Commentary

Patrick Flood: Community mental health system strained

Editor’s note: This commentary is by Patrick Flood, the former commissioner of the Department of Mental Health, the Department of Disabilities, Aging and Independent Living and former deputy secretary of the Agency of Human Services. He recently retired from Northern Counties Health Care.

In a recent VTDigger article, several legislators expressed concern about the adequacy of the mental health system in Vermont, and in particular, the number of psychiatric hospital beds. While there is good reason to reassess the adequacy of mental health services, looking at the number of acute care beds is likely missing the forest for the trees.

First, it needs to be stated clearly that Vermont has more, not fewer, treatment beds for persons with mental illness than when Irene struck. The Vermont State Hospital had 54 licensed beds then, and 52 were full the night Irene closed the hospital. Not all of those beds were being used for acute care. Seven or eight were being used by persons who had been at the state hospital for years. Another 10 or so were occupied by persons waiting for a community placement. In effect, Vermont really had only about 35 beds available for acutely ill, what we now term “Level I” patients.

Those beds were replaced by 45 new Level I beds: 25 at the new state Vermont Psychiatric Care Hospital, 14 at the Brattleboro Retreat, and six at the Rutland Regional Medical Center. In addition, seven beds were added for the long-term placements at the temporary secure residential facility in Middlesex. There was additional growth in crisis beds from 29 to 40, and in residential treatment beds for post-hospital care, from 20 to 40. A five-bed Soteria House, an alternative to hospital care, was also added.

So, the number of treatment beds actually increased. Yet there is no question that people with mental illness continue to experience stays in emergency rooms. So what is the problem?

The real problem is that the community mental health system is strained to the breaking point. This is very important because the community mental health system is there to help support people and prevent them from having crises, which then very often result in a need for hospitalization. The mental health agency staff are doing great work every day, but they struggle to meet the need. There is stark evidence of the problem in the documented fact that across the community mental health system there is a 20-25 percent turnover rate. This is primarily because the agencies cannot pay the staff enough to recruit adequate qualified personnel or to retain them. Often staff leave the community system to go to work for the hospitals or the state agencies where they can make significantly more money. There is also a much greater need for services than the agencies can meet, leading other persons to go into crisis and require treatment. Without a stable workforce of competent and experienced staff, the community mental health system is unable to meet the need. One result is that people unnecessarily end up in crisis and needing hospital care.

The system needs different overall management to make the best use of bed space. As the CEO of the Brattleboro Retreat said last year, Vermont does not really have a system of mental health care.

 

There are other issues the Legislature should assess.

The Legislature should assess the impact of the Kuglioski case, as mentioned in the VTDigger article. Asking mental health agencies to take on a greater level of risk, even as they remain understaffed, is unreasonable and will fail. The Kuglioski ruling is causing both hospitals and agencies to take the safe approach and keep people in the hospital longer.

The Legislature should also assess how beds are being utilized. There are 188 psychiatric hospital beds in Vermont (including the 45 Level I beds). On any given day, according the statistics from the department of mental health, about 15 percent of all psychiatric beds remain empty while people wait in emergency rooms. In addition, some people are staying in the hospital for long periods of time. The system needs different overall management to make the best use of bed space. As the CEO of the Brattleboro Retreat said last year, Vermont does not really have a system of mental health care.

There is another significant factor we have not addressed. Most of the individuals with acute mental illness have suffered trauma which either caused or exacerbated their mental health issues. Unaddressed trauma can result not only in mental health problems also lifelong chronic disease such as heart disease or diabetes. The costs are enormous. Until we as a state address trauma and its devastating impacts, we will continue to see health and mental health costs increase.

More acute psychiatric care beds are an expensive approach that will not really solve the problem we face. We need a stronger and expanded community mental health system that is able to address trauma if we ever expect to successfully and cost effectively address health system costs.

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  • Ethan Rogati

    I know someone who works for one of the community mental health agencies. A large part of that agency’s turnover is that they train their people very well and support higher education for their people. So, they have well qualified personnel that are then headhunted by other agencies and entities who can pay more because they don’t put the same effort into training.

    They’re not going to change their policy of having well-qualified, well-trained staff, but perhaps they should be helped with funding so they can afford to keep those staff.

  • Alan Lampson

    We also need to take into account the harm that is done to a patient every time they decompensate and have to receive acute care services. The harm includes the stress of a new living situation, being cared for by people who might be strangers, the possibility of being farther away from loved ones, being put on new or additional medications. Think about the last time you might have been in the hospital and how stressful that felt and then consider a psychiatric patient who faces limits to their autonomy while in the hospital and uncertainty about when they will be able to leave. This is also very stressful for the family and friends of the patient. As Mr. Flood says the solution is not more acute beds, although there will always be a need for acute beds, but more community services to prevent as much as possible the need for acute services. More community services mean more money, federal and state. And it also requires more understanding from society, and more compassion.

  • Grant Morrison

    I worked in community mental health for a number of years. My one comment is good luck getting agencies committed to improving the welfare of their staff. FLSA was a well-intentioned attempt to prevent these agencies from paying employees a salary and then forcing them to work more than 50 hours a week. However, now employees have their hours restricted as to avoid violating the law.

    The job is a never ending cycle of meeting ridiculous productivity hours and note keeping so the agencies can farm medicaid. In addition to paying a pitiful wage, agencies offer no competitive leave time, no tuition reimbursement, a pathetic healthcare plan, and no assistance in gaining licensure. While at the same time administrators are paid six figures to do nothing but maintain the status quo. Any job in or out of mental health seems reasonable by comparison. What motivation is there to get licensed and stay at a place that feels no obligation to be civil to it’s employees?

    • Lisa Nicholson

      Not sure where you worked but the Designated Agencies I know, while not paying as much as inpatient hospitals, provide excellent benefits including vacation time, personal time, health ins as good as any you can get, reimbursement for licensure expenses and paid continuing ed.
      It is backwards, if vermonters truly support community mental health treatment, to pay staff in inpatient settings $10,000. more per year….

      • Grant Morrison

        Yeah. Well I guess I’m not sure what you would consider “excellent benefits”.

        I will admit that there is a difference between designated agencies in terms of benefits and pay provided. For example, Some agencies give an annual raise. I got one raise in eight years.

        The larger point is there’s no commitment to invest in clinicians or staff that I have seen. It’s obvious to everyone except the people in charge. As employees leave to get better jobs a greater responsibility and workload is put on those that stay. It makes more sense to go into private practice out of school than bother with community agency dysfunction. The administrators are so out of touch they can’t see or refuse to see what the problem is. If it wasn’t so tragic it’d be laughable at how these administrators are baffled as to why they can’t fill open positions. It’s as if they genuinely believe they’re providing a position competitive with what’s out there.

  • Curtis Sinclair

    Great commentary. It makes the points I have been making is responses to mental health articles. I also want to point out that one of the traumas that mentally ill people suffer is actually the treatment they get from the mental health system when that treatment is involuntary. I don’t think most people have any idea how horrific the process is. Patients get locked up for indefinite periods with no chance to make bail. They are then forced to talk to psychiatrists who probe into ever detail of their personal lives. These ‘doctors’ then testify in court about such things while often misrepresenting many details or outright lying about things. But their view is that their testimony is only an opinion and an opinion cannot be a lie. The after this kangaroo court the patients are held down and forcibly injected with mind numbing drugs that have terrible permanent side effects that include brain damage. The state really should consider eliminating involuntary treatment.

  • Jean Copeland

    I have Major Depressive Disorder. Current and former generations of my relatives have been treated in Vermont for other Serious Mental Illnesses (SMI) including schizophrenia, bi-polar, and post-partum depression as well as addiction. Waterbury State Hospital was the permanent home for at least one of us and temporary home for several. We continue to use community mental health services. Today, there is noplace for us (the population with SMI) to live long-term with the help we need, once we reach adulthood and leave the family home. The state expects us to live alone, keep an apt.,pay bills, shop and cook, get our prescription refills have friends, work/volunteer, to live like normal adults. But we can’t! Part of living life with a broken brain means needing people to live with, help keeping a routine, Help staying motivated to get out of bed, encouragement to take our daily meds, someone to make meals, just a room to clean, not a whole apt., We are easily overwhelmed.