnerable. This week we’ll see if common sense still lives in the Vermont Legislature.

VTDigger

We support most of the Shumlin administration’s mental health care proposal. However, we are extremely concerned that the administration’s plan seriously underestimates the need for Level 1 psychiatric beds in northern and central Vermont. The current proposal is for a 16-bed hospital. We strongly believe that adding 25-30 beds in this part of the state (in addition to the ones slotted at Brattleboro, Rutland and Springfield) is needed to provide safe patient care.

The surgeon general’s 2003 report on mental illness estimated that approximately 20 percent of the population is affected by a mental health problem in any given year. Not all the 20 percent have serious illness. Serious mental illness is estimated to be 4.7 percent (i.e. 29,610 Vermonters) of the population. Of them only 169 are being treated in a hospital setting at any given time in Vermont and (even before the closure of 54 Level I beds at the Vermont State Hospital) 93 percent of the hospitalizations were occurring in community hospitals. The vast majority of care to persons with mental illness is delivered in outpatient community-based facilities. The governor’s plan is to be commended in as much as resources are being utilized for outpatient services. We are also impressed and very much support that the administration has made the mental health bill a priority as we have been in crisis mode for many years.

We are alarmed, however, by the false dichotomy that has been defined and debated regarding “community” versus “institutional” level of care. Mental health care should be an integrated system and requires adequate medical/psychiatric resources at each level of care. It is not an “either-or” situation and we feel strongly that the reduction to the number of Level I beds in the plan is very concerning and dangerous from the perspective of patient safety. A patient obtaining treatment in a Level I center is receiving psychiatric care with the goal of stabilization and return to their community. Level I care in this debate has been inaccurately described as “institutional,” creating a false perception about the skilled clinical treatment needs of these patients.

The designated community hospitals (Fletcher Allen Health Care, Rutland Medical Center, Central Vermont Medical Center, Springfield Hospital and Brattleboro Retreat) began accepting involuntary (in addition to voluntary) hospital admissions in the 1990s and this significantly reduced the total bed number at the Vermont State Hospital. The change that occurred in the 1990s was conditional so that the VSH Level I beds would still be available when a designated community hospital needed to refer a patient for a Level I intensive care bed. VSH served as the intensive care facility with the expertise to treat patients who were at greatest and most acute risk of harming themselves or others.

Think of a Level I bed being analogous to a cardiac intensive care unit bed. If a patient entered any emergency room in Vermont and had the profile of crushing chest pain, increased cardiac enzymes and an EKG suggestive of a heart attack, that patient would be immediately transported to a tertiary care facility capable of treating such an emergency. That patient could not be safely treated at a community hospital. It is exactly the same in psychiatry. As referenced earlier, the vast majority of patients with psychiatric emergencies can be treated at any of the designated hospitals; but a very small (but extremely important) number of highly acute (usually potentially violent or assaultive) patients require a tertiary care intensive setting. Community-based services are not certified or clinically equipped to treat this type of acute patient need.

On the night of the flood, there were 51 patients who were (and needed to be) at VSH. The designated hospitals had been running close to capacity and emergency rooms were and continue now to board patients who need psychiatric beds. We have been operating beyond capacity since that time and have had to turn away record numbers of patients who need hospitalization. We are deeply concerned about the current lack of access to Level I beds and the continued boarding of patients in emergency rooms across the state. This lack of immediate access to intensive care greatly increases the possibility of an untoward event occurring. We do not feel that the administration’s plan adequately addresses this need in the future.

We are extremely concerned that the administration’s plan seriously underestimates the need for such beds and that the total number of Level I beds should be in the 50-60 range. We are strongly in favor of adding 25-30 beds in the northern or central part of Vermont to provide for safe care in the context of the whole system. Once again, the additional resources for outpatient services are laudable but there is a serious shortage of intensive care beds in the proposal.

We are writing as advocates for our patients. The people we are all involved in treating are amongst the most vulnerable in our society. As physicians and nurses we are calling for caution and prudence. The governor’s plan is overall excellent in many ways but is seriously flawed in proposed reduction of Level I beds. We are ever so close to passing an historic bill which will shape the system of mental health care in Vermont for decades to come. Let safety and clinical excellence trump money and politics.

VTDigger

The public discussion about how Vermont should replace the Vermont State Hospital has focused – to the exclusion of almost everything else – on the size of the Level 1 facility that will be built in central Vermont. In the end, the House settled on a building for 25. The Senate and the administration settled on 16. There will be a conference committee to hammer out a compromise.

Lost in these discussions is the fact that the administration’s plan does not replace the original 54-bed capacity at VSH with 16 beds. Prior to Irene, in addition to VSH, there were 175 beds around Vermont for people whose mental illness required overnight care, but did not rise to needing Level 1 care. So, while it is true that the plan would build 12 fewer Level 1 inpatient hospital beds, it is also true that the plan increases overall community capacity by 25 percent.

There are two reasons why a person might need a Level 1 bed. The first is that he or she is suffering from an episode of mental illness that requires the safety and expertise that can only be found at a Level 1 facility. The second is that he or she is suffering an episode that could be cared for in a less restrictive community-based setting that is unavailable. Both situations put people in Level 1 facilities. The first reason should. The second shouldn’t. The administration’s plan to increase community capacity while lessening dependence on Level 1 inpatient care goes a long way toward eliminating the second reason.

Also lost in all the talk about the number of beds has been the fact that the new system, instead of being anchored by an antiquated and uncertifiable 54-bed state hospital, will be anchored by a comprehensive care management system. Done right, care management works to prevent people from having to go to the hospital in the first place, diverts them from the hospital whenever it is clinically appropriate and, when Level 1 care is required, sees that people are discharged to community-based resources as soon as it is clinically indicated. This is an entirely new approach in Vermont which, if executed well, will allow for a better experience for those Vermonters and a much more effective use of both inpatient and community-based resources.

Among other innovations, the newly configured system increases the use of peers – people who have lived experience of mental illness – as supports in both inpatient settings and the community. There is a growing body of clinical evidence that peer support increases the effectiveness of care no matter in what setting it is applied. The plan also increases community-based crisis bed capacity by more than 20 percent and available intensive residential recovery capacity by 150 percent. These are significant enhancements to the system, each of which will decrease the need for inpatient beds.

Recently, there has been discussion about whether or not we can afford to build a facility for 25 given the fact that, so far, the federal government has said it will not pay for anything larger than 16 unless it is part of a medical center. If this was any other disease, this wouldn’t even be part of the discussion. Since it is, however, I believe smaller (and coincidentally more affordable) is better, as long as those in the smaller facility have near immediate access to regular medical care. It is better because there is a growing body of empirical data that community alternatives to institutional care are far better for those receiving the care.

In the final analysis, the debate about 16 vs. 25 will diminish in importance because the enhanced community resources and the new care management system will be in place long before a shovel goes into the ground for the new facility. It will be much clearer in a year or 18 months from now how much inpatient capacity is necessary in the new system. With time, we will have real numbers on which to base the final decision. For now, which number prevails is more about the political tug of war between the administration and the legislative chambers than it is about clinical need.

VTDigger

Vermont State Hospital. VTD/Josh Larkin

The Vermont Senate approved the governor’s plan for a 16-bed, state-owned psychiatric facility as part of a decentralized, regional mental health system on Wednesday night. The vote was 28-0.

Though in the end the decision was unanimous, senators debated the issue for nearly four hours and defeated three amendments which would have expanded the replacement facility for the Vermont State Hospital to potentially accommodate at least 25 beds.

The discussion centered on the merits of a community-based system and on the uncertainty regarding federal funding for the construction and operating costs for the facility, which would likely be sited in central Vermont.

Republicans and liberal Democrats joined hands in opposition to the governor’s plan; Shumlin Democrats outnumbered the minority two to one.

Proponents of the smaller facility cited financial concerns and said they had faith that a community-based approach would work; opponents questioned whether patients from northern Vermont who need intensive mental health services would be turned away because of a lack of bed capacity.

There were fundamental disagreements on community versus institutional care, but the debate largely revolved around numbers — the number of beds, the number of patients, the number of caregivers and especially the amount of money it would cost to run the new system.

Senate President Pro Tempore John Campbell told the senators that they had a choice between an institutional model and a community-based model with one smaller central facility — and the difference between no federal support and $8 million to $12 million a year in Medicaid subsidies. The 60 percent match isn’t available for Institutes for Mental Disease, or standalone psychiatric facilities with more than 16 patients, he explained.

“We’ve heard many times about what the Centers for Medicaid and Medicare will pay for and won’t pay for,” Campbell said. “The federal government decided they were going to make a policy decision we were not going to go along with the institutionalized model.”

The state would need to obtain a federal waiver to operate a larger facility. Campbell held up a letter that outlined a conversation the governor had with CMS officials. Shumlin says the federal agency will not fund a facility with more than 16 beds. Calls and emails for information about the waiver from VTDigger.org have not been returned by CMS.

Sen. Peg Flory, R-Rutland, asked why the governor wasn’t seeking help from the congressional delegation for a waiver, in light of Shumlin’s assurances in press appearances that the state could obtain waivers from the federal government for his signature, single-payer health-care reform plan with assistance from Rep. Peter Welch and Sens. Patrick Leahy and Bernie Sanders.

“I can remember being on the floor passing bill requiring five waivers, two of which couldn’t be applied for for five years,” Flory said. “We have a wonderful congressional delegation that will help us get the waivers. I agree with that. We have a wonderful delegation that would help us.”

Another Republican senator, Joe Benning from Caledonia County, pressed for an option to expand a 16-bed facility to 25 beds if needed. He cited monthly declined admission numbers from regional hospitals. Forty patients a month are turned away by Fletcher Allen Health Care in Burlington, he said. Rutland Regional and Brattleboro Retreat also decline patients access to care because of a lack of capacity. When Fletcher Allen goes off-line, Benning questioned whether the community-based system would have enough beds to accommodate roughly 160 patients who regularly need intensive psychiatric care, since 68 percent of those patients live in northern Vermont and the governor’s plan relies on facilities in southern Vermont. Benning’s amendment was defeated 10-19.

“There are two steps to the financial question of how do we pay for what we’ve built — that’s where the FEMA money comes into play — and how do we pay for what we’ve built to operate it,” Benning said. “The Medicaid money is in a state of flux. No one can tell us if we will receive the money. … If we’re unable to obtain waivers to continue operations already granted to us for $10 million in costs if we don’t get that waiver, then the cynic in me says how is it then possible to obtain waivers to run a $5 billion health-care system. If the governor believes we can do that then there are ways to get operating costs for this facility.”

Sen. Claire Ayer, D-Addison, said the debate was not about 16 beds or 25 beds for patients with severe psychiatric problems, but about 41 or 54 beds that would be available to Vermonters in the proposed community system model.

“It’s about providing intervention and support at the local level,” Ayer said.

Sen. Philip Baruth, D-Chittenden, said lawmakers frequently repurposed a quote from the film, “Field of Dreams” — “If you build it they will come” in discussions about building a facility with more than 16 beds that would be “magically” filled.

“I don’t believe that myself,” Baruth said. “If you followed that logic you’d build nothing and no one would come. That is simply fantasy.” His amendment for a 25-bed facility, which was co-sponsored by Sen. Tim Ashe, D/P-Burlington, failed 10-19.

The legislation, H.630, was precipitated by Tropical Storm Irene. The Vermont State Hospital was damaged on Aug. 28 when floodwaters from the storm swamped the Waterbury facility, which housed 54 patients and cost about $22 million to operate. Because the hospital had been decertified by the Centers for Medicaid and Medicare the state was not eligible to receive federal funding.

That changed when patients were placed in regional hospitals after Irene. The state received a 60 percent match for qualifying patients, totaling about $10 million a year.

Gov. Peter Shumlin urged lawmakers to move quickly to approve a plan for a decentralized system of mental health care that includes “step-down facilities,” more supports from a regionalized community care system, peer services and a state-owned hospital for patients with severe mental illnesses for 16 patients. The Department of Mental Health would also outsource services for “level one” patients to regional hospitals in southern Vermont. Brattleboro Retreat would provide 14 beds and Rutland Regional Medical Center would have six beds. The state would pay for new units to accommodate the additional patients at the private facilities.

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. The Federal Emergency Management Agency will likely 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 replacement cost for the state hospital in Waterbury.

Lawmakers have said they don’t want to leave one-time FEMA money for construction on the table.

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.

The Senate vote comes on the heels of a mass layoff of 80 Vermont State Employees Association members. The Shumlin administration announced the reduction in force of the workers last Friday.

After Irene, state workers had been reassigned and asked to provide support for patients who were moved to Rutland Regional Medical Center, Fletcher Allen Health Care and Central Vermont Medical Center. In many cases employees were asked to work 12-hour shifts and drive long commutes to their new workplaces, leaving their families for periods of time.

Sen. Vince Illuzzi, R/D-Essex-Orleans, pushed for a union-friendly amendment that would have created a 50-bed hospital and required regional hospitals to hire state employees. The proposal failed 10-18.

Though senators praised state employees for their dedication in the aftermath of Irene, they stopped short of approving provisions for early retirement options, or guaranteed placements at local hospitals or in other positions in state government.

State hospital workers testified in hearings that the Shumlin administration’s human resources department gave them the option of taking jobs with lower pay in the private sector or state government.

Conor Casey, a lobbyist for VSEA, said the Senate vote was “very difficult for our members.”

“When the governor makes such a bad decision, we look to the Legislature to intervene,” Casey said. “We thought the Illuzzi amendment was a very reasonable proposal. It allowed people to continue to do the jobs they loved.

“We know the Legislature can’t rescind reductions in force from the executive branch, so these are the only proposals we can make,” Casey said. “The governor talks about Vermont strong; this decision was Vermont weak.”

The Labor Caucus met on Wednesday afternoon to pass a resolution honoring the “heroes of Tropical Storm Irene,” the state workers with the Vermont State Hospital who worked long hours far from home to ensure that patients received good care at regional facilities.

The stage is now set for contentious conference committee negotiations, which will likely take place after the next week’s Town Meeting Day break. Though the House and Senate bills are nearly identical, the House overwhelmingly supported a 25-bed facility on Feb. 2 (story here), and debate over that issue will likely be intense.

The Senate plan does not include an option to expand the 16-bed facility to 25 beds if more capacity is deemed necessary at a later date.

Such an expansion clause, as proposed by Benning, could be the compromise pressure point in conference committee negotiations. When asked if the administration, which has been adamant about a 16-bed solution, would consider a provision that would allow for an expansion of the facility from 16 beds to 25 beds, Jeb Spaulding, secretary of the Agency of Administration, didn’t rule out the possibility. He said: “We’d prefer not.”

Editor’s note: This story was updated at 6:15 a.m.

VTDigger

Gov. Peter Shumlin, Feb. 22, 2012. VTD/Alan Panebaker

The triangulation continued on Tuesday between the Shumlin administration, the Senate and the employees’ union over the size of the facility that will replace the Vermont State Hospital.

Gov. Peter Shumlin wants a 16-bed facility; the Vermont State Employees Association is pushing for a psychiatric hospital with 50 beds; and the state Senate will take up amendments this afternoon that range from 25 to 50 beds.

The vehicle for the legislation, H.630, under consideration in the Senate today, originally included 25 beds as approved by the House a few weeks ago. The Senate version of the bill has 16 beds, with no option to increase that number.

At his weekly press conference on Tuesday, Shumlin insisted that a larger psychiatric hospital would not be eligible for Medicaid funding. The governor said he met with officials from the Centers for Medicaid and Medicare in Washington last week. They said, according to Shumlin, that they would not support a 60 percent federal match for an institution for mental disease larger than 16 beds.

“I made very clear the discussions going on in this Legislature about whether we could build 16 beds or 25 beds or 30 beds,” Shumlin said. “All I can tell you with certainty is this: It is incredibly likely that should this Legislature vote for more than 16 beds, Vermont taxpayers will be paying $10 million every single year out of their pockets that should be paid for by the federal government. I was very specific with them about our situation and what they said was, ‘Governor, you have to know there’s no example in the country where if you build more than 16 beds in a new facility that you’ll get reimbursed from federal government.’”

That $10 million is a reference to the current reimbursement rate from the Centers for Medicaid and Medicare for patients now placed at regional hospital facilities around the state in the wake of the Aug. 28 flood that destroyed the Vermont State Hospital. Before the Tropical Storm Irene disaster, the state had been ineligible for the 60 percent Medicaid match from the feds because the state hospital was decertified by CMS in 2003. For at least eight years, the state lost about $10 million a year in federal funding for the psychiatric facility.

Shumlin wants to preserve that federal funding going forward by moving toward a decentralized mental health system that relies on private hospitals like Rutland Regional Medical Center, Brattleboro Retreat and Fletcher Allen Health Care.

“We are running a business here in the respect that government is an operation that has to be fiscally responsible,” Shumlin said. “All I can say is our plan has found the balance between the best quality with the patients who come first and the best deal for Vermont taxpayers. This debate’s important. I need a bill on my desk that allows the administration to build a 16 bed facility not a 17 bed facility.”

The governor, who originally asked for a bill on his desk by Feb. 17, urged lawmakers to move as quickly as possible.

“I think what the Legislature must understand is that we are in crisis,” Shumlin said. “People’s lives are at stake here. Get me a bill. This crisis will not get better with time. Every day a bill is not on my desk it’s more likely that a tragedy is going to come to Vermont.”

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