Editor's Note: This is one of the final two articles in a series on the state of Vermont's mental health care system since the closure of the Vermont State Hospital in August 2011.
BRATTLEBORO -- When Tropical Storm Irene swept across Vermont in 2011, it devastated the state office complex in Waterbury, which resulted in the closure of a building that many had been trying to close for years before the storm -- the Vermont State Hospital. It had lost its accreditation nearly a decade earlier and legislators, department heads and state administrators were struggling with how best to remedy the situation -- renovate the building, close it down and build a new one, or disburse the patients to other facilities around the state.
Irene forced the state's hand when the Winooski River, swollen by the torrential downpour of the storm, overflowed its banks and flooded the hospital, and the Department of Mental Health was left scrambling to find beds for its patients.
The Brattleboro Retreat, which was in talks to take some of the state hospital's patients prior to Irene's arrival in Vermont, made room for 14 people.
Rob Simpson, the Retreat's CEO and president, said the board of directors didn't have to open the doors of the private facility to the state's patients, but after a brief but intense discussion, gave the go-ahead.
"It was the right thing for the state. It was the right thing for the Retreat. It was the right thing to do," he said.
The Retreat is now in the process of renovating a floor of one of its buildings, at a cost of $5 million to the state, converting it into a formal 14-bed unit for patients in need of acute mental health care. The Retreat has signed a four-year contract with the state, said Simpson, but he hopes the relationship will be much longer term than that.
Since the closure of the hospital, the Retreat has had 370 patients who would have gone in the past to the state hospital, pass through the Retreat's inpatient care facility, said Dr. Fritz Engstrom, the Retreat's medical director.
"That's similar to other psychiatric facilities in the state," he said.
The Vermont Legislature enacted Act 79 in 2012 to reform the state's mental health system. It calls for the mental health system to be integrated into the overall health care system, with resources distributed based on demographics and geography to increase the likelihood of treatment as close to the patient's home as possible.
"Despite strong pushes to deinstitutionalize these patients, there's still a significant core that requires inpatient care," said Engstrom, who noted there have been concerns by some staffers that the Retreat hasn't been doing enough to protect patients and employees.
"These are very challenging patients," he said. "It's very easy to point fingers."
"We take seriously the safety of our employees," added Simpson, admitting the Retreat has been playing catch-up since the closure of the hospital. "The first year was challenging, but things are getting better. When serious problems arise, we have a track record of fixing them and moving on."
The Retreat has been put on notice twice in the past year by the Centers for Medicare and Medicaid Services that it is in danger of losing federal funds, most recently due to "deficiencies" in three areas identified in a CMS review.
"The Retreat has some areas that need improvement, including patient rights," said Mary Moulton, the commissioner of the Department of Mental Health.
Last week, Peter Albert, the Retreat's senior vice president for government affairs and a licensed social worker, briefed members of the House Human Services Committee about the CMS review.
The March 11 letter from CMS to the Retreat detailed an allegation of a patient having sex with another patient and a delay of several hours following the incident for a requested "specific medical intervention."
In another incident, an adolescent patient was placed in seclusion by a person not qualified to make that decision and in a third incident a patient was given medical treatment against his or her wishes.
The Retreat has 30 days to respond to CMS with a plan that addresses the deficiencies, but during the legislative hearing, Albert was taken to task for what some legislators perceived to be a lack of communication between the Retreat and state agencies.
During a meeting with the Reformer last week, Simpson pointed out that the Retreat sees approximately 5,200 patients a year, 60 percent of them Vermonters. Total inpatient days per year average about 44,400 and residential days average about 11,100 a year. The average length of an inpatient stay is nine-and-a-half days.
In addition, the Retreat was host to more than 32,500 ambulatory, or outpatient, visits for individual counseling sessions, and it hosted 12,150 school days for high school students who were receiving treatment in 2012.
Simpson said as the need for acute care at the Retreat increases, it has affected its bottom line.
"Financially, the Retreat is more challenged than two years ago," he said. "Staffing costs have risen. We have hired 220 new employees over the past two years, though they are not all state hospital related."
The Retreat, the third largest hospital in Vermont and the second biggest employer in Windham County, had a $55 million total expense budget in 2012, most of which -- $43 million -- went toward payroll. It has 757 employees, including 24 physicians and 11 licensed independent practitioners.
A re-evaluation of the Retreat's services and the introduction of new services -- such as its Uniformed Services Program and its LGBT Inpatient Treatment Program -- resulted in a small number of layoffs and staff realignments, which sparked some public consternation from some of the Retreat's staff members.
Bob Audette can be reached at firstname.lastname@example.org, or at 802-254-2311, ext. 160. Follow Bob on Twitter @audette.reformer.