Health Care

New psychiatric facility hasn't solved crisis in care

Vermont Psychiatric Care Hospital

Vermont Psychiatric Care Hospital in Berlin. Photo by Roger Crowley/for VTDigger

[I]t has been a year since the doors of the Vermont Psychiatric Care Hospital opened, adding much needed beds for people in mental health crisis.

The additional space is beginning to show signs of easing the strain on hospital emergency rooms, which since the fall of 2011 have been overwhelmed by psychiatric patients. A recent report from the Department of Mental Health shows the number of psychiatric emergency room visits is on the decline.

“We have seen noticeable improvement,” said Frank Reed, interim commissioner at the Department of Mental Health (DMH).

How did Vermont get here?

The mental health care crisis in Vermont didn’t begin with Tropical Storm Irene, it began with a federally sanctioned facility in Waterbury. Vermont had begun contemplating reforming the mental health care system for a good decade before the storm shut down the state-run hospital.

Vermont was already in the vanguard of a national decentralized movement that shifted care from large state-run facilities to community settings. By the mid-1960s, Vermont had nine community mental health centers and one state hospital reserved for patients in the “greatest need category,” as Rep. Anne Donahue, R-Northfield, describes them.

When federal investigations of patient deaths, loss of federal funding and lawsuits focused attention on the problems plaguing the state hospital in Waterbury, Donahue was among those lawmakers looking for solutions. They explored what became known as "The Futures Plan," which at one point looked at Fletcher Allen Health Care (now UVM Medical Center) as a central location for psychiatric care. That idea fell through.

“There was a lot of effort going into trying to implement this [Futures] plan but it hit all the traditional roadblocks,” Donahue said.

Vermont is a forerunner so there were no other states to look to for ideas. “Vermont had the lowest number of people in the state hospital in the country and had the highest investments in community services. We were avoiding the more expensive hospital care for people who didn’t need it,” Donahue said.

The question became when would Vermont hit the point of no return -- when do you need to stop putting more effort into community support while subtracting beds? Right about the time policymakers were fixated on this issue Tropical Storm Irene swept through the state, forced the closure of the state hospital and created a crisis that left no room for discussion.

“Suddenly, the ability to have an engaged debate about the real needs and how many beds went right out the window because all the sudden the situation was dire,” said Donahue.

It wasn’t long before new theories entered the debate, one was the idea that if “we created diversion beds, crisis beds or improved one program or another then we wouldn’t need these level 1 beds,” according to Dr. Robert Pierattini, chair of the Department of Psychiatry and physician leader at UVM. As it turned out – this theory was wrong, he said.

“We lost level 1 beds and we built something else instead and that is not what we needed. The community mental health system delivers a lot of good care and because it’s so good we hospitalize people at a lower rate than other states. But this doesn’t mean that we don’t have a core need for a tiny number of people to receive secure inpatient care,” Pierattini said.

Driven by the urgent need left in the wake of Irene, Gov. Peter Shumlin proposed a regionalized system of care and a much smaller state hospital. Federal funds had been loosened for Vermont to rebuild and because the governor wanted to stay within the parameters for reimbursements from the Centers for Medicare and Medicaid Services, he proposed first a 14-bed facility at the Brattleboro Retreat and a 16-bed centralized hospital to replace the previous 54 beds. Eventually, another six beds were added at Rutland Regional Medical Center.

“Instead of our reforms working through the legislative process it became the Legislature reacting to the governor’s plan – and we needed to react within months,” Donahue said.

The majority of patients were receiving care at regional hospitals and only the most acutely ill were using the state hospital before it closed. But she argued that Vermont had hit the threshold and breaking things down more would mean losing economy of scale.

“You would never put a burn unit in every hospital just so the patient would be closer to home,” Donahue said.

Pierattini agrees and says Vermont was not a good candidate for regionalization. It would require offering 24-hour, seven-days-a-week treatment at more than one site. During the Futures planning process this concept had been deliberated and rejected.

“We were concerned about cost … we were concerned about the integration of mental and physical care,” Pierattini said.

Another consideration was that unlike other states, Vermont doesn’t have a forensic hospital for mentally ill patients from the correctional system. It isn’t always safe to mix these patients with the general population patients.

The state created temporary housing in Middlesex for forensic patients, and it is now looking at building a permanent secure facility.

Vermont is also different in that if a patient refuses to take medication and the doctors have to get court approval then the patient often waits a very long time without treatment.

The governor's proposal would have served a varied, acutely ill population with 18 fewer beds than the state hospital. “At 54 we were already running into emergency room delays before Irene,” said Donahue. “So the Legislature pushed back and pushed back and through negotiations ended up with 25 beds instead of 16.”

While Rep. Anne Donahue, R-Northfield, isn’t ready to pour the foundation for a new hospital, she does think a serious problem exists. “We put a solution together but we still have a big chunk of the problem, even if it is less than it was two years ago. In theory it should have been solved,” she said.

A majority of patients waiting for a bed have been placed within 48 hours of arriving at an ER, according to the report filed with the Health Reform Oversight Committee. While from July 2014 until March 2015 there were still too many patients sitting in the state’s ERs for too long, the report indicates that the trend began to taper off in April and May. Reed said that not all the new beds were available until February.

“Even looking back to June 2014 – about 48 percent waited less than 24 hours and 19 percent had no wait time. Right now, about 58 percent wait less than 24 hours and 30 percent have no wait times,” Reed said.

But advocates for mental health patients and health care workers say more beds for acute care are needed.

The latest report identifies a core group – 25 percent of the most acutely ill patients -- who find their way into Vermont’s emergency rooms and continue to wait longer than 24 hours.

Dr. Peter Weimersheimer, chief of the ER at the University of Vermont Medical Center, said the hospital recently held a patient in the Emergency Department for 130 hours because there were no acute level beds available.

“The long and short of it is that there isn’t a level 1 bed anywhere in the system that can accommodate this person,” Weimersheimer said.

Doctors say they continue to be troubled by what they see as a lack of progress.

“The system just doesn’t work anymore,” said Dr. William J. Nowlan, who has worked in Porter Medical Center’s emergency room in Middlebury for nearly two decades. “The new state hospital has clearly met a need but it has been maxed out.”

After the former 54-bed Vermont State Hospital in Waterbury was damaged by Tropical Storm Irene in August 2011, the Shumlin administration opted to create a decentralized system of psychiatric care with three smaller acute care facilities instead of rebuilding an equivalent sized psychiatric hospital.

The Vermont Psychiatric Care Hospital (VPCH) in Berlin opened a year ago with 25 acute care, or level 1, beds for patients in severe psychiatric distress. The decentralized state system includes five other hospitals with 188 inpatient psychiatric beds, of which 45 are set aside for acute care.

The Brattleboro Retreat has 14 beds and Rutland Regional Medical Center has six more. Both are meant to buttress the Berlin facility’s 25 beds. In all, there are nine fewer acute care beds now than there were before 2011.

Donahue, the ranking lawmaker on the House Committee on Health Care, says that in a practical sense there is a greater disparity in acute bed availability.

“Even though on paper it says there are 25 beds, often we have fewer because they aren’t admitting any more patients,” Donahue said.

The hospital is obligated to provide safe care on the unit and if they have a severely ill patient or a violent patient they can’t operate at capacity, she said. Also, not all the facilities offering level 1 beds are equipped to care for patients with medical and psychiatric needs, meaning more beds are taken offline.

There are staffing problems, too, as not all hospitals have a psychiatrist on staff or available 24/7 -- consequently, the doctors are shared across the regionalized system.

“Often we hear from a facility with an available bed that they don’t have the staff” to take on one of the patients in Porter’s ER, Nowlan said, or they say that “'this patient would be a bad mix with our patients.' I’m not making this up. This is a common thing.” Nowlan added that since Jan. 1, the Porter ER has had 19 involuntary patients that typically stayed for several days. “Our record is 20 days,” he said.

Not good enough

Jack McCullough, an attorney with Vermont Legal Aid who represents people with mental illness, said that the system of care isn’t good enough. Even if the “majority of people wait for under 24 hours, there are still people waiting for days.”

Jack McCullough of the Mental Health Law Project speaks about Taser use by law enforcement as Allen Gilbert of the ACLU looks on. VTD Photo/Taylor Dobbs

Jack McCullough. File photo by Taylor Dobbs/VTDigger

He cites a case this year in which a person was stuck in the emergency department of a general hospital for almost a month. It was an involuntary treatment case and the patient didn’t see a psychiatrist because there wasn’t one at the hospital.

“He was basically just locked up,” McCullough said, adding that it’s a violation of the patient’s liberties. “It takes a lot to justify keeping someone locked up and if you are going to hold them in a place where they are not getting real treatment for their condition – I think we have a very serious problem,” he said.

Weimersheimer said patients are floundering and “they are not getting the care that medically they should be getting for their condition. Having someone sitting in our ER for a week waiting for a bed is hard to take.”

Doctors say the ER rooms patients end up in often have no natural light and some don’t have doors; there isn’t a bathroom or food service. In many cases they have a minder watching every move they make 24/7.

“We are a small community ER is boarding some of the sickest mental patients in the state,” Nowlan said.

He ticked off a list of disruptions that occur when such a patient arrives in the emergency room – they have to get a sheriff’s deputy onsite, at least one nurse must be taken off the floor to work with the patient, and staff works in an atmosphere of minute-to-minute crisis control. This continues until an appropriate hospital or bed can be found, Nowlan said.

Sadly, Nowlan said, the sicker the patient is, the harder he or she is to place.

“It is, at times, cruel and unusual treatment for this patient. The system is broken and the thing that is discouraging is that it doesn’t seem like anyone is accepting that or working very hard to fix it,” he said.

McCullough, who advocated for more level 1 beds during legislative deliberations, said that the shortfall is a problem.

“There was a time before Waterbury closed when it was really rare for people to be waiting in the ER for any time at all. They would be taken almost immediately to Waterbury or one of the other psychiatric hospitals and be admitted,” he said.

Still more beds needed

In January, DMH reported to the Legislature on the implementation of Act 79 – the 2012 health care reform law – that “demand for inpatient care frequently exceeds current capacity.”

Since Vermont’s mental health treatment system became decentralized, “placement considerations have become more complex,” according to the most recent DMH report. Part of the reason some patients are experiencing lengthy waits is because other complex cases are remaining in acute psychiatric beds for long periods, creating a bottleneck.

The Vermont Medical Society, which represents 2,000 practitioners, is challenging the state to add more beds and decrease wait times to six hours.

“The mental health system in Vermont should have sufficient capacity to ensure that patients with mental illness do not wait for hospital admissions longer than patients with other medical issues,” said Dr. David Coddaire, the society's president and a family physician at the Morrisville Family Health Center. The Vermont Medical Society also wants to see the most acutely ill patients prioritized so they are not waiting longer than patients with less severe illnesses.

“There needs to be a priority as to how to get patients into the system and treated in a timely manner. Right now the default is to hold them in the ED. Clearly, there is not enough space for our current population,” Weimersheimer said, adding that more staff would also be needed to tend to any additional beds at psychiatric facilities.

Frank Reed, the DMH commissioner, stands by the decision to fund 45 beds.

“We are within range to make the 45 beds work. It is getting that flow fine tuned. It’s a little premature to say we don’t have enough,” he said.

Frank Reed, deputy commissioner of the Vermont Department of Mental Health. Photo by Roger Crowley/for VTDigger

Frank Reed, interim commissioner of the Vermont Department of Mental Health. File photo by Roger Crowley/for VTDigger

The emphasis, Reed says, needs to be getting long-term patients back into the community more quickly.

Donahue agrees that the system hasn’t been fully vetted, but she still thinks it’s a good time to start contingency planning.

“I think we probably reached the lowest point we could get in patient care and the expectation that we could reduce it more and still meet the needs for inpatient care was overly idealistic,” she said.

Vermont should be thinking ahead and building capacity as the population grows and new issues like drug abuse continue to rise and add to the state’s mental health treatment needs, she said.

Vermont isn’t alone. Mentally ill patients are stuck in ERs for extensive stays across the nation.

“There is a well-documented crisis in the lack of acute inpatient or crisis stabilization services for people experiencing psychiatric emergencies or urgent need. This has contributed to the problems with ‘psychiatric boarding’ in emergency rooms,” according to the National Alliance on Mental Illness.

The same organization says that when large numbers of people in psychiatric crisis are filling ERs it is evidence that the mental health system is broken.

Rep. Anne Donahue, R-Northfield (seated).  File photo by Andrew Nemethy for VTDigger

Rep. Anne Donahue, R-Northfield (seated). File photo by Andrew Nemethy for VTDigger

For years, other states have been experiencing this problem even though they have more beds per capita than Vermont does, Donahue said. “We always looked at them and thought how could they be doing something so terrible,” by allowing their mentally ill to board in their ERs.

At the same time, the Great Recession has forced more than half of U.S. states to close state hospitals and shed 3,222 level 1 beds, according to the National Association of State Mental Health Program Directors. They report that fiscally pinched states chose to focus their spending on protecting community based services to the detriment of state hospitals.

Dr. Robert Pierattini, chair of the Department of Psychiatry at the University of Vermont and leader of it at UVM Medical Center, testified before policymakers during Act 79 deliberations and advised them to add more beds. While he recognizes there has been some improvement since VPCH opened, Pierattini says that Vermont has always been very conservative about hospitalizing patients as compared to other states. “So tightening the number of beds had a bigger impact here than it would have in other places.”

Vermont is unique nationally, according to Pierattini, because it has very liberal patient first medication and hospitalization policies that require court approval for patients that refuse treatment. That makes Vermont an “outlier” compared to other states.

“If you have laws and policy that allow people to determine the course of their own lives as we do in Vermont there will be an irreducible number of people that make choices that lead them to acute mental illness. I think given what we are seeing in the emergency departments we probably have fewer beds than that irreducible number,” Pierattini said.

McCullough says patients’ right to refuse medication is not significantly contributing to the problem. “It is always going to be true that there are people who may go into crisis and wind up hospitalized as a response,” he said and added that when the courts get involved things happen “very quickly.”

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