Shumlin proposes to decentralize treatment centers to replace Vermont State Hospital

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.

Christine Oliver, Patrick Flood, Rebecca Heintz

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.

Andrew Nemethy

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  • ruth kaufmann

    I’m not sure I understand how this type of plan can be cost effective. With high acuity patients, staffing becomes quite important. We live in a state that has opted for extremely restricted use of involuntary medication. The result is that patients often experience high levels of agitation that can lead to aggressive outbursts. The small facilities proposed by the governor will likely either have to be staffed quite generously or the state will have to accept a high incidence of staff and patient injury… or involuntary medication guidelines will need to be revisited.
    It’s also unclear how a group treatment model can be implemented effectively with a small census of individuals who will likely be dealing with a full spectrum of acute symptoms. This was already a problem at VSH where individual symptomologies frequently clashed. In a small group of extremely diverse highly acute mentally ill individuals, maintaining safety is often elusive; trying to create a therapeutic, open environment of trust is simply unrealistic.
    It’s disheartening that our governor appears so unwilling to listen to the advice of experts who have so much experience and education in the field of psychiatry.

  • J Singh

    I don’t understand how the Governor’s proposal could be more efficient. 5 small units spread apart cannot be cheaper than 1 unit. The decentralization also will mean lack of high degree of expertise that VSH has had. The article mentions the reason for decertification of VSH was “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”. I don’t see how the the Governor’s proposition will help, it would do the opposite.

    Legislation may be necessary, but I would trust patient advocates and physicians who have the experience and knowhow to do it right and aren’t influenced by election years.

  • Eric LeVasseur

    Although it was a positive sign that the governor was not privatizing the mental health system, this plan is ill advised and is merely a poorly constructed band-aid. It is short sighted and all but admits that if the forensic population is increased, then they will be sent to the DOC. It is difficult to understand the shifting of more beds to the south when the population in the north is greater. Making the Brattleboro Retreat a facility that would admit patients that normally would be in the state hospital is a poor one. The location of the retreat and the proximity to New York and Massachusetts will guarantee that those states will “dump” patients they deem to be “problems” into southern Vermont. Setting Brattleboro up as a no refusal facility will require them to take these patients, thus making fewer beds available to Vermonters. If the governor wants to make a donation to the mental health systems of New York and Massachusetts, then he can make a tax deductible donation.

    I agree with Dr. Batra’s recommendations, in that a larger hospital with more units would allow for segregating more violent patients from those in a different type of distress. This would also allow for centralized services, training and treatment, all with a consistent theme. Treatment at the Brooks building was solely the work of the wonderful staff despite our last two governors not seeing the treatment of one of the most vulnerable populations as being important. A new facility, with a less institutional and more therapeutic makeup and enough space and units to provide more targeted care, is the right move. Hopefully our lawmakers will actually listen to people that provide care for these patients, something our governor has refused to do.

  • Cynthia Browning

    I share Rep. Donahue’s concerns about this plan, and I will add a few comments of my own.
    I think that people need to keep in mind that this issue is surrounded by a network of federal rules and regulations that affect operating funds. When the old VSH was de-certified, the state lost Medicaid re-imbursements for treating some of the patients there. I believe that since patients are now at other private facilities, those re-imbursements have resumed. I think that if the state builds a new VSH with more than 15 patients that is not connected to a medical hospital, it will be classified in a way that also limits federal subsidies. So any plan has to be developed in the context of balancing all the money issues with the patient care issues.
    I personally would like to see a new large facility located in central VT or Northwest VT near a medical hospital that would have the depth of staff and expertise that is required for treating the variety of difficulties that patients have. The beds around the state are good, but can each small facility have enough depth of training and expertise? Better community treatment options are good — the problem will be to ensure continuous funding of these programs, because it is easy to make such promises and hard to fulfill them. But I tend to agree with the experts quoted in the piece above: the best thing for patients with the most acute conditions is to have a facility that the state controls directly that can provide the depth and variety of treatment that they need. I would design this facility in a way that would allow for flexibility, so that the different wings or modules could be used in different ways depending on the changing mix of the patient population. I wonder if there would be a way to incorporate a program for inpatient substance abuse treatment at the same facility. Certainly many of those with mental illness self-medicate with drugs or alcohol so this might be a natural fit, and substance abuse treatment programs are needed.
    While the decentralized model in the governor’s plan may be what we have to go forward with coming out of the Irene emergency, it is hard for me to see it as a permanent long term solution. But to do what I would want would likely take more money than is available and it would run into the federal rules again.

    Rep. Cynthia Browning

  • D. Gruss

    It is most unfortunate to think, as I do believe this is the case, that if VSH served a patient population that was not as disenfranchised as the chronically mentally ill, that there would be no hesitation to serve their needs with more urgency, respect, and care.

    I strongly disagree that less beds is what’s needed. On the contrary, we need more and a greater variety of services, namely step-down programming, which works to ensure that when Vermonters come back to their county of residence that they have the greatest likelihood of maintaining their recovery – not to mention that the CHMC’s can work to meet their needs. With CHMC the high caseload rates as they are, with little liihood of decreasing, I don’t see how it is reasonable to assume that case managers can successfully support consumer needs. And, as research shows, the longer we allow individuals with major mental illness, specifically psychosis, to go untreated or under-treated, their likelihood of recovery diminishes. Why add to the problem with a loosely held together system of care, that does not hold itself to a common standard of care – as a variety of providers would bring about – knowing that oversight of this new proposal would be unwieldy at best.

    It is not the bricks and mortar that dishonor the patients, governor Shumlin. The Waterbury buildings, if one were to continue to employ metaphor as rhetoric, are strong, noble, and have shown themselves to evidence the resolve indicative of the rugged Vermont spirit. The facility could be radically improved with the $ 26+ million that is apparently available to devote to the highly specislized care of the mentally ill. It begs the question… Why was it permissable to allow Vermonters to give or receive care in an underfunded and neglected facility … to the point where patients and staff had to suffer – both literally and figuratively?

  • Donna Porter

    I think any time you have a politician making medical decisions is a very scary time indeed. The fact that there will be five regional places to be staffed by people trained to work and care for the mentally ill instead of one centralized place makes absolutely no sense to me at all….

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