Editor’s note: Floyd Nease is executive director of the Vermont Association for Mental Health and Addiction Recovery.
The public discussion about how Vermont should replace the Vermont State Hospital has focused – to the exclusion of almost everything else – on the size of the Level 1 facility that will be built in central Vermont. In the end, the House settled on a building for 25. The Senate and the administration settled on 16. There will be a conference committee to hammer out a compromise.
Lost in these discussions is the fact that the administration’s plan does not replace the original 54-bed capacity at VSH with 16 beds. Prior to Irene, in addition to VSH, there were 175 beds around Vermont for people whose mental illness required overnight care, but did not rise to needing Level 1 care. So, while it is true that the plan would build 12 fewer Level 1 inpatient hospital beds, it is also true that the plan increases overall community capacity by 25 percent.
There are two reasons why a person might need a Level 1 bed. The first is that he or she is suffering from an episode of mental illness that requires the safety and expertise that can only be found at a Level 1 facility. The second is that he or she is suffering an episode that could be cared for in a less restrictive community-based setting that is unavailable. Both situations put people in Level 1 facilities. The first reason should. The second shouldn’t. The administration’s plan to increase community capacity while lessening dependence on Level 1 inpatient care goes a long way toward eliminating the second reason.
Also lost in all the talk about the number of beds has been the fact that the new system, instead of being anchored by an antiquated and uncertifiable 54-bed state hospital, will be anchored by a comprehensive care management system. Done right, care management works to prevent people from having to go to the hospital in the first place, diverts them from the hospital whenever it is clinically appropriate and, when Level 1 care is required, sees that people are discharged to community-based resources as soon as it is clinically indicated. This is an entirely new approach in Vermont which, if executed well, will allow for a better experience for those Vermonters and a much more effective use of both inpatient and community-based resources.
Among other innovations, the newly configured system increases the use of peers – people who have lived experience of mental illness – as supports in both inpatient settings and the community. There is a growing body of clinical evidence that peer support increases the effectiveness of care no matter in what setting it is applied. The plan also increases community-based crisis bed capacity by more than 20 percent and available intensive residential recovery capacity by 150 percent. These are significant enhancements to the system, each of which will decrease the need for inpatient beds.
Recently, there has been discussion about whether or not we can afford to build a facility for 25 given the fact that, so far, the federal government has said it will not pay for anything larger than 16 unless it is part of a medical center. If this was any other disease, this wouldn’t even be part of the discussion. Since it is, however, I believe smaller (and coincidentally more affordable) is better, as long as those in the smaller facility have near immediate access to regular medical care. It is better because there is a growing body of empirical data that community alternatives to institutional care are far better for those receiving the care.
In the final analysis, the debate about 16 vs. 25 will diminish in importance because the enhanced community resources and the new care management system will be in place long before a shovel goes into the ground for the new facility. It will be much clearer in a year or 18 months from now how much inpatient capacity is necessary in the new system. With time, we will have real numbers on which to base the final decision. For now, which number prevails is more about the political tug of war between the administration and the legislative chambers than it is about clinical need.
