Vermont's Psychiatric Bed Crisis Befuddles Policymakers 

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• Thomas James

Vermont Human Services Secretary Al Gobeille has said his top budget priority this year is creating more beds for psychiatric patients. But last week, some key state lawmakers balked at his plan to locate those beds in a prison complex.

Gobeille's proposal attempts to address a crisis in the state's mental health system that's left patients waiting weeks for one of 188 beds in Vermont's six public and private hospitals.

The secretary has asked for $2.9 million to build a temporary 12-bed psychiatric wing at the Northwest State Correctional Facility that would cost $6.5 million annually to operate. The House Health Care Committee formally declared its opposition last week, on financial and policy grounds.

While most lawmakers agree on the need for more beds, there's no consensus on the best solution. That doesn't bode well for a larger challenge that policymakers have yet to confront: Vermont is three years away from losing millions of federal dollars that help pay for a large portion of inpatient beds in the state system.

"We've gotta get this moving now," Gobeille said.

The bed shortage reached such a crisis that, last August, emergency room doctors and nurses from Central Vermont Medical Center showed up unannounced at Gov. Phil Scott's office in Montpelier and demanded to meet with him. The governor wasn't available, but he sent Gobeille to talk with the group the next day.

What the hospital staff told the human services secretary wasn't news to him: Patients are languishing in emergency rooms, where they occupy badly needed beds without receiving the treatment they require.

Officials tend to trace the problem back to Tropical Storm Irene, which flooded the 54-bed Vermont State Hospital in Waterbury and prompted officials to replace it with a decentralized mental health system. The state built the 25-bed Vermont Psychiatric Care Hospital in Berlin, contracted with Rutland Regional Medical Center to provide seven beds, and made a deal with the Brattleboro Retreat, a private psychiatric facility, to provide another 14 beds. Those 46 beds are reserved for the highest-need patients, who have been hospitalized against their will and placed in the Department of Mental Health's custody.

Many policymakers, and even more hospital staff, are convinced that effort isn't enough, especially as the need grows.

Private hospitals recorded 1,920 inpatient mental health admissions in 2012. That number rose to 2,104 in 2017, according to data from the Vermont Association of Hospitals and Health Systems. The figure does not include admissions to the Brattleboro Retreat and the Vermont Psychiatric Care Hospital, data for which wasn't readily available, according to the Department of Mental Health.

The doctors' desperate gesture last summer made an impression on Gobeille, who concluded that the quickest way to reduce pressure on emergency rooms would be to build a 3,000- to 5,000-square-foot addition at the Swanton prison. The temporary forensic psych unit would house patients who have entered through the criminal justice system. They could include individuals who have been charged with a crime and are awaiting a psychiatric assessment, defendants who have been deemed incompetent to stand trial or found not guilty by reason of insanity, and inmates who experience a psychiatric crisis while in prison.

About half of the patients at the Vermont Psychiatric Care Hospital fit one of those descriptions. They tend to stay longer because of the complexity of their legal cases, creating a bottleneck that clogs up the state's entire inpatient treatment system, according to Gobeille.

Some patients accused or convicted of crimes end up at the Brattleboro Retreat, where they've threatened and occasionally injured staff, according to CEO Louis Josephson. On March 1, he told the House Corrections and Institutions Committee about an incident in which two such patients "jumped" an employee as she brought them coffee.

Calling Gobeille's forensic unit a "no-brainer," Josephson stressed to lawmakers: "I want to be crystal clear that this is an urgent, immediate need in the state."

Committee chair Alice Emmons (D-Springfield) wasn't buying it. A "forensic [unit], I think, is being seen as a silver bullet, and I'm not convinced it is a silver bullet," she said.

In an interview, Emmons explained that she has reservations about investing money in a temporary facility. She suggested that it would be more prudent to add beds to an existing hospital and provide more housing for patients after they're released.

Josephson came away from the committee meeting with a different impression. As he left the room, he said to no one in particular, "Now I get it. They don't want to pay for it."

Gobeille's long-term solution centers on a permanent 50-bed forensic facility, but it's part of a 10-year plan to construct a 925-bed prison complex in St. Albans — an idea that lawmakers and advocates have panned. In a report to the legislature earlier this year, the secretary also recommended creating more state beds at private hospitals and contracting with nursing homes to provide psychiatric care to older patients.

Not everyone believes more beds is the answer. "This is not a system that needs more capacity to deal with crisis," said Wilda White, executive director of Vermont Psychiatric Survivors, a Rutland-based advocacy organization. "This is a system that needs more capacity to deal with prevention and early intervention."

White said Vermont should instead invest in more housing, therapy and community centers that could support people with mental illnesses.

The temporary forensic unit proposal didn't fare better in the House Health Care Committee, which formally rejected the idea in a memo released February 28. Those lawmakers shared Emmons' concern about spending millions on a temporary building, but they also raised a philosophical objection to segregating patients who have been charged with a crime.

"We have never distinguished in Vermont and said, 'Because you're coming through the door of the criminal justice system, even though you have the same clinical need, we're going to segment you somewhere else,'" said Rep. Anne Donahue (R-Northfield). "This would be a big change. It would really need to be thought out."

In the meantime, the committee recommended that Gobeille's team come up with a different plan — one that would add beds to a current facility.

Gobeille has also floated such a solution but said he needs more direction from lawmakers. "What I found interesting is, they say we need inpatient capacity ... but [the memo] is pretty nondescript of exactly what to do," he said.

The Brattleboro Retreat would be a natural location because it currently has 119 beds and, according to its CEO, has the space and is federally approved to serve 149 patients.

The private psychiatric hospital, however, is facing what Josephson deemed an "existential threat" because of a decision at the federal level that could destabilize Vermont's entire mental health system.

The U.S. government has for years barred states from spending Medicaid money on mental health facilities with more than 16 beds, a policy designed to discourage the "warehousing" of mentally ill patients.

For the last two decades, Vermont benefited from an exemption to the rule that allowed the state to use federal money to pay for beds at the Vermont Psychiatric Care Hospital and the Brattleboro Retreat. But in October 2016, federal officials ended the arrangement, notifying Vermont officials that it would phase out its contribution to both facilities over six years, starting in 2021. The feds pay 55 percent of the bill for beds the state uses, meaning Vermont would lose $23 million annually if it doesn't make any changes.

Along with the 14 state beds at the Brattleboro Retreat, the cut would affect an additional 50 private beds at the facility. Although the state doesn't permanently reserve those spots, it still uses a number of them for patients with less intense needs.

"We think we have a problem now? We haven't seen anything," Josephson warned.

Lawmakers sound alarmed, too.

"I'm very concerned," Emmons said. "Conversations need to start happening now."

Senate Health and Welfare Committee chair Claire Ayer (D-Addison) called the situation "pretty urgent." Institutions Committee chair Peg Flory (R-Rutland) described it as "a little frightening."

Flory and others expressed hope that the state could somehow renegotiate another exemption, but according to Gobeille, the federal government "is not budging on this at all."

Despite the concern over the impending funding crunch, policymakers have yet to put a contingency plan in place. The Agency of Human Services has outlined several broad options, which include reducing the Vermont Psychiatric Care Hospital to 16 beds to continue to qualify for federal aid.

At the moment, lawmakers seem preoccupied with yet another imminent threat to the state's capacity to care for the mentally ill. In 2013, the state built a secure, seven-bed facility in Middlesex for patients who don't need hospital-level care but aren't ready to be released into the community. It was meant to be temporary, but nearly five years later, it's still operating, and the state has made little progress in finding a new, permanent location.

The state had told the town selectboard that the facility would close by January 2016. Last year, the town refused the state's request for an extension, but the psychiatric center remained. Selectboard chair Peter Hood isn't happy but said, "I think we're reconciled to our fate that it's likely that thing is going to be there" for the foreseeable future.

Other partners may not be so flexible. The state built the facility after Tropical Storm Irene with $2 million from the Federal Emergency Management Agency on the condition that it would be temporary. If it's not gone within four years, Vermont would have to give back the money, Gobeille said.

To avoid that scenario, he has proposed replacing the Middlesex building with a 16-bed secure residential facility in a location yet to be determined.

He's asking the legislature for $2 million in this year's capital bill to purchase property, if necessary, and prepare to build it. Lawmakers seem more inclined to grant this request. "We've got to get out of those temporary modular units," Emmons said. But she cautioned that these projects take a while: "We're not getting a shovel in the ground this summer."