Vermont Ramps Up Community-Based Mental Health Support
When floodwaters from Tropical Storm Irene forced the closure of the 54-bed Vermont State Hospital in 2011, the state’s mental health care system found itself in crisis.
Some, however, saw it as an opportunity.
“It forced us to look at what we really need across the state,” said Linda Chambers, executive director of the Clara Martin Center, a mental health organization in Randolph.
The hospital, built in 1891, had been falling apart for years and was decertified by the federal government in 2003. But the problems facing mental health went beyond decrepit physical infrastructure.
What the state really needed, lawmakers and health policy experts determined, was a system that placed less emphasis on inpatient care and gave more support to a community-based approach, one that would reach Vermonters with mental illness before their conditions deteriorated to the point where they would need to be hospitalized.
Many parts of the plan legislators passed last year, Act 79, adopt that strategy and have already been implemented. The state has set up a management system to track patient progress and help clinicians in the field. Construction on a new 25-bed hospital in Berlin to treat the most severe “Level 1” patients began in January and the facility should open next year. Smaller inpatient units at the Brattleboro Retreat and Rutland Regional Medical Center are planned. And less intensive “stepdown” programs are rolling out across the state, aimed at helping mental health patients transition back to functioning lives within their communities.
Health advocates believe these changes will be more cost effective and also provide better care for the mentally ill.
But not everyone is convinced these efforts will be enough, and as the state builds out this infrastructure, hospital officials say their resources have been stressed to the limit, often serving as mere holding tanks while the mental health system catches up with demand.
“We are still in crisis mode,” said Robert Pierattini, a psychiatrist at Fletcher Allen Health Care in Burlington and chairman of the Department of Psychiatry at University of Vermont’s College of Medicine. “If anything, it’s actually worse.”
The instances when beds are unavailable when needed for involuntary admissions — typically, the most severe cases — has been on the rise, according to a January report from the Department of Mental Health. Between April and June last year, there were delays in admitting patients 19 percent of the time. Over the next three months, admissions increased slightly but the delays more than doubled, occurring 42 percent of the time, according to the report.
The number of patients who left the hospital but had to be readmitted also increased during that time, going from 2 percent between April and June to 10 percent between July and September.
Fletcher Allen was among the hospitals that agreed temporarily to take on some of the patients from the old state hospital.
A year and a half later, Fletcher Allen’s 16-bed secure unit for the most challenging psychiatric patients is almost always full, Pierattini said. Many have arrived at the emergency department, and once placed in a room, require monitoring and an intense level of care. Some have been disruptive and even threatening, he said.
“Some people are just loud and interruptive,” he said. “Some are threatening. Some are aggressive. They may attack staff. Some people are suicidal.”
These are not patients who can be treated in outpatient settings based in a community, Pierattini said. They require acute care in a hospital, and the number of beds Vermont is planning to build won’t be enough to accommodate the anticipated need.
The new Berlin facility is less than half the size of the 54-bed state hospital it will replace. Other Level 1 units are being established at the Brattleboro Retreat and at Rutland Regional Medical Center, bringing the statewide total to 45 beds, but still nine fewer than the state had before Irene.
“I’ve never thought that enhancement in community (outpatient programs) would reduce the need for hospital beds,” Pierattini said.
“People requiring involuntary admission are people who can’t be treated in the community. ... This is a level of illness that requires what hospitals provide.”
Linda Minsinger, vice president of Gifford Medical Center’s hospital division, also wonders whether Vermont is planning to build enough Level 1 beds. The need for them had been increasing for years, she said.
“I think that outpatient community mental health is excellent. ... But there are inpatient needs for people to be safe and inside,” she said. “Not everything can happen outpatient and that’s the balance we need to figure out.”
The state’s Department of Mental Health has acknowledged the challenges in meeting inpatient care. The demands for those beds often exceed the existing capacity, according to the department’s January report. However, state officials and the community based agencies say that could change for the better as Vermont builds out its revamped system.
“The reality is that you’re not going to be able to know until some of these other places come along,” said Chambers, of Clara Martin.
Department Commissioner Mary Moulton said the 25-bed hospital, combined with the other inpatient beds in Rutland and Brattleboro, should be adequate to support the number of patients needing hospitalization for severe mental health needs. Nearly half of the 50-plus patients at the state hospital before Irene hit could have been treated in less intensive environments, Moulton said, which is why the state opted to build a smaller hospital.
“With the number of alternative community settings ... the determination was that the number 25 would be a number that would sufficiently” meet the acute need, Moulton said.
The department has set up an “electronic bed board” that is updated daily to track and help manage the patients who need to be hospitalized. Moulton knows hospitals have been struggling, but said that expanding the number of inpatient beds over the next two years should alleviate the pressure on the system.
Vermont’s emphasis on outpatient services existed before Irene.
The state historically has been below national averages in its reliance on its state hospital to treat patients with mental illness.
It is also well above national averages in the number of residents who are treated in the community, with 38 out of every 1,000 Vermonters served, according to the report. Nationally, the average rate is 21 out of every 1,000 people.
Regardless of what happens with inpatient hospital demand, there are other issues that Act 79 doesn’t address.
There are not nearly enough psychiatrists in the state to offer outpatient services and work with primary care doctors in developing treatment plans for patients, hospital officials said.
Mt. Ascutney Hospital, for example, contracts with an outside agency to provide psychiatric services five days a month, said Cathy Schneider, the Windsor hospital’s chief medical officer. It helps a little, Schneider said, but is not nearly enough to meet demand in Windsor.
“It’s not a robust service,” she said. “We don’t have really good psychiatric services. We’re just barely maintaining the bare minimum.”
There are also delays in getting court orders to treat patients who have been involuntarily hospitalized but refuse medication, said Pierattini, of Fletcher Allen.
In Vermont, no person may be medicated involuntarily without court approval. But getting this court approval can take weeks or even months. Last fiscal year, it took an average of 53 days to get court approval to treat such patients at Fletcher Allen, Pierattini said. That is 53 days in which the patient is just sitting in a hospital bed, not receiving treatment.
“They’re taking months and months to do the review and make a decision,” Pierattini said.
Lawmakers will meet in November to review the progress being made on Act 79 and, in particular, plans for the buildout of the Berlin hospital, Moulton said. They may open with only 16 beds to start and then phase in the remaining nine beds over time. But that will depend on what happens with the inpatient demand over the coming months.
Minsinger says hospitals have been caught in the middle of the state’s revamping of the mental health system. But she hopes it won’t stay that way.
“I think it’ll get better,” she said. “I think we’ll find there is some relief.”
Chris Fleisher can be reached at 603-727-3229 or firstname.lastname@example.org.