“This is a historic moment,” said Rep. Ann Pugh, D-S. Burlington, as she spelled out to House lawmakers details of the sweeping bill drafted to respond to the loss of the 54-bed state hospital in Waterbury, which was flooded and closed by Tropical Storm Irene.

By a 124-3 vote, legislators agreed with Pugh, chairwoman of the House Human Services Committee, that it was time to seize “this tremendous opportunity growing out of the crisis Irene gave us.”

“We’ve been talking about transforming the mental health system in Vermont ever since I’ve been a legislator,” said Pugh, noting the state’s extensive and futile effort in the past decade to plan and fund a replacement for the antiquated buildings that comprise the state hospital.

Lawmakers have been working feverishly for weeks with the administration of Gov. Peter Shumlin to draft legislation that addresses the mental health treatment crisis caused when the acute-care state hospital beds were removed from the system.

The governor launched the process in December when he declared patients would never go back to the Waterbury facility and set out a plan to trim acute-care beds, arguing for a comprehensive proposal that stresses treating mental illnesses in a spectrum of community settings instead.

Lawmakers in the House tweaked Shumlin’s plan and together with Mental Health Commissioner Patrick Flood filled in innumerable blanks on funding to come up with the consensus bill that won backing Thursday.

Flood said Thursday that the pricetag for the proposed system is around $174 million, roughly $20 million more than the fiscal 2012 mental health budget. However whether there is any actual cost increase to the state is unclear because of the complexities of extensive federal Medicaid reimbursements.

The one major dispute over the bill involved the size of Shumlin’s proposed new state hospital in central Vermont, which lawmakers decided needed to be bigger than the 16 acute-care beds proposed. The bill, H.630, proposes a 25-bed facility instead. Those beds are paired with a six-bed facility at Rutland Regional Medical Center and 14 beds at the Brattleboro Retreat.

The bill also calls for a secure five-bed acute-care facility for patients under department of corrections control.

Rep. Alice Emmons, chairwoman of the House Institutions and Corrections Committee, told House lawmakers her panel struggled with the complexities of deciding the right size for the new state-run hospital since Vermont doesn’t know how much FEMA and insurance money will be available for the $25 million facility. But she also said because the hospital won’t be built for “anywhere from two to three years,” stakeholders in mental health will have to time to make sure the 25-bed hospital is right-sized for the needs of Vermonters.

Pugh noted more than 70 individuals from psychiatrists and clinicians to mental health experts and consumers came before her panel, some urging no state hospital beds at all and others as many as 100.

“We spent over a month trying to weigh those different perspectives,” she said. Her committee eventually concluded by a 9-1 vote last Friday that a 25-bed facility was needed in the northern part of the state and formed the best “backstop” to meet the needs of Vermonters and provide a professional “staff to promote recovery.”

“We were not able to receive sufficient data that a 16-bed facility could do that,” she said.

The overhaul bill includes a range of other beds outside of the acute-care facilities: four short-term crisis beds designed to avert hospitalization, a five-bed voluntary non-coercive residence with peer support; and one 15-bed and two eight-bed facilities around the state providing for intensive recovery.

A wide variety of peer services provided by those who have had experience in the mental health system, crisis intervention teams, housing subsidies and mobile support teams are also provided in the bill. The community services, housing and the four-bed and five-bed beds facility are estimated to cost $8 million annually.

The bill that reached the floor included a provision to ensure that the 240 state hospital workers, who were dispersed to work at facilities around the state, will have extended and preferential rights for jobs when the new state hospital is built. Emmons said those provisions were agreed to by the Vermont State Employees Union and the administration.

Rep. Thomas Koch, R-Barre Town, rose to support the bill, humorously saying he felt like a member of the audience throwing flowers on the ice at the national skating championships. Noting he had “become extremely frustrated by the lack of progress” during the last nine years in reforming mental health, he praised the committees that slogged through the complex process and found consensus.

While he had his own concerns about letting private institutions handle some of the former state hospital patients, he said lawmakers should be “extremely proud” of the bill.

“There’s been a lot of inaction, a lot of talk. We’ve done more in the last five months than we had done in the last eight and a half years,” he said.

The bill will have its final reading Friday and upon passage move over to the Senate for that body’s review.

Rep. Pugh was elated with the large margin for passage.

“I think a vote of 124-3 is incredible,” she said, especially considering how “controversial” replacement of the state hospital has been in the past.

Asked what is likely to happen in the Senate, she said she didn’t know and was just going to let the process work.

Emmons had the same response, calling the vote “terrific.”

“Now we’ll see where it goes,” she said.

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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

A big contingent of Vermont State Hospital staffers wore T-shirts to Tuesday's hearing on Vermont's mental health system. Above, Kathy Bushey, left, and Priscilla DeGumbia outside the hearing room. VTD/Andrew Nemethy

MONTPELIER – Two distinct themes emerged in Vermont’s debate on how to rebuild the state’s shattered mental health system.

One is that Vermont’s effort to strengthen and broaden community mental health treatment and peer services is laudable, essential, workable and long overdue.

The other is that Vermont’s proposal for replacing the acute-care mental health beds lost when Tropical Storm Irene flooded the Vermont State Hospital is ill-advised, insufficient, inadequate for care, geographically unbalanced and will stress the entire system.

That, in general, is what emerged from morning legislative testimony in the House Human Services Committee and from an emotional, standing room only afternoon hearing that packed one of the largest rooms in the Vermont Statehouse with more than 80 people from around Vermont.

Take psychiatrist Terry Rabinowitz of Fletcher Allen Health Care in Burlington, who said the state’s plan for acute mental health care falls short and marginalizes the state’s most vulnerable population. He called it “not only a disservice but a dishonor.”

“Do we Vermonters want to do this to our most vulnerable population? I think not,” he said.

There’s no shortage of moving parts as Vermont attempts to rebuild its mental health system after Irene wiped out use of the Waterbury state hospital’s 54 beds and the experienced staff who had expertise in treating the most acutely ill patients.

Gov. Peter Shumlin has proposed spreading out 36 acute care beds to replace the state hospital, using three facilities: 14 at the Brattleboro Retreat, six at the Rutland Regional Medical Center, and a new 16-bed facility expandable to 25 beds to be located near Central Vermont Medical Center.

The plan also calls for expanding community services, from emergency intervention, housing, crisis beds, services provided by peers (people who have been in the mental health system and can relate to patients) and intensive local mental health outpatient and residential services. Administration officials contend those services will preempt the need for more acute care beds.

Criticism of the acute care part of the plan has been building as discussion continues in the Legislature and on Tuesday it turned into a crescendo.

In the morning, Dr. Peter Thomashow, medical director of Central Vermont Medical Center, and James Tautfest, a psychiatric nurse who heads the 14-bed psychiatric unit, added their voices to those of other key medical professionals in the state who say the governor’s plan doesn’t provide enough acute- care beds for the mental health system.

In testimony to the House Human Services Committee, Dr. Tomashow said the state needs a 30 to 40 acute care bed facility in central Vermont, much more than the 16-bed facility proposed. He said he strongly supported the governor’s overall plan, but he and Tautfest said the state desperately needs the intensive care “safety net” that the former state hospital beds provided for assaultive and dangerous or self-harmful patients.

His comments mirrored those of the state hospital director and head of Fletcher Allen’s psychiatric unit, who have already advocated a similar number or even more beds. Tomashow said the governor’s plan simply underestimates the difficulty of the patients who were sent to the state hospital, many involuntarily. Professionals in the wards and emergency rooms see things differently, he said.

“We’re talking about the most difficult population in psychiatry,” he said.

He also said the governor’s plan does not provide enough acute care in northern Vermont where the biggest population is, and suggested that an uptick in acute care needs from aging baby boomers means even more beds may be needed in the future.

Tautfest suggested the state consider reopening – only temporarily – a ward at the state hospital to ease the crunch that has existed since Irene, which forced regional and community hospitals to treat patients who would have ended up at Waterbury and has flooded emergency rooms with “very sick” people.

More than 40 people, many of them also nurses, doctors and mental health professionals, as well as relatives and patients, testified along the same lines in short yet emotionally packed 2-minute statements in the late afternoon.

“I do believe that we need a state hospital in one central location, not for or five little bitty ones located around the state,” said Nancy Colby, a Chittenden County resident who said she had 25 years of personal experience with mental illness. She said having several small acute-care facilities would duplicate services and not be as effective as one larger facility.

“We worked with people no one else was able to treat,” said Kristy McLaughlin, a social worker at the Vermont State Hospital. “A decentralized system will not be making us better,” she said, warning that the state’s plan would “demolish” the mental health equivalent of an excellent intensive care unit if the governor’s plan goes through.

Dr. Ruth Grant of Waltham, who said her 20-something son had schizophrenia, said the state needed a “no-reject” acute care full-service facility in the northern part of the state and more beds than proposed. She urged the panel to listen to the opinions of the front-line care providers who were saying the governor’s plan falls short.

Jack McCullough, a legal aid lawyer with long experience in mental health judicial proceedings, agreed that community treatment is the ideal, but when it came to acute beds, he said “my judgment is that scattering beds around the state is not an efficient way to provide care.” And he said the governor’s plan is a “dramatic shift of resources down to southern Vermont” to private facilities, which raises legal issues the state needs to address.

The rights of patients when it comes to involuntary admissions and medication was also a concern to Ann Klein, a nurse at the state hospital. She said staff there were well-trained and kept up-to-date on involuntary procedures ordered by the courts. “We’re the most vulnerable patients’ protectors,” she said, but if the acute care is split into three places, two of which are not state run but private, “there will be no continuum of care.”

Many testified to the benefits of the community care proposals and urged lawmakers to make sure funding is sustained for the long term, noting drastic cutbacks in recent years.

Roxi Smith urged more support for organizations such as Another Way in Montpelier, which provides peer support and has helped her overcome “a lot of my own fears.”

“Peer support works,” she said. “Only people who have had mental illness can understand it,” she said.

Josh Sawyer, 43, of Montpelier choked up as he told lawmakers he had been at the state hospital twice and how Another Way had helped him and now he was on its board of directors.

“I ask you to continue funding for these programs,” he said.

Marla Simpson of Randolph provided a patient’s stark perspective, explaining she was one of the last to be evacuated from the state hospital when Irene hit. She called involuntary hospitalization, seclusion and restraint the same as “psychological rape,” but at the same time she praised the “outstanding” staff at the shuttered state hospital and said a 16-bed northern facility was not enough either for the acute care needs or to maintain expert well-trained staff.

Erica Smith of East Montpelier, a psychiatric nurse for 15 years who worked at the state hospital and now is in community mental health, said community treatment can have “wonderful” results for some people. But she cautioned that people misunderstand the high level of illness that afflicts some patients and some just do not do well in community programs and need intensive care.

“I am very fearful 16 beds is not enough and people are not going to survive in the community with this many beds,” she said.

That was also the message from Allison Hall, a psychiatrist at Fletcher Allen in Burlington. Hall said while she has been on call duty she has seen the hospital struggle to deal with patient emergencies since the state hospital closed. Fletcher Allen, along with the Brattleboro Retreat and Rutland Regional Medical Center and others, has had to take on many added patients in crisis with the state hospital’s closing.

She said she was “very concerned” that the governor’s acute care plans would be inadequate to treat the patients she has been seeing, she said. And she said state hospital staff, who are assisting around the state since the closure, are far better trained and able to de-escalate difficult situations.

“I strongly feel breaking up a strong team and scattering them around Vermont is unwise,” she said.

A physician’s assistant questioned why the state is even considering anything but building a new central state hospital, noting if a “top flight emergency room” had been wiped out in a flood, no one would even question rebuilding it. Mental health patients’ suffering is just as real, he said, and they deserve a top-flight hospital, too. Another psychiatrist made the same analogy, saying the governor’s acute care proposal “falls far short of the current and future needs of the state, ” noting it was tantamount to replacing a specialized cardiac care unit with a community health center.

Alexandra Forbes raised another problem with spreading acute care around to several community facilities. Speaking for the Vermont Psychological Association, she said one centralized facility with several units would provide the best clinical treatment and staff. She added that transferring people among three facilities means transporting them by sheriff in shackles, which is traumatic and humiliating.

“Truly it is embarrassing that the state is not committed to what we really need, a state-of-the-art facility,” she said. “The state should make that commitment.”

Several people lamented that the dispute over beds has overshadowed the larger issue of the positive transformation that the state is undergoing. Others said the state needs to go slow and make sure it gets it right.

Becky Moore, a state hospital social worker, said the rush to come up with a solution to the state’s crisis worried her and reminded her of the saying, “Marry at haste, repent at leisure.” She said an unfortunate “fallout” of the hospital’s closing was that different parts of the system felt they were being pitted against each other.

“It’s a false dichotomy or trichotomy, or whatever, because were all part of the same continuum,” she said. “I implore all of you as you make this decision, as you decide the future or mental health in our state, remember, we need all the parts of the mental health system.”

Mental Health Commissioner Patrick Flood, who sat in on the hearing, has said he finds the testimony in support of community services “very affirming” about the state’s direction. But he insisted despite the criticism Tuesday that the state’s proposal for acute-care replacement beds is “on the right path” and at this point said there was no plan to change it.

He also said the idea of reopening a ward at the state hospital even temporarily to handle some patients is “just not feasible” for a host of reasons.

Correction: Alexandra Forbes spoke for the Vermont Psychological Association; her affiliation was incorrect in an earlier version of this story.

VTDigger

Vermont State Hospital. VTD/Josh Larkin

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The administration’s proposal calls for 36 acute care beds to replace the state hospital, spread out at three facilities: 14 at the Brattleboro Retreat ready as early as July; six at the Rutland Regional Medical Center as early as fall; and a new 16-bed facility to be located near Central Vermont Medical Center in the future. Acute care is now also being provided at Fletcher Allen in Burlington but that is not part of the long-term plan.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

VTDigger

Recently, someone told me of a joke going around certain circles that goes something along the lines of: What is the recipe for closing the Vermont State Hospital and building a much more robust community-based system in its place?

Just add water.

Others had also previously quipped in one form or another about how it took a tropical storm as well as flooding to do in one day what politicians and advocates have been talking about doing over the course of roughly 30 years.

During all those many years there had been a multitude of conversations, meetings and discussions as well as study upon study done and plan upon plan formulated, including the so-called Futures planning initiative, however, with no real, meaningful or lasting results to show for all the hot air expended and failed efforts, not too mention all the state taxpayer funds wasted in vain while doing so.

The Vermont State Hospital, along with the mental health system as a whole, had become virtually stuck within a vacuum, a massive black hole, seemingly sucking all the energy, available resources and life, as well as removing any opportunities for improvement in being able to do anything better and truly different, out from the realm of possibility.

Frustration and despair reigned and many people became resigned to stick with the status quo and thus settling for less, including by keeping expectations lowered.

Although some have stated there had been consensus on what should be done and this included the building of a new version of the same thing (read: same old treatment model), the only such consensus was in fact merely among those who had agreed about this course, even though there were those of us who had long argued along very different lines and consistently stated such on various occasions.

Among what was being argued by myself as well as others over the years was how crucial it would be to not to focus on beds and institutions, nor the needs of the system and service providers, but rather on what the actual needs of those being served were, including by asking persons currently being served as well as those previously served what they knew to both work and not work in improving outcomes as well as quality of life.

Then, about roughly two months prior to Tropical Storm Irene devastating much of Vermont as well as the town of Waterbury and the state office complex, which included the 54-bed state hospital, Deputy Agency of Human Services Secretary Patrick Flood began reaching out to various stakeholders, including myself, asking for direct input concerning what to do regarding VSH and the mental system as a whole.

It had long been my view that what was missing and sorely needed was a truly open and public discussion as well as process concerning what was needed and about how to proceed. Although some suggested this had already taken place, it in fact had not been the case, not until Tropical Storm Irene forced the matter to the fore.

There have been many lengthy open discussions held since, sometimes these have occurred on a one on one basis and at other times, particularly later in the process, done in group settings with various parties attending.

A slew of various proposals were submitted to the Department of Mental Health for consideration and two different days of review by a variety of stakeholders were held.

Out of this process, not only has Gov. Peter Shumlin and his administration decided not to return to the VSH facility in Waterbury, but he and his team has come up with a plan for moving forward in strengthening mental health services across Vermont. View the video here.

Shumlin’s proposed plan includes yet is not necessarily limited to the following:

•15 bed state managed facility in central Vermont (Fletcher Allen will provide 7 to 10 intensive inpatient beds while this facility is being constructed and staffed)
•14 beds at Brattleboro Retreat
•six at Rutland Regional Medical Center
•Up to five beds secure residential on campus of Windsor Correctional Facility
•Step down beds (transitional beds as people move off acute care)
•Improved emergency services
•Improved individualized services
•Housing vouchers and peer services (people who have been patients who now are willing to run services for others – hotline, beds any number of supports)

Although it is my opinion that the administration’s current plan still focuses too much on institutional beds, particularly what I view as being the same old treatment model and should instead go much farther in building a more robust community services system than is already being planned, one much less dependent on the medical model as well forced treatment and medication in general, at the same time I do happen to believe the plan is certainly heading in the right direction toward attempting to do so.

In a somewhat related development, Shumlin also recently swapped the roles or positions of Patrick Flood and Christine Oliver, making Flood the commissioner of DMH and Oliver the deputy AHS secretary.

In doing so, the governor stated how “Christine and Patrick have both done an extraordinary job under difficult conditions over the past year. As I have worked closely with them in the wake of Irene, it has become clear to me that at this unique moment, Christine’s background and talents are better suited to managing the agency’s overall work, while Patrick’s legislative and state government experience make him best suited to helping realize my vision for creating a comprehensive, post-Irene mental health system.”

From here on out, the Vermont Legislature will be considering and deliberating over the plan as well as taking testimony from various stakeholders as well as members of the public concerning how best to proceed.

Anyone who desires to be heard on these and related matters should make their opinions known to the governor as well as to their local members of the Vermont Legislature, whether — either or both — directly or via letters to the editor in local or statewide newspapers.

VTDigger

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

MONTPELIER – They wandered all morning through the corridors of history, seeking a glimpse of the future.

All afternoon, they waded through the numbers, nuances, conflicting opinions and complex policies of Vermont’s mental health system.

By 5:30 p.m. when it was over, House Institutions Committee Chairwoman Alice Emmons of Springfield, looking tired, clearly spoke for her panel when she said, “Who knows where we’re going to go.”

She got sympathy from Rebecca Moore, a licensed psychiatric social worker who was the last to testify in a day that began with the panel getting a long guided tour of the vacated Waterbury State Hospital and the labyrinthine corridors of the rest of the office complex flooded by tropical storm Irene. The panel then looked at two possible state hospital sites being considered in Berlin.

“You poor people,” said Moore with a smile, agreeing the task before the Legislature in deciding how to reconstruct Vermont’s mental health system after Irene is anything but an easy one. As Rep. Cynthia Browning admitted – in a joking phrase heard often in the State House this year – they have a “Waterbury complex.”

House Institutions is one of a handful of key committees in the Legislature tackling a revamp of mental health in the state proposed by Gov. Peter Shumlin. His plan calls for a broad spectrum of beefed up community mental health services and three separate small intensive care facilities for those in acute mental health distress, replacing the acute care provided before Irene’s flooding solely in the 54-bed Vermont State Hospital in Waterbury. The governor’s proposal now calls for 36 acute care beds spread out at three facilities: 14 at the Brattleboro Retreat, six at the Rutland Regional Medical Center, and a new 16-bed facility to be located near Central Vermont Medical Center.

The governor’s plan has raised a raft of difficult issues that are financial, programmatic and even philosophical: Is a standalone 16-bed facility big enough to hire and keep staff and doctors for adequate treatment? Should the state privatize care of the state’s most mentally ill in facilities in Brattleboro and Rutland. What kind of legal and transparency issues does that raise in case of problems? What will the capital costs and operating costs be, considering the mix of federal and state money? What will happen to the 240 former VSH employees now working at sites around the state?

And perhaps underlying all this: Can the state maintain the elaborate expanded community services needed to underpin the governor’s plan and avoid building a new larger state hospital facility – especially in light of a history of cutbacks over the decades?

That issue was front and center for Moore, who since the hospital was flooded has been working at Burlington’s Fletcher Allen psychiatric ward since employees were displaced from Waterbury.

She said Vermont’s community mental health budgets were “decimated” in past years by cutbacks – and when that happens the state hospital is where untreated patients end up in more severe crisis.

“The state hospital does not exist in a vacuum,” she said. She said the patients she works with have numerous issues that are not easily resolved and many require extensive time in an acute care setting to get ready to go back into the real world.

She said in her opinion, the number of intensive-care beds in the governor’s proposal is “inadequate to meet the need.”

VSH Medical Director Jay Batra seconded her comments, comparing the shifting state policies and funding in mental health care as “playing the seesaw like whack-a-mole.” He said there is widespread agreement of the need and benefits of improved community mental health services outlined by the governor, calling them “long overdue.” At the same time he repeated his call for a centralized four-unit acute care facility with 12-15 beds in each unit, saying the governor’s plan doesn’t account for the actual “unmet need” in Vermont.

Batra said Vermont’s ratio of acute care mental health beds to population is already one of the lowest at nine per 100,000 people. New Hampshire’s ratio is three times as high and Massachusetts is 15 per 100,000, he said.

Batra also said the state of Minnesota tried similar sized 16-bed facilities to avoid a federal cap on funding eligibility as the governor has proposed and has decided that system has failed, noting that keeping and hiring staff for a facility that small is very costly.

“It simply does not work,” he said. “You can’t staff the place.” Training and treatment quality is also an issue. Staff, he said, learn from patients, from other staff and from extensive practice “over and over again” that teaches them how to deal with disruptive and difficult patients needing Level 1 care. A 16-bed facility simply doesn’t meet those criteria, he said.

He also vigorously argued before the panel that Vermont needs an “absolutely accountable, non-refusal facility” that will take involuntary admissions and those under care of the corrections department, which private facilities may not be able or willing to do.

“Having a place that simply cannot say no is essential to this,” he told the committee.

Batra’s opinion on the need for a larger replacement state hospital has been buttressed by the head of Fletcher Allen’s psychiatric unit, who testified last week that a central hospital with some 30-40 beds is needed. However some mental health advocates in Vermont want to see even fewer beds and more people treated in their communities.

Rep. Jason Lorber, D-Burlington, asked Batra what the Shumlin administration thinks of his opposition. After a pause, Batra joked, “Do I have the right to remain silent?”

Both he and Moore were asked if they were consulted on the governor’s state hospital plan and they said no. But Batra, who has been at the state hospital for five years, said he didn’t want the conflict over bed numbers to distract from the larger important debate on how best to formulate a good statewide care system, calling that debate a “false dichotomy.”

The chore facing the panel, which will have a say on any facilities built, is not just difficult but urgent. Rutland Regional Medical Center Thomas Huebner testified for the second time in a week that the crisis caused by the closing of the state hospital has created tremendous stress on his hospital, not only in dealing with difficult patients but because treating patients who would have formerly gone to the state hospital means others in the region are turned away.

“This cannot continue any longer than necessary,” he told the panel, urging them to approve something soon even if it is not “perfect.”

While he urged action on the governor’s proposal, he cautioned that there had to be a real financial commitment to whatever is passed. He said his “biggest fear” is that the community mental health system and places such as his hospital won’t be adequately funded, which means treatment will falter with more people facing more acute crisis.

“We have to be accountable for outcomes,” he said.

Peter Albert, a senior Vice President at the Brattleboro Retreat, also urged the committee to concentrate not on finding the perfect number of beds for mental health care but to focus on what would constitute the best system.

The committee’s lengthy day began with a sobering tour of the inside of the now-empty state hospital, the small Spartan rooms, dark corridors and thick doors putting a grim face on the oft-used word applied to the building, “antiquated.” The entire red-brick complex, parts of which date back to before 1900, once housed some 2,000 “insane” Vermonters, and when Irene hit, housed around 1,500 state office workers and 51 state hospital patients.

After its tour, the panel also visited a state parcel behind the regional library in Berlin, a possible site for the governor’s 16-bed state hospital facility, which the plan says could be expanded to 25 beds. Part of the 5-plus acre parcel, however, appeared to be frozen swamp and would require substantial backfill. It is also located about half a mile from Central Vermont Medical Center. Experts and advocates have said any new modern mental facility should be adjacent to a medical hospital.

The second site visited Wednesday is a substantially larger parcel owner by Henry Lague with two small houses on it that is at the corner of Paine Turnpike and Fisher Road, much closer to the medical center.

Construction of any new state-owned Level I mental health facility in Berlin is at least two years away, state officials have said.

VTDigger

Mental Health commissioner Patrick Flood testifying before the House Human Services Committee Thursday. VTD/Andrew Nemethy

MONTPELIER – The dollars and details are spilling out as the Shumlin administration scrambles to spell out a drastic revamp of mental health care in the wake of Tropical Storm Irene’s devastation.

A harried Mental Health Commissioner Patrick Flood appeared before the House Human Services Committee with the first detailed take on how the state plans to rebuild the mental health system after the flooding closure of the 54-bed Waterbury State Hospital.

Lawmakers on the panel, who convened this week for a new session, also listened to mental health providers who several times used the word “urgent” to describe the need to get moving on a plan to alleviate the crisis caused by the hospital’s closure. The providers praised Flood for visiting them and many of their facilities in the past two weeks since he took over as Mental Health commissioner in a job swap with Christine Oliver.

The panel got a front row seat on the central disagreement over the plan when they were told via speakerphone by the head of Fletcher Allen Health Care’s psychiatric unit, Dr. Robert Pierattini, that the state cannot get by without a 30-40 bed state hospital staffed to handle patients needing intensive mental health care.

The governor’s plan rejects the need for a central facility that size, and that issue is shaping up to be the major point of contention.

Flood made it clear he understands anxiety and stress remain in the mental health community since Irene hit four months ago.

“We are in a situation that is evolving as we speak. There is no way around that,” he said, acknowledging as he handed out version one of the detailed plan that there already is a version two. “I know this document will change by the end of the day.”

Flood said he was impressed by the cooperation and hard work of everyone in the field, though he warned “hard choices” lie ahead.

“Together we will come up with the best choices for Vermonters, I am sure,” he said.

The governor’s proposal, unveiled last month, includes 36 acute care beds to replace the state hospital, spread out at three facilities: 14 at the Brattleboro Retreat ready as early as July; six at the Rutland Regional Medical Center as early as fall; and a new 16-bed facility to be located near Central Vermont Medical Center in the future.

It also proposes to greatly expand community services, from emergency intervention, housing, crisis beds, so-called peer services and intensive local mental health outpatient and residential services that administration officials say will preempt the need for a larger state hospital.

Flood put some dollar signs and timelines on the plan for lawmakers on Thursday. The capital costs of the Retreat beds would be $4 million; the new ward at Rutland would be $6 million; and the state-run facility would cost $16 million, for $26 million total in capital costs, he said.

Flood said FEMA may cover some of those expenses since they were created by the flooding at the state hospital. Alternatively, the costs may be built into the rates charged by the facilities.

Importantly, he said the state is now eligible for an additional $20 million because all the new sites are eligible for Medicaid and Medicare reimbursements that the federal government previously denied the state because of quality of care issues at the Vermont State Hospital.

The funds from the Centers for Medicaid and Medicare will be used to strengthen community services, Flood said.

The proposal detailed Thursday includes $1 million for four new crisis beds; $600,000 for up to 100 housing vouchers since lack of housing often precipitates mental health crisis; $1 million for so-called “peer services”; and $5.6 million for new residential program beds such as those at Second Spring in Williamstown, which takes patients whose needs can be handled in a less than acute setting.

Joining Second Spring with “step-down” beds will be a new seven-bed facility in Westminster that is under development and expected to be ready in February and another one with 15 beds in northwestern Vermont that could be available in six months once it is approved by the Legislature, he said. Second Spring will add eight beds for a total of 22, he said. In all, the plan includes 30 new community based spots.

Flood said he anticipated additional staffing costs for his department to ensure that the expanded, decentralized system is well-integrated and a new web-based tracking system for patient needs is established. He said the state is still urgently seeking a solution for housing patients under court order, since they cannot continue to stay at the correctional center in Springfield.

Flood conceded the “fewer versus more” debate over state hospital acute care beds is key, but he also noted the central Vermont facility would not be ready for two to two and a half years.

Rep. Anne Pugh, D-Chittenden, chairwoman of the House Human Services Committee, addresses a standing room only crowd with Rep. Anne Donaghue, D-Northfield foreground. VTD/Andrew Nemethy

“I want to emphasize that point so we don’t get inordinately stuck on that one point,” he said.

At the same time Flood emphasized that the facility is being designed for “quick expansion” to 25 beds if needed.

Providers question plan

Pierattini told lawmakers on the panel that Fletcher Allen’s experience with taking patients who would have ended up at the state hospital before Irene has been dramatic and difficult. “We are doing our best,” he said, but “the mental health system is at the very edge of adequacy,” he said, telling stories of his own personal experiences working over New Year’s Eve.

“Our units were full, they were overcrowded, they were dangerous,” he said, and the hospital has also had to turn away patients who needed care. This was not the case before the state hospital closed, he said.

Pierattini said the state needed a “Level 1” intensive care mental health facility with 30 to 40 beds to replace the Waterbury State Hospital, and the facility absolutely needs to be in a medical center and provide the full range of medical care. He said mental health patients now at Fletcher Allen display a host of “extensive medical issues” from diabetes to suicide attempt wounds to seizures, renal failure and hypertension and drug addiction.

“These are very typical,” he said, adding that it was “inconceivable” to him that the system would try to treat the most acutely ill anywhere but with full hospital care.

“If we don’t do this people will die because we absolutely have to have these medical services,” he said, specifically excluding the idea of using a nearby hospital where response is “by vehicle.”

It is unclear in the governor’s plan how close the 16-bed Central Vermont facility will be to the Central Vermont Medical Center and what medical services it will have.

He also strongly backed the contention by the Vermont State Employees Association and Dr. Jay Batra, the head of the Vermont State Hospital, that a central facility with well-trained staff is best able to deal with patients in acute crisis, and he said the new state plan does not provide enough beds in the northern part of the state. He further raised issues of accountability when private institutions treat mental health patients under state care, an issue raised by the state employees association as well.

The state plan, he said, should be modified.

“We need a replacement hospital that is accountable to the commissioner of mental health and fully integrated into a medical center,” he said.

Ann Pugh, chair of House Human Services, pressed Pierattini on how he came to the conclusion that a 30- to 40-bed hospital is necessary, noting that Flood had testified that as many as half of the patients at the state hospital could have been served elsewhere if services and beds were available.

Pierattini said the 54 beds at the former state hospital were “not an arbitrary number” but based on trial and error and data over many years of experience. He cited a 2006 study that called for 30 to 40 beds.

Pugh replied that if the state built 100 or 200 beds they would fill up. She said overbuilding capacity was problematic. Rep. Anne Donahue, R-Northfield, said the key was finding the right balance.

But Pierattini stuck to his guns, insisting that the system has to plan for “for peaks in census (because) the averages can be misleading.” He urged the panel to talk to more practitioners in the field and not just administrators for their advice.

“I think it’s very important to get testimony from actual mental health clinicians,” he said.

That touchy subject was raised by Rep. Topper McFaun, R/D-Barre, who asked Flood whether state hospital employees on the frontlines had been consulted in drafting the plan. Flood conceded he didn’t know the answer to that question. Batra, the state hospital chief, has testified no one from the Agency of Human Services consulted him on the governor’s plan.

Rutland Regional Medical Center President Thomas Huebner and Brattleboro Retreat President and CEO Robert Simpson both stressed the urgency of the situation and they asked the panel to move quickly to approve funding for expanded acute care beds.

They agreed with Pierattini that the system is in extended crisis, treatment is suffering, and that stressed-out staff need to know the state is working quickly to resolve the issues.

“We’d like to get a yes as soon as possible” said Huebner of the proposed six-bed facility for his hospital, which has been accepting disruptive patients who previously might have been at the state hospital and forced to turn people away as well.

Citing the severity of the need and patients who can’t get or decline treatment because of the crowding at the hospital, he said, “There are moments we really don’t sleep well at night.”

Simpson agreed with Huebner.

“The system is very shaky,” he said.

The one blessing, he said, is that a real sense of teamwork has developed among all the providers since Irene, and the closure of the state hospital has provided “a wonderful opportunity to take a stab at stigma.”

VTDigger

Department of Mental Health Commissioner Patrick Flood. VTD/Josh Larkin

MONTPELIER – The Vermont State Employees Association has thrown up a major roadblock to the state’s newly announced decision to decentralize acute mental health care.

VSEA President John Reese said VSEA will use “any and all means at our disposal” to oppose Gov. Peter Shumlin’s proposal to replace the state’s 50-bed hospital, which was damaged in the Tropical Storm Irene flood, with a 15-bed facility in Central Vermont.

Shumlin announced on Dec. 13 that he wants to spin off care for severely ill mental health patients from one facility to a handful of private regional hospital facilities on Dec. 13.

“We are not confident that the plan put forth by the administration is going to provide the necessary level of care for individuals around the state,” Reese said Thursday.

Reese said the administration didn’t consult with mental health professionals in drafting the plan, and he suggested the smaller facility may be driven more by cost considerations than an obligation to provide the best care. That point was pungently made when Dr. Jay Batra, the medical director at the now-flooded out state hospital in Waterbury and a psychiatric professor, testified in the Legislature endorsing a 48-50 bed state hospital replacement the same day Gov. Shumlin announced his plan to move in the opposite direction.

Dr. Batra has since said he was not consulted on the governor’s proposal.

Reese said he’s “confused as to why the administration has come up with this plan,” especially considering the administration itself had previously announced its support for one centralized hospital for treatment with 40-50 beds, a view he said was also taken by Shumlin when he was running for governor.

Administration Secretary Jeb Spaulding said the state simply disagrees with the union on the best way to treat patients with acute mental illness.

State officials decided in the “long view” a community-based care system was the best method for treatment. Spaulding said the state had to move quickly to deal with a stressed system following the closure of the Vermont State Hospital.

“I think you’ll find the vast majority of those interested in mental services all agree as well,” he said, adding “it doesn’t mean it’s unanimous.”

Buildings at the Waterbury State Office complex. Photo by Don Shall.

Conor Casey, the VSEA legislative coordinator, said the VSEA will consider what legal options it has in light of contract provisions that cover situations when the state seeks to “privatize” care.

He said the organization will vigorously oppose the proposal in the Legislature.

“We’re going to fight this thing every way we can,” Casey said. “We feel it’s a very bad policy decision. We feel a central facility is the best option.”

Some 240 employees were at the state hospital when it was flooded out Aug. 29 by tropical storm Irene and they are now working at facilities around the state under a cobbled together system created after the state hospital closed.

Casey said a larger facility would provide patients with access to higher quality care and preserve a highly trained work force attuned to the needs of patients who need acute mental health care.

The VSEA’s vocal opposition comes after an emotional and disputatious meeting Friday at the Montpelier VFW hall that drew around 100 state hospital employees to talk with Spaulding and then-Mental Health Commissioner Christine Oliver. (Oliver this week switched her post to become Deputy Secretary of the Human Services Agency and Patrick Flood, who has been the administration’s point man on the state hospital, left that post to take Oliver’s position.)

VSEA staffer Doug Gibson attended and said some staffers were in tears and others were frustrated though civil. He said among front-line state hospital staffers there is “unanimous” agreement that the plan is a “travesty” and the state is going in the wrong direction – and not just because jobs are at stake.

“People are seeing what this privatized system will look like,” he said. “In some instances, they’re not liking what they’re seeing,” he said.

VSEA plans to present an alternative proposal.

The administration’s proposal calls for replacing the 54-bed state hospital with a new 15-bed state-managed facility near Central Vermont Medical Center; 14 inpatient beds at the privately run Brattleboro Retreat; six at the Rutland Regional Medical Center; and up to 5 beds at the Windsor Correctional Facility to handle patients under court jurisdiction.

Mental Health Commissioner Flood has indicated that beyond those 40 beds, a raft of new community care beds will be added providing more mental health beds in the system than were at the state hospital. Mental Health officials have testified in the Legislature that as many as 20 of the 51 patients at the state hospital when it was flooded didn’t need to be there but were awaiting other placements, part of their argument that a larger new state hospital isn’t needed.

Shumlin’s plan also relies on a broad continuum of additional community services, including transitional beds for people moving off acute care, improved emergency services, housing vouchers and peer support, as well as an expanded case management system.

Some lawmakers appear to agree with the VSEA view that one central hospital is the best option for treatment of severely ill patients, while others have indicated they are open to what the governor has proposed. Flood indicated Wednesday that the administration intends to come in with a specific bill that will outline programmatic and financial steps the Legislature must approve.

Casey asked why the drafting of the plan was done in secrecy without reaching out to VSH staff. He said the union was “caught completely off guard” by the governor’s proposal and only learned about it in media reports after the announcement.

VSEA officials are not critical of all aspects of Shumlin’s proposal. They praise the beefed-up community care aspects but insist the most acutely ill need to be treated in a specialized facility with staff trained to deal with them. Dr. Batra has testified that the state needs the mental health equivalent of a “level I trauma center,” making the analogy that a broken leg can be treated at the local emergency room but major trauma needs to be treated in a specialized facility.

Dr. Batra’s assessment is correct, according to Gibson, who said VSH employees have reported that the private facilities can’t handle abusive patients.

“The hospital staff has years and years of training. They have the techniques to handle the situation,” he said. In a post on the VSEA website, Gibson wrote that the Shumlin plan will “throw away a century-plus of caregiving expertise down the drain.”

Casey said the governor’s proposal also underestimates the numbers of mentally ill patients who are now being sent to corrections facilities who need to be taken care of in a central state hospital. He said VSEA officials are hearing from corrections employees that they are being forced to deal with mentally ill prisoners who should not be in the jails and need treatment.

“They don’t have the training they need” to deal with them, he said. The state’s proposal to have up to five beds at the Windsor prison facility for people under corrections department control is “absolutely insufficient,” he said.

One of the issues disputed between VSH staff and Spaulding at Friday’s meeting was Spaulding’s contention that the state is limited to building 15 beds or less for any new mental health facility if it wants Medicaid funding participation. Spaulding said he remains convinced that is the case, though he was challenged about it the meeting.

Spaulding said a number of issues remain to be decided in the governor’s proposal, including who will pay for any new construction or physical alterations at the Brattleboro Retreat and Rutland Regional Hospital and details of a state contract with those institutions on how they will handle Vermonters in mental health crisis.

Spaulding said he understood the anguish of VSH employees who are commuting long distances to their jobs now and facing uncertainty about their jobs. He said the state would make every effort to try and keep them in the mental health system or in other state employee positions.

“I realize it’s a very emotional issue,” he said.

For his part, Reese said the VSEA is urging VSH employees to speak up and voice their concerns to lawmakers. He predicted the governor’s proposal faces “a long bumpy ride.”

VTDigger

MONTPELIER – Gov. Peter Shumlin announced on Tuesday that his administration plans to replace the Vermont State Hospital in Waterbury with a decentralized, “community-based” plan with 40 inpatient beds in four locations around the state.

Shumlin described the emergency closing of the 1935 Brooks building in the wake of flooding from Tropical Storm Irene as a “golden opportunity,” a chance, as he put it, to create a new mental health system that would “deliver the best quality care of any state in the country.” The governor made the announcement at an unusually crowded press conference on the Fifth Floor, with several dozen advocates, lawmakers and hospital administrators in attendance.

The unveiling of Shumlin’s proposal came on the same day a top mental health psychiatrist called for almost the exact opposite of what the governor proposed. Dr. Jay Batra, medical director of the state hospital since 2009 and a professor at UVM, told lawmakers at a hearing on Tuesday that the state should have one central mental health facility serving 48 to 50 patients in order to provide the best clinical treatment and best staffing model.

That accidental juxtaposition highlighted the continuing upheaval created by the state hospital’s closure Aug. 28. The state has been struggling to cope with acute treatment needs as a result of the closure and has rushed to develop a proposal – amid no shortage of conflicting opinions – to present to lawmakers to rebuild the system. Shumlin’s proposal sits atop a tall pile of previous ideas: The debate over the state hospital and what form its replacement should take has stretched on for around a decade. In 2003, the Centers for Medicaid and Medicare Services decertified the Vermont State Hospital because the facility didn’t provide patients with a therapeutic environment. Nonviolent patients with severe mental illness were housed with patients with violent tendencies, making treatment extremely difficult.

While several mental health and hospital officials gave cautious backing for the governor’s plan at the press conference, one legislator who attended the presser gave the idea a lukewarm greeting. The scattering of the state’s acute care system to four locations also appears to run counter to some parts of a draft report by the Legislature’s Mental Health Oversight Committee also released Tuesday, whose “guiding principles” include a call for any acute care facilities to be integrated and co-located as part of a medical hospital.

“This is really an odd flip,” said Rep. Anne Donahue, R-Northfield, one of the committee’s members and a lead policymaker on mental health issues. She said she supported the administration’s previous move toward one main facility near the Central Vermont Medical Center in Berlin. Donahue is less enthused about the decentralized plan.

“I think now we’ve shifted to expediency: What can we do with FEMA and insurance money instead of paying attention to what quality care means,” she said.

The Shumlin administration must seek legislative approval. On Monday, Jeb Spaulding, the secretary of the Agency of Administration, told a legislative panel that the plan must be passed as soon as possible.

The details of the administration’s proposal call for replacing the 54-bed state hospital with a new 15-bed state-managed facility near Central Vermont Medical Center; 14 inpatient beds at the Brattleboro Retreat; six at the Rutland Regional Medical Center; and up to 5 beds at the Windsor Correctional Facility to handle patients under court jurisdiction.

It also relies on a broad continuum of additional community services, including transitional beds for people moving off acute care, improved emergency services, housing vouchers and peer support, as well as an expanded case management system. The state is working with the designated mental health agencies throughout the state, HCRS in southwestern Vermont; Northwest Counseling Support Services and Central Vermont Medical Center to expand community treatment options.

Floyd Nease, executive director of the Vermont Association for Mental Health and Addiction Recovery, praised the community model and said it has the potential to work if it is “executed well.” He said he would monitor the process” and will be looking for some “canaries in the coal mine” as the system evolves.

The Vermont State Hospital replacement beds are expected to cost $22.5 million a year, or about what it cost to operate the Waterbury facility. The difference now is federal money. The Centers for Medicaid and Medicare, which had decertified the hospital in 2003 and cut off money for patients eligible for federal funding, is now reimbursing the state for patient care in the regional hospital facilities. The 60 percent federal, 40 percent state match makes it possible for the state to invest more money in community services, officials said.

Department of Mental Health Commissioner Christine Oliver, AHS Deputy Secretary Patrick Flood and Department of Mental Health Deputy Commissioner Rebecca Heintz speaking before a joint committee on Wednesday. VTD/Josh Larkin

Shumlin said the new system will be “more affordable” and offer better care than could be provided at the antiquated state hospital building. The governor went out of his way to make it clear he felt VSH staff provided excellent care, but were hamstrung by the facility.

The capital investments in facilities would be $26.6 million, most of which would be reimbursed by FEMA and insurance monies, the governor said. The additional community services have a price tag of $16 million, $9 million of which is federal money.

The 15-bed facility in central Vermont would be on 8 acres of state-owned land adjacent to the regional library in Berlin, which is about a mile from the Central Vermont Medical Center. The initial cost officials said is roughly $15 million; Shumlin said expansion would be possible if needed. The 14 beds at Brattleboro Retreat are already being used to handle acute patients who, under the contract with the state, may not be rejected. Capital improvements at the facility would cost about $4 million.

The six Rutland beds are new and would come at a cost of $6 million. The five beds at the Windsor prison ($1.6 million) would be for patients that need to be in a secure setting for transitional housing for legal and other reasons, according to Christine Oliver, the commissioner of the Department of Mental Health. Forensic psychiatric treatment will be offered at the Brattleboro Retreat. Patients will also continue to be treated at the state’s correctional center in Springfield, until the 15-bed facility in central Vermont is constructed.

Differing points of view

In testimony on Tuesday, Dr. Batra told lawmakers that the state needs a state hospital that can treat different types of high intensity patients at one site. In his view, a 48 to 50 bed facility would be the “bare minimum,” based on national and Vermont data and his experience at the hospital. He said the facility should be integrated with a medical hospital and include four-units with 12-15 patients per unit.

Dr. Batra, who was questioned closely by lawmakers, said that a central facility works best because staff can train together and gain the expertise to deal with severely ill patients and patients can get peer support. He also said he felt there was a demonstrated need for 48-50 inpatients state hospital beds.

That view resonated with Donahue, who called the governor’s proposal “untenable” and said it was a “couple of decades behind state of the art” for not co-locating patients in a medical facility. That, she said, “perpetuates the stigma and isolation” mental health patients face.

Donahue also criticized the geographic “spreading around” of patients, which shifts most of the beds to the southern part of the state when she said two-thirds hail from central Vermont and the northern tier.

Becky Moore, a social worker at the hospital who also testified before the mental health oversight panel Tuesday, said after the hearing that the governor’s proposal was “very disheartening” and “ill-advised.”

“I think he’s inadequately informed and and has an inadequate grasp of the most acutely ill of the psychiatric population of the state,” she said.

She said VSH workers were a “well-oiled human hospital machine” with a passion for their work and scattering the workforce was neither cost effective nor the best option for treatment of patients.

Sen. Sally Fox, D-Chittenden, co-chair of the oversight panel, said some of what emerged Tuesday is a “difference of philosophies” between the mental health administration and the staffers who actually work at the hospital on the front lines.

“I think we realize that the state hospital had a place in the system and there’s some different thinking going on,” she said.

The community based system proposed by the governor raises a host of questions. One is what will happen to the 240 state employees who worked at the Vermont State Hospital. They are currently dispersed and working throughout the state at hospitals and other facilities that have taken on acute patients. The governor responded defensively to a question about their future Tuesday.

Conor Casey, government relations director of the Vermont State Employees Association, said he’s pleased the governor wants to move ahead with a state-owned and operated state hospital, but the union has qualms about the much smaller size of the facility, which he said is far from sufficient to care for Vermonters with acute mental illness.

“You’re going to lose a lot of expertise if you choose to privatize the state hospital,” Casey said. “When you have only 15 beds, you don’t have a large enough safety net and you might see … added pressure on correctional facilities as people are rejected from hospitals.”

Casey said lawmakers who will be evaluating the plan need to determine whether the private entities meet the criteria of the privatization contracts under statute. When state employees are replaced by private contracts, the entities are obliged to show that they will provide the same service at comparable cost. Privatization will also likely lead to less transparency as the hospitals and other agencies won’t likely be subject to public records requests, he said.

Another issue is how the administration will move the proposal through the Legislature and how much leeway lawmakers will have to weigh in with their concerns and objections. Deputy Human Services Secretary Patrick Flood discussed with lawmakers Tuesday afternoon, saying he welcomed their input.

Lawmakers will have a say through appropriations via the budget process and also the capital budget, which sets aside money for new construction such as the proposed 15-bed facility in Berlin.

Sen. Fox said there was a clear need to move as quickly as possible considering the stresses on the mental health system, but also noted that any decision would affect care for a long time – Gov, Shumlin said for the next “hundred years.”

“I think the bottom line on this is the Legislature does need to weigh in,” she said.

Editor’s note: Anne Galloway contributed to this report. A write-thru and quotes from Conor Casey were posted at 7 a.m. Dec. 14, 2011.

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