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Challenges Abound for Vermont’s Mental Health Care System Vermont’s Adult Mental Health System of Care



Sunday, September 28, 2014
Randolph — For evidence of the failings and limitations of the network of public and private providers that deliver mental health care in Vermont, look at the headlines.

In recent months, there were stories of the suicide of Vermont Law School professor Cheryl Hanna a few days after she was forced to wait in a emergency room until a psychiatric bed became available in the state’s largest hospital; of a patient kept in restraints for 12 hours at a Bellows Falls mental health facility and coerced into taking medication; of a pair of suicide attempts by teenagers receiving psychiatric care at the Brattleboro Retreat.

For a view of what the state is doing to prevent future tragedies, as well as to improve care and replace a problem-plagued, 54-bed psychiatric hospital in Waterbury that was destroyed by Tropical Storm Irene, look to Act 79.

That law, passed in 2012, put forward a master plan for a comprehensive, humane and efficient mental health care system that encouraged even some skeptics. “There’s a lot good to be said about Vermont’s system,” said Ed Paquin, executive director of Disability Rights Vermont, a nonprofit that represents and advocates for Vermonters with disabilities. “We’re pretty supportive of the direction that Act 79 puts the state in.”

But implementing that plan has proved challenging. Said Julie Tessler, executive director of the Vermont Council of Developmental and Mental Health Services, an organization of 16 social service agencies: Act 79 expressed “a wonderful vision and we are still working on it.”

That work is done every day and night by caregivers around the state, often in the psychiatric wards of hospitals and — less visibly — in local clinics and other community programs.

“People don’t understand what we do,” said Linda Chambers, executive director of the Clara Martin Center, which provides services in Orange and parts of Windsor counties. “We’re doing the heavy lifting with the hardest clients,” she added. “Otherwise, they go to higher levels of care.”

Clara Martin is one of 10 nonprofit organizations tapped by the Mental Health Department to deliver front-line care for mental illness in their communities. Like their counterparts in many states, Vermont advocates and caregivers would like to see the role of large state hospitals minimized and caregiving decentralized and integrated in communities. But as in other states, the shift in caregiving responsibilities to local clinics and programs has rarely been accompanied by a similar shift in resources.

Constrained for revenue, community mental health providers have been hard-pressed to offer competitive salaries. That has made staff recruitment and retention difficult. The resulting vacancies in caregiving positions can translate into extended waits for therapy and other programs. And that can delay the start of treatment for new patients and leave stranded in high-level care facilities patients who have recovered enough to return to treatment closer to home that is less expensive.

The repercussions don’t stop there. When scarce high-level care beds are occupied by less severely ill patients, they aren’t available for those whose needs are desperate. And when care is unavailable from mental health specialists, patients turn instead to hospital emergency rooms and primary care doctors.

The public is likely to notice when mentally ill patients fill waiting rooms in hospital emergency departments. But underlying problems — low salaries, staff vacancies and long wait times for appointments — may not draw much attention.

By comparison, the July 2 opening of the Vermont Psychiatric Care Hospital in Berlin, which Act 79 funded as the flagship of the state’s mental health care network, drew plenty of attention. As he cut the ribbon on the $28.5 million facility, which was designed to meet the needs of some patients with the most severe mental illnesses, Gov. Peter Shumlin proclaimed: “Finally, we can truly say Vermont is protecting and caring for some of our most vulnerable neighbors in an efficient, high-quality building and appropriately treating mental illness like any other disease.”

As of late last week, 21 of the new hospital’s planned 25 beds were available and 18 were occupied, Frank Reed, deputy commissioner of the department, told the Legislature’s Joint Mental Health Oversight Committee.

Act 79 also committed the state to write new rules limiting the use of seclusion and restraints, establish a system for reviewing deaths or serious injuries of patients who had recently received inpatient care, expand its supply of housing subsidies, increase the availability of peer services from caregivers who have experienced mental illness and improve coordination among caregivers, in part by creating an “electronic bed board” to track the availability of inpatient care.

Last but not least, Act 79 included a list of services that the state’s 10 community mental health care centers were expected to upgrade: emergency responses, coordinated case management, adult outpatient care, mobile response teams to cooperate with police and alternative living options.

Vermont’s efforts to shift the locus of care from central state facilities into community clinics and programs correspond to a decades-long, nationwide trend that was fueled by outrage at abuses and warehousing of mentally ill patients in large hospitals.

Federal laws, including the Americans with Disabilities Act, prohibit needless and prolonged institutionalization of mentally ill patients and require that care be delivered in communities or other settings with the fewest possible limitations on patients’ social, personal and economic activities.

‘Cultural Change’

Transforming the vision of Act 79 into reality can’t be reduced to a to-do list. Realizing its promises will require “cultural change,” Paul Dupre, commissioner of the Mental Health Department, told the legislative oversight committee. “Everybody has to change their mentality about how they do business.”

And business takes money. The Mental Health Department’s budget for fiscal 2015 is $217 million, up from $199 million in fiscal 2014. A majority of the department’s revenue comes from Medicaid, the joint federal-state program that pays for health care for low-income individuals and families.

Act 79 repositioned the department within the thicket of Medicaid funding rules and laws in such a way as to boost Medicaid revenue by $45 million, according to Dupre. After allowing for the portion of Medicaid revenue that comes from Vermont taxpayers, the net annual addition of federal revenue was about $27 million, he said.

But don’t expect similar revenue growth in the future, Dupre told several hundred caregivers who attended his department’s annual conference on Sept. 10 in a resort hotel in Killington: “We’ve got to take what we have and figure out how to make it work.”

And sometimes what administrators think they have vanishes. This year, when shortfalls in tax revenue prompted the Shumlin administration to trim planned expenditures by $31 million, about $2 million came from the Mental Health Department cuts: about $1.5 million in reduced Medicaid payments, and $500,000 from community-level treatment programs.

It is no simple task to measure the state’s progress toward realizing the promises of Act 79. Just navigating through the landscape of mental health care services can be daunting for a patient, a patient’s family or even an elected representative.

At a recent hearing of the Legislature’s Joint Mental Health Oversight Committee, lawmakers puzzled over a schematic representation of providers and programs provided by the Mental Health Department, noting that the colorful flow chart did not distinguish services being delivered from items still to come.

Some things were clear. Seven planned intensive residential recovery beds in northwestern Vermont aren’t ready, while a low-medication treatment facility with five beds won’t open until next year. Some promised upgrades to peer support and transportation services also remain in the pipeline.

Meanwhile, Vermont lawmakers must assess the effectiveness and efficiency of the array of mental health care programs, agencies and hospitals that provide outpatient services to 12,000 adults and 10,000 children and operate 186 beds for patients in psychiatric hospitals and wards, 45 beds in intensive recovery residential facilities, 36 beds in crisis residential and hospital diversion programs and 134 beds in group homes

Work remains to be done. Patients still end up stranded in emergency rooms waiting for psychiatric beds to open. “Demand for inpatient care frequently exceeds current capacity,” according to the Mental Health Department’s January 2014 Report to the Legislature on the Implementation of Act 79. “Emergency departments across the state have had to hold individuals needing inpatient psychiatric care while waiting for an open bed.”

There has been some progress this year. Through July, the monthly average number of mentally ill patients waiting at any time for admission to an inpatient psychiatric facility ranged from six to 11, according to the department’s most recent monthly report to the legislators.

In August, after the new state hospital in Berlin opened, the average number of patients waiting fell to four. In March, 58 percent of patients sent for involuntary admissions to hospital psychiatric care faced a wait of more than 24 hours, but by August only 37 percent waited that long.

But averages don’t tell the full story.

In late September, a patient at Rutland Regional Medical Center waited six days for a psychiatric bed, Reed told the legislators. “An unparalleled surge” of seven additional patients briefly boosted the census of those waiting for inpatient mental health care to eight one evening, although all had been placed in psychiatric beds by the next morning, he said.

Holding patients in emergency rooms for hours or days as they await treatment would be seen as “unconscionable” for any but mental illnesses, said Paquin of Disability Rights Vermont. “The system is still not doing everything that it should,” he added. Remaining in an emergency department “can’t be good for one’s psyche,” he added. Patients need “tender, loving care and real medical care.”

Staff Shortages

Even the gleaming new hospital in Berlin remains at less than full capacity due to a slower than expected ramp-up in staffing, so that traveling nurses have been brought in on some shifts, Mental Health Department officials told legislators last week.

The state’s failure to anticipate a nurse shortage at its flagship mental health facility seemed too much for Sen Claire Ayer, D-Addison, vice chair of the oversight committee: “Had no one done the math?”

Reed said the Mental Health Department was “actively recruiting” and that the price tag for using traveling nurses, with an hourly compensation of $54, was not that much more than the $45 hourly rate of skilled psychiatric nurses.

Jay Batra, medical director for the department, said that it was to be expected that it would take time to fill jobs in what is “one of the highest risk environments (where) you can be a psychiatric nurse.”

That made sense to Ayer, a nurse herself: “When the riskiest people in Vermont are in this one confined area, you need the best.”

The system has other limitations, Rep. Anne Donahue, a Northfield Republican, member of the oversight committee and patient advocate, said in an interview. “The problem with access to outpatient therapy has not changed and it is not getting (attention) right now because the inpatient problem” is the main focus, she said. “Unless you’re in an emergency, you can’t get help.”

The Mental Health Department has acknowledged the problem. Waiting times for outpatient treatment “vary from days to several weeks when services may also require medication management,” Dupre wrote in a report issued in July.

Dupre said at the oversight hearing that staff vacancies remain a problem for mental health caregivers. “We do know that there are salary issues,” he said. “We’re still paying pretty low salaries, and that’s part of the problem.”

The issue is an especially tough one for Vermont’s community agencies, where annual salaries are $10,000 to $15,000 lower than those paid by state government and hospitals, Tessler said. That makes employee retention especially challenging.

Turnover has reached an annual rate of 30 percent in some agencies, Tessler said. It is “pretty devastating at times to the people we serve to have turnover like that,” she added.

Upper Valley agencies have not been spared. On Sept. 15, the website of Springfield-based Health Care & Rehabilitation Services of Southeastern Vermont listed 25 individual positions and eight positions for which multiple openings exist. The agency has 650 employees, according to its tax filings.

The Clara Martin Center, which is based in Randolph and has clinics in Bradford, Chelsea and Wilder, employs more than 125 professionals at 11 locations. As of Aug. 8, Clara Martin had posted 15 full-time and eight part-time jobs on the JobsinVT website.

Chambers, the agency’s executive director, said turnover on her staff had jumped to 30 percent in the fiscal year that ended June 30, up from 20 percent in previous years.

Over the last two years, Clara Martin saw six employees leave to take policy or administrative positions at state social service agencies, which, Chambers said, “can offer higher salaries and more benefits.”

Licensed caregiver positions at Clara Martin come with salaries in a range from $34,000 to $40,000, while similar jobs at the state level or in a state program to expand the reach of primary care services may pay $50,000 to $60,000 with better benefits, she said.

At Clara Martin, where salaries and benefits make up 80 percent of the budget, it isn’t possible to cut elsewhere to boost salaries. And with the Legislature holding the purse strings, local agencies remain vulnerable to the budget ax, Chambers said. “Even if we do get a salary increase, within a year or two (legislators) can turn around and cut it.”

Chambers stressed that members of her staff are self-sacrificing and “will break their backs to help people.” That’s why they ought to be well paid, she said: “My job is to make sure that they are treated equally and fairly in what they do.”

Some observers stress that Act 79 isn’t Vermont’s final answer to questions about mental health care. The state still hasn’t “caught up with other jurisdictions” on some issues, said Paquin. For example, the state needs to go further in reining in the use of seclusion, restraints and emergency involuntary medication, which are not treatments but “indications of treatment failures,” he said.

‘Fragmentation’

Other big questions remain.

“Our system is built on the premise and promise of psychiatry,” Sandra Steingard, medical director for mental health and substance abuse services at HowardCenter, a mental health service provider in Burlington, said at the Killington conference. Perhaps there are less expensive and more effective approaches, she said.

And the system remains “fragmented,” she said, so that it is difficult to manage and sometimes subject to “ideological fragmentation.”

And other social services affect mental health care. For example, the state’s foster care program is “grossly underfunded,” said Catherine Simonson, HowardCenter’s director of child, youth and family services. “The current financing structure is so low that it is difficult to recruit foster parents.”

As a result, she said, children that could be cared for by foster parents end up occupying psychiatric beds.

Substance abuse and treatment also affect mental health. The growing population of parents with substance abuse problems or in treatment is affecting the system “in a major way,” Simonson said.

Those aren’t fringe viewpoints. At the Mental Health Department conference, Agency of Human Services Secretary Harry Chen said the state needs to work toward “integrating mental health, substance abuse and physical health. Until we get there, we will not have arrived.”



Rick Jurgens can be reached at rjurgens@vnews.com or 603-727-3229.