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Vt.’s Backup Plan for Brattleboro Retreat Looks Like Post-Irene

The federal government will decide in mid-August if it will continue funding the Brattleboro Retreat. The retreat, the state’s largest private psychiatric hospital, faces decertification because it failed to meet federal standards in a review last spring. If the hospital cannot satisfy the Center for Medicaid and Medicare Services, the agency could terminate Medicaid funding for the retreat or shut down the facility entirely.

Doug Racine, the secretary of the Vermont Agency of Human Services, says if the retreat loses federal funding the state will pay full freight for patients with severe psychiatric conditions, or about $7 million to $8 million a year more for treatment. If the retreat is forced to close, the state will have to rely on regional facilities much like it did after Tropical Storm Irene heavily damaged the Vermont State Hospital nearly two years ago. That’s because the state’s 25-bed replacement facility for the hospital now under construction in Berlin won’t be completed until next year. In the interim, the retreat, which is part of the state’s new regional mental health system, is taking 25 to 30 patients — 10 to 15 more — than the 14 patients the hospital originally planned for. The retreat also provides specialized treatment for children and adolescents who are under the state’s care.

“It’s not as serious as when the Vermont State Hospital closed, but it would not be a good situation,” Racine said.

The Irene floodwaters forced the evacuation of the facility on Aug. 28, 2011, and state officials scrambled to find emergency placements for about 50 patients. Since then, the state has developed a network of regional facilities to care for psychiatric patients. The retreat, however, is the lynchpin for the system, and if it closes, the state would be in a difficult position.

Many more patients would likely seek treatment in hospital emergency rooms, Racine said. As it is, the state’s 14 regional hospitals have seen a spike in the number of severe psychiatric cases this spring, and wait times for treatment have increased significantly as facilities struggle to meet the need.

“If the Brattleboro Retreat is decertified in some way, but continues to operate, we have the option of paying full freight, which is what we did at state hospital for many years,” Racine said. “If the Retreat can no longer take our patients, that’s a different circumstance. The Retreat is unique in that they take patients with limited options.”

Those options include placing patients in “community settings,” such as the state’s new secure facility in Middlesex, Second Spring in Williamstown or a new program run by HCRS in Springfield. Racine says Department of Mental Health officials have been developing a contingency plan with the community facilities, but even though the state has more regional treatment centers online, it’s likely that hospitals will be on the front lines for urgent psychiatric care.

“I think we’d see more people backed up in emergency rooms and that would be a difficult situation as we discovered after Irene hit,” Racine said.

Though the state could make arrangements for some adult patients, Racine said, there is no other residency program that takes children who are involuntarily committed. The state has gone through a planning process with the Howard Center.

“We will continue to convene with them to see if there are options for children if for some reason the retreat can no longer treat children,” Racine said.

Racine said the uncertainty has put the state and the retreat in a difficult position. “We don’t know how Brattleboro Retreat will respond and we don’t know how other states and insurers who have patients at the retreat will respond,” he said.

The state decided to extend its contract with the retreat, which expired on June 30, for three months until the decertification question is resolved.

The Centers for Medicaid and Medicare Services surveyed the retreat last spring after receiving a complaint from a patient who was forcibly restrained, secluded and medicated. Investigators found that personnel were not properly trained. A comprehensive review of the hospital also revealed that 10 randomly pulled patient charts consisted of templates for psychiatric, medical and therapeutic care. Doctors and nurses had not created individual care plans for the patients.

Last month, CMS accepted the retreat’s “plan of correction,” i.e. its proposal for meeting federal standards of care. Officials visited the retreat two weeks ago, and will survey the facility again this month to determine whether the plan has been properly implemented.

Peter Albert, a spokesman for the retreat, told lawmakers last month that the retreat staff has been trained to update patient records, a clinical nurse is overseeing the documentation process, and the risk management director for the hospital is auditing patient charts.

The retreat is also training personnel to handle especially difficult patients who refuse medication. Under state law, psychiatric facilities must have a court order to involuntarily medicate patients.

“You want to create an environment of continuous learning,” Albert said in an interview. “One assumes you strive for perfection, but you don’t always get there but the more you learn the closer you get. So as processes are put in place you include in those processes ways in which how you are evaluating what you’re doing so you can evaluate how you’re doing better. If there is a seclusion and restraint that occurs you follow the policies and procedures, but at the end of it you say to the patient did we do as well could have, could we have done that better, did we miss something.”

The Department of Mental Health sent a quality assurance expert to the retreat in June to help the hospital prepare for the CMS review.

“In theory the plan of correction is an excellent plan, but it’s the implementation on day to day basis — it doesn’t take much to get out of compliance,” Albert said. “It’s a lot of work, and we’ve done it before and I don’t want to mislead anybody. It’s a lot of hard work.”

Last year, the retreat faced a similar situation. CMS threatened to pull funding after a 29-year-old man died of a prescription drug overdose. Regulators found that the retreat did not provide sufficient oversight of its medical dispensary protocols.

“It’s a very high bar CMS has set for proper treatment, and they’re doing everything they can to get there,” Racine said.

When CMS threatened to terminate funding this year, Albert told lawmakers that an influx of state patients — the retreat has taken twice as many patients as it originally agreed to — has made it difficult for the facility to meet federal standards. Patients “in the care of the commissioner,” that is patients who are involuntarily committed by the state to psychiatric facilities, are often more challenging to treat, in part, Albert says, because they can refuse medication.

Brattleboro Retreat officials have, however, for years sought to take state patients. It was only after Irene damaged the state hospital that the Vermont Legislature agreed to give the private facility the lion’s share of state patients.

At a recent Mental Health Oversight Committee meeting, lawmakers expressed frustration with the retreat management. Rep. Anne Donahue, R-Northfield, said in an interview that “they are try to lay it on the new population as opposed to addressing the systems issues that are hospital wide.”

Instead of addressing routine care issues, Donahue says the retreat is blaming the state patients, which make up a very small proportion of the patient population at the retreat. The Brattleboro hospital takes in about 3,000 patients a year; state patients make up about 10 percent of that number.

“What’s scary is they have used it as an excuse for issues that are about a hospital-wide standard of care,” Donahue said. “When the retreat was on a termination track last June, some major areas they’ve been cited for are the exact same ones that were repeated again this year. They had a plan of correction last year, and they repeated same elements in the plan of correction this year.”

Vermont’s Department of Mental Health has struggled to address adequate psychiatric care for patients with a level 1 or acute diagnosis for more than a decade. The Vermont State Hospital was decertified by CMS in 2003 and was not eligible for Medicaid funding for an eight-year period. The cost to the state was $8 million to $11 million per year.