State Of Mind: The Acute Care System: Are We Going in the Right Direction?
Vermonters know the first part of this story: Tropical Storm Irene slammed into Vermont and flooded the Vermont State Hospital in Waterbury. Patients were moved to other facilities and the state had to take action on a long-debated idea – a new mental health care hospital.
Now, more than two years later, construction is underway, but there is a big question: Will it work? State Of Mind is a series of special reports exploring the pressure points in our state mental health care system.
New State Hospital
Construction vehicles beep in the background as Governor Peter Shumlin gets a report from engineer Michael Kuhn on progress at a new state psychiatric facility in Berlin. The construction site sits on a non-descript road, between Barre and Montpelier, across from a car dealership and just down the street from the local hospital. Through the open spaces where walls and windows will soon be installed, mountains and trees provide the backdrop. This new hospital should be open and treating patients before the third anniversary of Tropical Storm Irene.
The storm devastated the original Vermont State Hospital in 2011. And the building was never reopened.
“Let’s be candid,” Shumlin says of the old hospital. “It was a dump. And we should have been out of there years and years ago. And when we made the promise to come out of Irene better than she found us, this is one beautiful example.” He spreads his hands to encompass the footprint of the new hospital. “We’re going to finally deliver mental health acute care in quality facility, gorgeous views, state of the art.”
The hospital’s design includes bathrooms in every room, art gallery space, two open courtyards, a library, a greenhouse, and a chapel. And it’s designed in small units that can be closed off from one another, to allow different configurations of patients within the 25-bed hospital.
Kuhn points out a nine bed unit that can be closed off from the other residential rooms and explains that multiple configurations will give the staff greater flexibility in accommodating the needs of different patients. “Treatment opportunities and the ability for DMH to break down patients who may have problems with one another and that kind of thing. This one includes a 4-bed pod and a 5-bed pod so you can do some much more individualized treatment opportunities.”
When it opens in July of next year The Green Mountain Psychiatric Care Center will be the centerpiece of Governor Shumlin’s plan to revamp the acute mental health care system in Vermont.
Like the old state hospital, it will treat patients going through court-ordered mental health evaluations and involuntarily admitted patients in severe mental health crisis. Right now, those patients are placed in other facilities around the state: at the Brattleboro Retreat, the Rutland Regional Medical Center, Fletcher Allen in Burlington, and a facility in Morrisville.
When the new hospital opens, Fletcher Allen will stop taking level 1 patients and the Morrisville center will close.
The result will be spots for 45 patients in Berlin, Brattleboro and Rutland in this kind of secure, urgent-care setting. More than we have right now, but nine fewer than when the State Hospital was in business.
Governor Shumlin says his plan is to minimize the need for this kind of treatment by beefing up community supports and less intense in-patient facilities.
But that’s the main question: Will Vermont provide good care for mental health patients with fewer beds?
Some mental health providers around the state say they’re not sure the plan will work. Dr. Sandra Steingard is the Medical Director at the Howard Center, a mental health agency that serves people in Chittenden County. She was initially supportive of the governor’s plan.
“And I think in some ways I was naïve,” Steingard says about her initial testimony before the legislature in support of the idea of building a smaller state facility to replace the state hospital. “It’s not that I don’t agree with the plan because I think it’s better to keep people out of the hospitals. But I underestimated the complexity of the system.”
Steingard says she’s watched patients in crisis voluntarily ask for help, only to be told there’s no space for them in psychiatric units at community hospitals. Sometimes they wind up waiting days or weeks in emergency rooms. And she doesn’t think it’s because there’s not enough space for them.
Steingard says Vermont’s community hospitals saw the original State Hospital go through repeated sanctions from the federal government, sanctions that caused the hospital to lose all federal funding. She thinks other hospitals are wary of admitting patients who face involuntary admissions, high rates of violence, and, often, criminal charges.
“I think it’s unfair to ask people to do high-risk work and then to be so highly regulated that if something untoward happens. You know, when you’re dealing with high-risk people, bad things may happen, even when you’re really good and you’re working really hard. And to put a hospital at the brink of losing Medicaid, which could basically put the hospital out of business, I think is unfair to them. So I understand my colleagues being risk-averse because it’s serious stuff. This is big stuff.”
Brattleboro Retreat Faces Potential Decertification
The Brattleboro Retreat has a contract with the state to take in patients who would, in the past, have gone to the state hospital. But the Retreat has come under scrutiny from the federal government and is possibly facing decertification.
The hospital has faced violations with seclusion and restraint and other patient well-being issues. The federal Center for Medicare and Medicaid Services is evaluating the hospital and expects to rule on certification by the end of the month.
The Retreat’s President and CEO, Rob Simpson, says it’s been a learning curve dealing with the state hospital patients.
“The reality is we have a unit now of 14 patients, all of whom are involuntarily committed, don’t want to be there, many of whom do not believe they have a psychiatric illness. Many of them have significant issues with trauma, including major mental illnesses like schizophrenia or bi-polar disease. Then they have criminal charges and they’ve needed to be involved in the forensic or the criminal justice system in some fashion. They’re more complicated to treat.”
The Brattleboro Retreat issue illustrates the difficulties many Vermont hospitals are dealing with as they learn to treat more volatile and violent patients than they used to.
In the midst of all this, patients are waiting for a long time in ERs that are not equipped to deal with them either.
Mid-morning on a weekday is a slow time at Central Vermont Medical Center’s emergency room. So emergency department director Dr. Mark Depman has a few minutes for a tour.
Depman explains that in the not-so-distant past, patients experiencing a mental health crisis were separated from the main emergency room until a bed was found. They were placed near what was known as the “drunk tank,” where intoxicated people were held. But when the Berlin hospital re-designed its emergency room four years ago, its plans reflected a more enlightened attitude toward mental health care that says these patients should no longer be segregated.
Depman flicks on the light in one of the two rooms directly across from the main nurses’ station. Inside is a couch and several chairs, but little else.
“They’re spacious,” he says of the specialized rooms. “But they’re also super-reinforced. So this room has steel wall reinforcements. It has this double entry door so no one can lock themselves in. It has a grate over the gas and water supply, so that’s all safe. They can’t be used as a hinge point for hanging or anything like that.
Since Tropical Storm Irene, this emergency department and others around Vermont have served as holding areas for patients who end up waiting days for a bed to open up somewhere in the state.
But despite their special accommodations, “these rooms with people in here for literally three, five, seven, ten days, have been literally trashed,” Depman says. “We’ve had walls broken in with fists and kicks and we’ve had these doors broken. And these are state of the art secure rooms.”
Depman says it’s not a good situation for the hospital or the patients. He says being in the middle of a hectic, high-pressure setting of the emergency department can be unsettling for anyone.
“This is not a treatment environment, never was meant to be, yet they are here for days. It’s the kind of environment that really doesn’t lend itself to de-escalation, doesn’t lend itself to treatment. That sort of sense of isolation and not being treated can, actually and typically does, escalate the behavior and make things worse. And, when that happens, they’re front and center here with staff, with a general population of patients, including children, the elderly, and people who are also very sick.”
The emergency department is not the only area of the Berlin hospital that’s been affected by the statewide shortage of beds for people with severe mental illness. Take the elevator up to the third floor and the door opens to a spacious, sunlit ward for the hospital’s psychiatric patients. A nurse is on the phone. “We’re almost full right now,” she tells someone on the other end of the line.
Dr. Peter Thomashow, director of in-patient psychiatry, says the pressure on private hospitals like CVMC started a few years before Irene, when the State Hospital began restricting the number of patients it admitted. But still, the Waterbury hospital was there as a relief valve to handle the most seriously ill patients.
Even before 2011, Tomashow explains, “the dysfunction and the crisis was very real. When Irene hit, unfortunately, and the beds at Vermont state hospital were taken off line, that just accelerated exponentially the crisis that was already present.”
Thomashow and Jim Tautfest, the nurse director of the psych unit, say they have to be very careful about the types of patients they admit. Tautfest explains the unit might not be full all the time, because they need to make sure that one patient’s violent outbursts, for example, don’t disrupt the progress of another patient who really needs a quiet space to recover. Tautfest says the need to have a safe mix of patients puts even more pressure on the system.
“There have been several times in the past year where we’ve had seven, eight patients who are involuntary in our unit, so they have a much longer protracted stay. .. It creates a bottleneck for patients in our community who might be depressed, going through their first maybe psychotic break. And they’re on voluntary status, and we don’t have the capacity to absorb them.”
The Vermont state legislature has kept a close focus on the backlog in hospitals and emergency rooms, through its Mental Health Oversight Committee.
At a recent meeting, the oversight committee heard from Tony Stevens, a licensed clinical mental health counselor. Stevens works in Franklin County, and chairs a committee of emergency services directors. He described a case this summer in Addison County when a patient was in crisis and came to a hospital and asked for help. But no bed was available so he had to wait for five days in the emergency room.
“That’s not unheard of, unfortunately, in the emergency room,” Stevens testified. “But that’s a long time. And much of those five days he ended up being requiring to be held in four point restraints. He came in asking for help, and this is sort of how it ended for him.”
Providers say the system obviously isn’t working because if patients came in with another severe medical emergency – such as a heart attack – they’d quickly be transported to get the most specialized care in the region. But people with a mental illness are held for days in emergency rooms.
“I think that for many people they feel like there is no help available to them,” says Stevens “And if they’re not feeling like there’s help, they’re probably not feeling like there’s hope at that point. And that’s the last thing they need at that time.”
The Shumlin Administration acknowledges the problem of lengthy stays in the emergency rooms. But Deputy Mental Health Commissioner Frank Reed is confident that the system will have enough acute care beds – called Level 1 beds – when the new hospital opens next spring.
"I believe that is the capacity that we need,” Reed assures concerned advocates, “based on what we’re seeing for numbers and the alternatives that have been created in the community that allow people that no longer need an in-patient level of care to continue their recovery.”
At the Central Vermont Medical Center, that’s not enough to calm Dr. Peter Thomashow. He’s counting the days until the new state hospital can admit patients. But he worries that there still won’t be enough beds in the system to keep people out of the emergency room.
“So I really fear this is a crisis that has no end in sight.”
Mental health advocates around the state seem to be holding their breath, waiting for the new state facility to open its doors next summer and hoping that will solve the backlog.
Fritz Engstrom at the Brattleboro Retreat says key to making sure acute care facilities are not over-burdened is having effective step-down community treatment.
“We have a lot of patients who could go to the next level.” Engstrom says there’s only so much a hospital can do. When a patient still needs treatment—in-patient or out-patient, there are other facilities that might be a better fit for the patient’s need. In-patient facilities might include lots of support but not as many visits from a doctor. They tend to be less expensive to administer. “And it puts individuals closer to real life than a hospital. In a hospital you’ve got four walls, they tell you when to get up, when to eat. That’s not real life!”
Engstrom says he hopes the state will continue to funnel money into these types of programs to help lessen the pressure on acute care hospitals. Effective lower-level care will be essential in making sure that a state system with just 45 level 1 beds can work for Vermont and ease the pressure on a system currently at capacity.