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.