As Mental Health Care Evolved, State Resources Fell Behind

(Editor’s Note: This article was published July 20, 2015. It’s part of the Uneven Efforts​ series.)

The movement of mental health care out of large institutions and into communities has been underway for decades in both Vermont and New Hampshire. After an initial surge prompted by the availability of new medications and public outrage over bad conditions in big hospitals, the “deinstitutionalization” push has since been propelled by a desire to treat patients near their homes and federal policies that supported community treatment but not large hospitals.

But hospitals have shrunk faster than community services have grown, leaving patients, families and advocates to demand more and better care and beleaguered state governments to perform the necessary budget magic. Only rarely have sufficient resources been produced to perform the tasks at hand.

The subsequent debates about the adequacy and costs of mental health care in Vermont and New Hampshire have percolated through a succession of lawsuits, study committees, legislative panels and regulatory proceedings.

Some elements of the mental health care landscape have changed in recent years. After Tropical Storm Irene destroyed its main state mental hospital in 2011, Vermont passed Act 79, a mental health care reform law. Last year the state opened a new 25-bed hospital for the most seriously mentally ill patients. New Hampshire added some inpatient psychiatric beds for the seriously ill, and agreed to settle a civil rights lawsuit by patients and advocates. But the contours of each state’s approach to mental health care reform have taken shape over decades.

In New Hampshire, reforms began at least as far back as 1981, when a federal judge ordered the state to stop unnecessarily keeping patients in large institutions and develop community clinics and services. A year later, a state study committee on mental and developmental disabilities reported to the governor that “the heart of any statewide mental health system is the community” and called for downsizing the state mental hospital.

That approach was written into state law in 1986, and the state expanded community treatment and residential services. The state built a new but smaller mental hospital, contracted with Dartmouth Medical School to provide psychiatric care and developed new programs to expand employment, housing and therapeutic supports available to patients. By the end of that decade, New Hampshire had been recognized by the National Institute of Mental Health as a leader in providing care at the community level.

Robert Drake, a psychiatrist at the Dartmouth Psychiatric Research Center in Lebanon who from 1984 until 1990 was medical director for West Central Behavioral Health, a Lebanon-based mental health provider, said that during his tenure it was unheard of to hold patients in hospital emergency rooms until psychiatric care became available.

New Hampshire was in the vanguard because of strong leadership and a willingness to innovate, said Sita Diehl, state policy and advocacy director for the National Alliance on Mental Illness. But the state proved unwilling to commit the resources to sustain those advances, she added.

That prompted a re-evaluation of the state’s efforts. In 2008, a task force of health care professionals, advocates and state officials looked at the state’s mental health care and “identified recommended services that were never implemented, the erosion of mental health services over the past 15 years and a growing state population with related rising demands for mental health care.”

“New Hampshire’s mental health care system is failing,” state Health and Human Services Commissioner Nicholas Toumpas said after the report was published. The “broken system” was putting strains on law enforcement, hospital emergency rooms, courts, county jails and patients and their families, he added.

The report included a so-called 10-year plan that called for the state to add to its inventory of inpatient psychiatric care beds in community facilities, create teams of caregivers to provide out-of-clinic treatments to some severely ill patients and spend more to provide housing for patients and better pay and training for caregivers.

Once again, New Hampshire had charted a course toward reform.

Vermont set out on its own path. The state can plausibly claim to have been on the road to deinstitutionalization since 1953, when a state panel considering a proposal to expand the flagship mental hospital in Waterbury recommended that community programs be added instead. In just over a decade, nine community mental health centers had been established around the state.

With community clinics in place, the patient population at the large state mental hospital in Waterbury steadily declined, from 1,243 in 1965 to 161 in 1988.

Yet conditions in the facility worsened. A 1986 inspection by federal Medicare officials led to decertification of that hospital and a 16-month shut-off of federal reimbursements for care there. Inspections in 2005, 2009 and 2010 had similar outcomes.

Meanwhile, a U.S. Justice Department investigation of the hospital led to a 2006 lawsuit alleging the state was “egregiously and flagrantly” violating the rights of patients by denying them adequate diagnostic, treatment, psychiatric, psychological, rehabilitation and pharmacy services as well as overusing seclusion and restraints. A settlement agreement committed the state to addressing those issues.

The mother of a schizophrenic patient recalled her daily visits to see him in the Waterbury facility in its later years. People were screaming, conditions were chaotic and therapeutic care was minimal, she said. “They had nothing for him to do during the day,” she recalled. “He sat in a room with a bunch of other people and watched television, and they let them smoke cigarettes. And my son didn’t smoke — but when he went there he did.”

The final verdict on Waterbury was, literally, an act of God: Tropical Storm Irene, which in August 2011 flooded and forced the evacuation of the centenarian hospital. With the facility destroyed, and patients crowding into other hospitals around the state, mental health care reform moved higher on Vermont’s legislative agenda.

Vermont responded to the destruction of its state hospital by enacting a law with a new vision for mental health care.

In New Hampshire, a lawsuit by patients, advocates and the federal government dissatisfied with progress four years after the state adopted a 10-year reform plan pushed the state to make similar commitments.

Each state has set out to strengthen the frontline care provided in community clinics and services and smaller facilities. Both are aiming to build and maintain round-the-clock, statewide and community-based capabilities to respond to people suffering mental health crises. They are moving to make more psychiatric beds available outside the main state hospitals, and they have promised to formalize reporting and oversight of progress.

In Vermont, Act 79 promises “a continuum of community and peer services, as well as a range of acute inpatient beds throughout the state.” The law also instructs the state Agency of Human Services to “fully integrate all mental health services with all substance abuse, public health, and health care reform initiatives” and calls for care to be made available to mentally ill prisoners.

The Vermont law sets specific goals for programs in which current and former mental patients provide support services, for developing small but high-level treatment facilities including one that de-emphasizes the use of mood-altering drugs and for writing new standards that limit the use of seclusion and restraints by caregivers.

Frank Reed, the interim commissioner of the state Department of Mental Health, said in an interview in late May that Vermont has “done just about everything with Act 79.” The main outstanding question, he said, is where to find a permanent location for residential recovery beds for patients that require treatment in a secure setting. Seven beds are now in a building with a temporary town permit in Middlesex.

Some legislators are skeptical. In October, Rep. Ann Pugh, a South Burlington Democrat who chaired the Legislature’s Mental Health Oversight Committee, wrote that “our State’s adult mental health system has not emerged from the crisis that began with Tropical Storm Irene.” Pugh noted “the significant instability of the current mental health system.”

Sen. Claire Ayer, an Addison Democrat who was vice-chair of that committee, which has since dissolved, said recently that not much has changed since then. Act 79 calls for a mental health care system with various levels of care available in different areas of the states, she said. “We haven’t finished the build-out,” she added. “We are not in a complete state by any means.”

Ayer said that efforts are underway to develop a mental health care system that offers various levels of care in different areas of the state. “If you consider the designated agencies and Medicaid mental health providers as part of the system, and I do, we were unable to add the money to provide raises for staff,” she said. “Because of that we’re falling behind.”

But Reed said that the state already “does a really good job of being able to provide services for the needs that are out there,” especially to patients who require high levels of care. Still, he said, more resources could be used to develop preventative services and promote mental health in schools, primary care doctors’ offices and workplaces as well as in community clinics.

A.J. Ruben, a supervising attorney for Disability Rights Vermont, which advocates for patients in the mental health care system, thinks that’s too rosy an outlook. “I don’t think there’s any basis to think that Vermont is doing a good job,” he said. “There are lots of parts of Act 79 that are great but they are not being fully funded or fully implemented.”

Ruben said that the state is “absolutely failing” in its efforts to beef up community care and services needed to support deinstitutionalization. Some mobile crisis workers who can respond in place of law enforcement to incidents involving the mentally ill are available around the state, but without the numbers or resources to constitute a real alternative, he added. Funding for employment counseling for patients in community treatment programs has also been cut, making it harder for them to support themselves, he said.

Rep. Anne Donahue, a Northfield Republican and the editor of Counterpoint, the quarterly newsletter of Vermont Psychiatric Survivors, a patient advocacy group, said that Act 79’s “entire approach was very flawed.” She said the law’s “concept of taking the most intense level of care and spreading it around the state” worked against taking advantage of economies of scale and expertise in mental health care. That, in turn, raised “adequacy of care issues and affects what’s available for community services,” she said.

Donahue gives the state’s mental health care a mixed grade. “I don’t think we have anything to be ashamed of,” she said. “There are a lot things we can do better.”

In New Hampshire, the settlement agreement for the class action lawsuit details the steps the state needs to take to meet its obligation to deliver mental health care in the “least restrictive” settings possible.

The New Hampshire deal obligates the state to upgrade and expand the use of multi-disciplinary Assertive Community Treatment teams that can provide high-level care outside of clinics and hospitals to at least 1,500 patients around the state. It must expand access to job supports and provide at least 600 housing units to patients as well as better care to mentally ill prisoners. The deal also includes a timetable for setting up an around-the-clock crisis system with mobile response teams to work with law enforcement, and community apartments for short stays by the critically ill.

Nick Toumpas, the state’ commissioner of health and human services, is still smarting under the sting of the lawsuit: “I object to using litigation as a tool of public policy.” But Toumpas, whose job situates him between advocates seeking reform and unsympathetic legislators who hold the purse strings, acknowledged that some good might have been done: “I’m not saying that what came out of that settlement did not add value at some level.”

Stephen Day, the expert reviewer overseeing adherence to the agreement, wrote in December that New Hampshire needed to address the “disproportional allocations of resources to institutional and congregate facilities at the expense of community alternatives.” In June, Day found that the state had missed deadlines to upgrade some community and in-home services, set up a new mobile crisis team and to provide job support services.

The New Hampshire Community Behavioral Health Association, an organization that represents the state’s mental health clinics, said in a statement that while “some progress has been made, it is critical that these efforts are continued and expanded.” The association warned that “promised additions to the system have not been carried out … the provider system is still very vulnerable … demand is still growing” and community mental health centers remain unable to deliver services to the mentally ill with the greatest needs.

Suellen Griffin, the executive director of West Central and the president of the CBHA, noted that only five of 10 promised new teams to deliver Assertive Community Treatment had been created and that the state has so far failed to deliver a promised acute residential treatment program and 74 new community treatment beds.

Claremont resident Mandy Dube, a plaintiff in the class action suit, also gave the settlement’s implementation low marks. “In my opinion, it improved very little,” she said. Reductions in mental health care spending had been “detrimental” and progress had been slow: “It seems to me they’re taking their time.”

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Rick Jurgens can be reached at rjurgens@vnews.com or 603-727-3229. Today’s story is part of project that was supported by an Health Care Performance Reporting Fellowship from the Association of Health Care Journalists and by The Commonwealth Fund.