Vt. Considers New Psych Hospital

Thursday, April 05, 2018

State officials are considering a dramatic realignment of Vermont’s mental health system that could result in more inpatient beds, shorter waits and less pressure on the state’s emergency rooms.

The proposals — unveiled on Wednesday in simultaneous meetings before the Green Mountain Care Board and the Senate Institutions Committee — feature a new “acute inpatient” mental health facility of still-undetermined size on the Central Vermont Medical Center campus in Berlin.

That project would produce a ripple effect, allowing the current Vermont Psychiatric Care Hospital in Berlin to become a less-intensive “secure residential” facility to replace the much smaller Middlesex Therapeutic Community Residence.

Because those changes would take several years, officials also are considering the addition of temporary mental health treatment capacity in either Swanton or Brattleboro.

Taken together, the projects would represent tens of millions of dollars of investment. And some of that would come from University of Vermont Health Network, which would allocate budget overages incurred by UVM Medical Center toward mental health projects.

“I think the intent on our part was to say, we recognize this need, and we want to be a participant in the solution,” said Dr. Robert Pierattini, who chairs the Psychiatry Department at the University of Vermont College of Medicine.

The proposed changes result from the collision of two seemingly unrelated issues: UVM Medical Center overshot its revenue target in fiscal year 2017, and the state’s hospitals are dealing with an increasing number of mental health patients in emergency rooms.

The Green Mountain Care Board, which regulates hospital budgets, has been considering how to address the fact that UVM Medical Center’s net patient revenues exceeded its state-approved budget by $38.3 million last fiscal year.

A few weeks ago, the board pitched a unique solution: UVM Medical faces a possible 3 percent rate cut penalty, but the rate cut could be alleviated if the hospital agrees to make a significant investment in the state’s mental health system.

That system is under strain. One indicator is the fact that many mental health patients are forced to spend extended periods in emergency rooms due to a lack of available inpatient beds.

On Wednesday, the Vermont Association of Hospitals and Health Systems presented data to the care board showing that the total number of days mental health patients spent in emergency rooms jumped 28.6 percent from 2015 to 2016. The statistic increased by another 29.7 percent from 2016 to 2017, when mental health patients spent a total of 5,237 days in emergency rooms.

The number of mental health patients showing up at emergency departments waxes and wanes. But in the past few weeks, “it has picked back up with a fury,” Mental Health Commissioner Melissa Bailey said. “We have a number of people who are waiting.”

Bailey told the care board she could not propose a single policy solution to address the increasingly intense demands on the state’s mental health system.

“I’d love to sit here and say there is one easy answer,” she said. “What I can tell you is, that’s not possible.”

That’s not to say, however, that there aren’t answers. And some care board members believe their budget-regulation talks with UVM Medical Center may provide a way to ease pressure on the mental health system.

While the board did not vote on the matter on Wednesday, one option presented to members is allowing the hospital to set aside $21 million of its fiscal 2017 revenues in order to “enhance inpatient mental health treatment capacity in Vermont.”

Pierattini presented a plan to do just that.

The proposal’s centerpiece is for Central Vermont Medical Center — which is part of University of Vermont Health Network — to host a new inpatient psychiatric facility.

It seems likely that officials will target a bed number higher than the current psychiatric hospital, which has 25 beds. But Pierattini said he could not commit to a size for the new facility.

“We don’t have a number,” he said. “I think arriving at that number is going to require considerable deliberation.”

But Pierattini also said the facility “has the potential to improve care in several ways.” First and foremost, it could provide more treatment capacity for more-timely admissions.

Also, Pierattini noted that Berlin is a central location that “would serve the entire state.” And he said the proposed hospital’s proximity to Central Vermont Medical Center and other psychiatric facilities could be advantageous.

“There’s an advantage of having things together in a closer, overall, operation,” he said. “You can just manage your resources more thoughtfully.”

Under UVM’s preliminary plan, the state’s psychiatric hospital would be transformed into a secure residential setting. That’s meant as a place for mental health patients to go when they’re ready for discharge from a psychiatric hospital but still require support and supervision.

The state’s Middlesex residential facility — which has just seven beds and was supposed to be temporary — would be phased out.

Bailey was enthusiastic about the UVM plan. “We’re very pleased and really interested in exploring it more with them and getting into the details,” she said. “We think, for parity purposes, to have psychiatric care (become) part of the general hospital is absolutely the direction to go.”

State Human Services Secretary Al Gobeille also threw his support behind the proposal to locate a new inpatient mental health facility at Central Vermont Medical Center.

UVM Health Network is a good partner for the state because it is large enough to take on the task of running a major mental health unit, Gobeille said. “This is not a small undertaking,” he said.

For that reason, it will take some time even if everything goes smoothly. UVM’s proposed psychiatric facility would require a certificate of need from the care board, and there would be other planning and permitting work needed before the project could move forward.

According to Gobeille, UVM Health Network has estimated that the new mental health facility would take three to four years to be operational.

So Gobeille, in his presentation to the Senate Institutions Committee, said the state should take smaller, more-immediate steps to expand Vermont’s mental health treatment capacity until the UVM Health Network-run facility opens.

One option would be to revamp a unit at Northwest Regional Correctional Facility in Swanton to make it a 12-bed facility that serves people who enter the mental health system through the courts.

The administration pitched that idea earlier this year, but the House did not include funding for it in the fiscal 2019 budget approved last month.

Another option would be a new facility. Gobeille said the state is considering some properties in Chittenden County or central Vermont to temporarily house mental health services, but he did not offer specifics.

Gobeille also told lawmakers that “the best idea” for a temporary facility may be to partner with the Brattleboro Retreat to conduct repairs on a wing of that facility. The state would help cover the costs.

No matter the solution, Gobeille emphasized the need for short-term mental health beds. “If you don’t do the temporary (treatment options), I think we’ve failed this session,” he said.

Sen. Peg Flory, R-Rutland and Institutions Committee chairwoman, said there are a lot of questions about how the administration’s proposal would work. She said she does not have enough details to know what steps the Legislature would need to take before the session ends in May.

“It’s got a lot of moving parts, considering we have about a month left to get these sorted out,” Flory said.

She asked Agency of Human Services officials to put together more information about how the proposal would compare to the state’s current mental health system.

Flory acknowledged an immediate need to expand treatment capacity. However, she is wary of spending money out of the capital bill — which is paid for by issuing bonds — on temporary solutions.