Tag Archives: Vermont Psychiatric Care Hospital

Fighting with both hands tied behind their backs

My pageview stats for the past several days tell a stark tale: I should stop writing about mental health, and go back to renewable energy*. So naturally, here I go with another piece about mental health. Ever the contrarian.

*Of course, if I really wanted to make clickbait, I’d probably write about nothing but Bernie Sanders.

The mental health care system has often come under attack in Vermont for mistreatment or overtreatment of patients, for alleged forced hospitalization, restraint, or medication. Indeed, the practice of psychiatry in general has few friends in the state. There’s a simple reason for this, and it has nothing to do with the quality of care.

It has everything to do with privacy.

Medical practitioners are legally bound to guard patient confidentiality. This is a very good thing, and I would not seek to change it. However, one of the unintended effects is that when a doctor or nurse or hospital is accused of harming a patient, only one side of the story is heard: the patient’s. If providers tell their story, they are breaking federal law and the ethical standards of their profession.

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Our mental health sandcastle, part 2

And every one that heareth these sayings of mine, and doeth them not, shall be likened unto a foolish man, which built his house upon the sand:

— Matthew 7:26

A few months ago I was chatting, off the record, with a former Shumlin administration functionary. The subject turned to post-Irene mental health care, on which I have been very critical of the administration. This person expressed pride in the new Vermont Psychiatric Care Hospital, calling it a “showplace” and urging me to take a tour.

And perhaps I will. But here’s the thing.

Building a building is the easy part. You can usually rustle up the necessary funds, with or without auctioning the naming rights. Government money, grant funding, foundation support, private donors — all are attracted to flashy new things.

It’s a lot less flashy to operate the building once the ribbon has been cut. Management, maintenance, operating costs; attracting and maintaining quality staff and motivating them to excel; creating the systems that will ensure performance equal to the bright shiny promise of the new edifice.

Am I talking about the new state psychiatric hospital here? You betcha.

The hospital has never been fully and properly staffed. Hard work and low pay — and a dangerous work environment — have proven to be strong disincentives to recruitment, and VPCH has suffered from a high attrition rate.

I’ve been hearing background chatter about this, but recently we’ve seen two stories documenting VPCH’s troubles.

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Our mental health sandcastle, part 1

And every one that heareth these sayings of mine, and doeth them not, shall be likened unto a foolish man, which built his house upon the sand:

— Matthew 7:26

Here’s something that close observers won’t find surprising at all: fresh signs of trouble in Vermont’s mental health care system. In my next post: staffing shortages and other troubles in the system’s crown jewel, the Vermont Psychiatric Care Hospital. This time: Again with the Brattleboro Retreat.

The Vermont attorney general’s office is conducting a criminal investigation into the Brattleboro Retreat following a whistleblower’s complaints about alleged Medicaid fraud at the private psychiatric hospital, The Associated Press has learned.

Ruh-roh. The AP’s Dave Gram quotes AG Bill Sorrell as characterizing the probe as “not narrow in scope,” and that it goes beyond the whistleblower’s complaint into other areas.

As for that complaint:

[Former Retreat staffer Thomas] Joseph alleged a yearslong pattern of instances in which, if overcharges showed up in patient accounts, Retreat staff would not make refunds but instead would change the account to reflect a balance of zero.

If the accusations are true, the Retreat would be in deep shit with Medicaid, which (according to Gram) supplies the Retreat with roughly one-fourth of its total funding.

Yeah, that’s not an enemy you want to make.

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Shumlin’s mental health care system still kind of a mess

Very interesting article by VTDigger’s Morgan True, which will get buried under today’s good news about Vermont Health Connect. The story details a plan to build a 16-bed secure inpatient facility for the severely mentally ill.

This specific plan comes from Northeast Kingdom Human Services, which proposes the hospital as part of a multipurpose “social service campus” in the distant hamlet of Bloomfield, pop. 262. How distant? It’s more than an hour northeast of Saint Johnsbury.

That seems like a bad idea for a number of reasons. It’s awfully far away from any sizeable hospital; proximity to a full-scale medical center is considered prudent for a secure inpatient facility. It’s a hell of a drive for the vast majority of those wanting to visit a patient. And there’s the problem of attracting qualified staff to such a remote locale.

This may be nothing more than a fever dream by NKHS; the state is nosing around for a new facility but has made no commitments to the Kingdom. But it does point out something I hadn’t realized: the administration is again looking to expand the system because it is still overstressed.

It’s almost a year since the new hospital in Berlin opened its doors, and there are still severely mentally ill patients waiting in emergency rooms for days at a time because there aren’t enough secure beds. And the state faces a looming, if somewhat unofficial, deadline to close a “temporary” seven-bed facility in Middlesex by 2018. Continue reading

Vermont’s new mental health system will have more inpatient beds than the old one

I wouldn’t blame Jay Batra if he felt personally vindicated today. Maybe even a little bit smug. VTDigger’s Morgan True: 

The state wants to replace a temporary psychiatric facility in Middlesex with a permanent structure twice the size, officials told lawmakers last week.

… Last June Vermont opened the doors of the Vermont Psychiatric Care Hospital in Berlin, but the system still lacks the capacity to keep people with acute psychiatric needs out of emergency departments.

How about that. “…the system still lacks the capacity…”

Vermont’s new, decentralized, community-oriented system currently has 45 beds: 25 at VPCH, 14 at the struggling Brattleboro Retreat, and six at Rutland Regional Medical Center. If/when the Middlesex facility is built, the system will have 59 beds.

Before Tropical Storm Irene, the Vermont State Hospital had 54 beds. After Irene, the Shumlin administration insisted, repeatedly, that if we had a more robust community-based system, we wouldn’t need that many inpatient beds. In the process, it ignored the counsel of psychiatric professionals, who said that 50 was the bare minimum.

What’s happened since then? The administration has slowly, quietly, built the system back up. And it has found that, yes indeed, those professionals knew what they were talking about.

Let’s take a trip in the Wayback Machine to Tuesday, December 13, 2011

Gov. Peter Shumlin announced on Tuesday that his administration plans to replace the Vermont State Hospital in Waterbury with a decentralized, “community-based” plan with 40 inpatient beds in four locations around the state. …

The unveiling of Shumlin’s proposal came on the same day a top mental health psychiatrist called for almost the exact opposite of what the governor proposed. Dr. Jay Batra, medical director of the state hospital since 2009 and a professor at UVM, told lawmakers at a hearing on Tuesday that the state should have one central mental health facility serving 48 to 50 patients in order to provide the best clinical treatment and best staffing model.

That, from a lengthy VTDigger account of Shumlin’s announcement, which was made in the conspicuous absence of Dr. Batra. At the time, Shumlin was planning on a central hospital with as few as 16 beds. It was a well-intentioned effort to avoid the serious problems that had plagued VSH in the past. But it was a misdirected effort, pursued against the advice of those actually in the field.

At the time, I wrote some highly critical stuff about the administration’s plan, and I got some active pushback from administration officials who basically accused the psychiatric community of professional puffery — overstating the need for their own expertise.

Now, it’s safe to say that the administration was wrong.

Assuming the Legislature approves the $11.4 million Middlesex facility, the mental health system will have more beds than before Irene, and those beds will cost more than a similar number at a single, central State Hospital. How much more, I don’t know. But the system has had persistent problems hiring and maintaining the staff it needs for the specialized care its patients require. Those problems are exacerbated when the beds are spread among four separate facilities.

Also unknown is how much money was [mis]spent on the long and winding road to get exactly where the experts thought we should go in the first place. Plus, we are left with a system that’s almost certainly more expensive to operate and harder to administer because of its geographic spread.

One of Governor Shumlin’s great strengths is his decisiveness. He can assess a situation quickly, make a decision, and carry it through. Well, it’s a strength when he’s right. When he’s wrong, and he stubbornly insists on staying the course, that same decisiveness is one of his great weaknesses.

Our still-broken inpatient psychiatric system

One of journalism’s highest purposes is to lance the boils of society — to expose unpleasant truths that everybody is doing their best to ignore.

A prime example appears on VTDigger today: a story by Morgan True about the continuing problems in the state’s psychiatric care system, and particularly the brand shiny new state hospital in Berlin.

Among the key points:

— Even after the facility’s opening, some psychiatric patients have found themselves parked in emergency rooms for days or even weeks.

— There have been 59 documented attacks by patients on hospital staff, some resulting in significant injuries.

— The hospital houses a couple dozen of the most severely ill people in Vermont. Many have been convicted of violent felonies. One doctor told True that the hospital is “one of the most dangerous workplaces in Vermont.”

— State law strictly limits the restraint or medication of patients against their will. Even the most violent.

— In part because of this dangerous work environment, the hospital has been consistently understaffed since its opening. As a result, it has yet to operate at full capacity.

Which brings us back to point one: several months after the hospital’s opening, severely mentally ill people are still being warehoused in ERs.

This is a whole lotta bad stuff. It shows a mental health care system that’s still functioning poorly even after the Shumlin Administration’s entire plan has been put in place.

The Department of Mental Health, for its part, seems to be taking a remarkably lax and unforthcoming attitude toward the situation. DMH knows the total number of attacks on staff, but it won’t release any information on staff injuries.

And according to DMH Deputy Commissioner Frank Reed, the department “has not tried to compare the number of violent incidents at VPCH to other psychiatric hospitals.”

Well, why the hell not? I’d think you’d want to know whether our problems are unique, or simply the natural consequence of caring for the most severely mentally ill.

Reed also flunks the transparency test when it comes to waiting times in hospital emergency rooms. He says average wait times have decreased, but…

Reed was unable to provide documentation of average wait times, saying those figures are still being “pulled together.” The numbers will be presented to a legislative oversight committee in January.

Perhaps Mr. True should apologize for inquiring at an inopportune time. But it shouldn’t be that hard to assemble those numbers. Indeed, I’d expect a Department that’s doing its job to compile those figures on an ongoing basis.

In fact, I’d be very surprised if DMH doesn’t have the numbers already. It’s Management 101, isn’t it? Keep track of your most important statistical markers?

True’s report raises all kinds of questions about state law, the Shumlin Administration’s concept of a mental health care system, and how many resources were spent trying to develop a system that was undersized from the start. DMH officials are talking about supplementing the system with a new 14-bed secure residential facility, but acknowledge that it’ll be a tough sell when lawmakers are under the gun to cut the budget. DMH may have already squandered its best opportunity to create a good system.

And please don’t insult me with the “No one could have foreseen” excuse. The people responsible for inpatient care were all saying the same thing after Irene: the Shumlin Administration’s plan was so bare-bones that it was almost doomed to fail. While their advice was ignored, how many millions did the Administration spend on inadequate plans, patchwork facilities, and extra costs? (One example: according to True, the state has paid more than $1 million since 2012 for sheriff’s deputies to monitor psychiatric patients in hospital ERs.)

And it turns out, to the surprise of no one who works in the field, that a 24-bed hospital costs nearly as much to run as the old 50-bed facility, and costs more on a per-bed basis because the foundational staffing needs are so high.

And, given that the new hospital has some of the same kinds of problems as the old one, I have to ask if our laws are out of whack. I mean, look: We’re talking about the two dozen  sickest people in Vermont, many of them violently, dangerously sick. The restrictions on restraint or medication without patient approval may be the best thing for the vast majority of patients; I believe different standards should apply to the very sickest. They are the ones least capable of exercising sound judgment, and most capable of inflicting harm on staff or fellow patients.

One commonality between the old hospital and the new is our strongly patient-centric laws. It seems clear to me that those laws are on point for the vast majority of patients, but that there should be a different standard for patients in the state hospital.

The new state hospital: A milestone, but not the end of the road

Yesterday’s happy-smiley ribbon cutting at the new State Hospital in Berlin was, indeed, a happy occasion. The post-Irene period — almost three years — has been extremely tough on seriously ill patients, their caregivers, and the entire mental health care system. Long waits, days spent in emergency rooms, endless shuffling of patients from one facility to another, constant searching for even a single empty bed. It’s been damn tough, and the interregnum has been longer than it should have been.

But nobody should confuse this milestone with the finish line. There are still a lot of questions to answer and issues to address. (Many of these were covered in Pete “Mr. Microphone” Hirschfeld’s fine piece for VPR, which went above and beyond the pro forma coverage of a ceremonial event and actually addressed the meat of the issue.) First and foremost: is this new hospital big enough?

After Irene, the experts were insisting that a new hospital needed to be at least as large as the old one. Instead, it’s half as big. I realize we’re trying to deemphasize hospitalization and move to a multifaceted, community-based system. But we’re talking about the sickest of the sick: even at 54 beds, that’s one bed per 11,593 residents. A central hospital isn’t for patients who might be better served in outpatient or community settings; it’s for the very, very small number of people who are too ill to function, too dangerous to themselves or others.

It remains to be seen whether 25 beds are really enough. It’ll definitely ease some of the intense pressure on the system, and it should prevent the widespread warehousing of patients in ERs or other unsuitable locations.

And there’s still widespread legislative dissatisfaction with the cost of the new facility, which makes me fear that the hospital will be nickel-and-dimed by lawmakers more concerned with the bottom line than with adequate patient care. Sen. Jane Kitchel, for one: she was more than pleased to take part in the ribbon-cutting, but she’d really like to see the hospital run more cheaply. 

Many lawmakers are complaining that the new hospital’s per-patient costs are substantially higher than the old one’s. That’s true, but I’d point out a couple of obvious items:

The old hospital was inadequate. Everyone says so. It lost its federal certification, which meant it did not qualify for Medicaid funding. If the old hospital wasn’t up to snuff, well, of course the new hospital will cost more.

Many of the costs are fixed. So when the Legislature happily signed off on a smaller facility, it tacitly agreed to much higher per-patient costs. A brand-new 54-bed state hospital would have had higher operating costs than the old one, but it would have cost a lot less per patient than the new 25-bed facility. This shouldn’t be a surprise to anyone in the legislature.

Many of the costs of the old state hospital are now redistributed across multiple locations, and helping to fund new community-based programs. (Or at least that’s the way it’s supposed to work.) This very intensive kind of psychiatric care requires staffers with special training and expertise; in a single central facility, you can have a more concentrated level of expertise. In the new system, we’ll have to spread those people around. And almost certainly hire more of them.

So I don’t want to hear any whingeing from the legislature about the new hospital’s cost. This was their idea.

But it must raise serious questions about the legislature’s willingness to fund the community-based facilities that are supposed to undergird the whole system and prevent a whole lot of hospitalizations. <a href=”http://digital.vpr.net/post/after-long-wait-mental-health-hospital-ready-first-patients”>Via Hirschfeld: </a>

Northfield Rep. Ann Donahue is a mental health advocate who has spent years advocating for a new state mental hospital. Impressive as the new facility is, Donahue says the system won’t function properly unless the community-based facilities are actually built. And she said much of the bed space and treatment capacity called for in the reform plan have yet to be constructed.

“Some of them are still in development, some of them are on budget hold. And we need to really enhance that aspect or we won’t reduce the need for inpatient care,” Donahue said.

At the ribbon-cutting, Human Services Secretary Doug Racine trumpeted the claim that Vermont “has the best mental health services in the U.S.” As of today, that claim is one step closer to reality but, fundamentally, it remains in the realm of political blather. The truth is, Vermont may well have the best mental health care system in the country ON PAPER. But a long struggle remains to turn it into reality. And penny-pinching Democrats are, sad to say, the biggest obstacle in our path.