The Vermont State Hospital Futures Project

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The Vermont State HospitalFutures Project

• May 4, 2004

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Purpose of the VSH Futures Project

• Develop a strategic plan for the Vermont
  psychiatric services delivery system currently
  provided through the VSH
• Done with the Input of all interested
  stakeholders
• Clinicians
• Providers
• Consumers

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Public Consulting Group, Inc. Submits Their
Report January 26, 2004

• Purpose of the report
• evaluate services currently provided by the VSH
• Identify systems issues that related to our
  ability to provide care
• Offer preliminary recommendations of how to
  evolve our system of care
• 8 major points

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Conclusions of the PCG StudyJanuary 26, 2004

• Consensus that the state should ensure that there
  is an inpatient capacity which will play the
  safety net function for clients who pose the
  most difficult clinical and legal challenges for
  the public mental health system .

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Conclusions of the PCG StudyJanuary 26, 2004

• VSH provides a specialized clinical function to
  patients who have not been successfully treated
  in other environments for reasons such as
• Refusal to accept treatment
• Demonstrating violent or aggressive behaviors
• The need for longer term treatment .

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Conclusions of the PCG StudyJanuary 26, 2004

• This specialized clinical function could continue
  to be provided by VSH, or by another facility,
  either in a statewide or regional setting if the
  facility(ies) develop the necessary specialized
  functions .

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Conclusions of the PCG StudyJanuary 26, 2004

• At the time of the report , the data on
  admissions and discharges did not suggest that
  there were too few beds to meet Vermonts need
  for state hospital services .
• The report assumed
• No change in the mix/acuity
• No change in the admission or discharge criteria
• No change in the capacity of community services
  and designated hospitals

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Conclusions of the PCG StudyJanuary 26, 2004

• A significant number of (current) VSH patients
  could be treated effectively in community
  settings if appropriate service capacity was
  developed.

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Conclusions of the PCG StudyJanuary 26, 2004

• VSH serves all people who refuse to take
  medication beyond a point tolerated by the
  designated hospitals.
• This makes it difficult for the staff to maintain
  a safe and therapeutic milieu for all of the
  patients.

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Conclusions of the PCG StudyJanuary 26, 2004

• There is an overwhelming perception that VSH
  operates in isolation from the community mental
  health system .
• This results in poor continuity of treatment and
  difficult placement planning .

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Conclusions of the PCG StudyJanuary 26, 2004

• VSH currently serves Vermonts highest need
  consumers , both in terms of acuity and complex
  diagnoses, in an antiquated setting.
• This creates additional significant barriers to
  treatment
• There is very limited ability to retrofit the
  environment

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you can observe a lot just by watching Yo
gi Berra

• Past is prelude
• Opportunity
• Meaningful reform in public sector mental health
  almost always comes from such opportunities
• Hit the reset button
• Define, refine operationalize
• Brisk time line
• Focus on the Futures Project
• Form follows function
• State of the art system, data driven, accommodate
  changing needs

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Our Timeline By Mid-May 2004

• Explore Alternatives
• Final definition of target groups for services
• Clarify functions to be addressed (e.g. step
  down, diversion, etc.)
• Examine impact on VSH census

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Assumptions

• The State of Vermont (through DDMHS) will
  continue to play a key role in the provision
  and/or oversight of involuntary inpatient care
  for discrete, identified populations.
• The existing Vermont State Hospital IMD model for
  provision of inpatient care is less economically
  viable.

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Assumptions

• Designated hospitals (DHs) and designated
  agencies (DAs), formerly known as community
  mental health centers (CMHCs) may play an
  expanded role in the future care of discrete
  populations.
• A significant portion of patients at VSH require
  longer term care can also be expected to require
  involuntary medication.

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Assumptions

• The State of Vermont will remain committed to the
  principle of maintaining the locus of care in the
  community.

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Our Task Today

• Explore Alternatives
• Define target groups for services
• Clarify functions to be addressed (e.g. step
  down, diversion, etc.)
• Examine impact on VSH census

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Clinical Categories Identified at the VSH

• Persons whose stay is at the discretion of the
  courts
• Charged with or committed serious crimes
• Persons ordered for inpatient evaluation by the
  court
• Non-violent
• Stay lt30 days

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Clinical Categories Identified at the VSH

• Persons with mental illness requiring longer term
  inpatient care
• High risk for dangerous behavior or in need of
  intensive medical care
• Low risk for dangerous behavior
• Persons requiring enhanced nursing home care

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Clinical Categories Identified at the VSH

• Persons with acute illness dangerous behavior,
  requiring a short inpatient stay.

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Persons whose stay is at the discretion of the
courts

• Who are they?
• Persons found NGRI (post-adjudication)
• Persons found incompetent to stand trial
  (pre-adjudication)
• The psychiatric acuity in both groups may range
  from acute to symptom-free

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Persons whose stay is at the discretion of the
courts

• Treatment setting(s) must be able to provide
• Setting(s) sufficiently contained and supervised
  to reassure the court and community of public
  safety.
• Active treatment
• Ability to recognize early signs of
  decompensation
• Capacity to lock setting when needed
• Capacity to reliably track patients/detainees
• Specialized reports to the courts
• Acute treatment needs provided in hospital setting

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Persons whose stay is at the discretion of the
courts

• Systems issues
• Ability to rapidly return person to involuntary
  care (EE standard may not suffice and revocation
  of ONH not timely)
• ability to rapidly return client to involuntary
  care
• Capability to interface with the courts and legal
  process
• potential need for a locked or lockable
  environment
• communitys concerns about risk/liability make
  placement difficult
• Potential Settings
• secure (locked or staff secure) community-based
  residential group home
• individually supervised community wrap-around
  placement

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Persons ordered for inpatient evaluation by the
court

• Who are they?
• These individuals with mental illness are sent to
  the VSH for a court-ordered evaluation to
  determine sanity and competency to stand trial.
• Often indistinguishable from persons committed to
  VSH through the civil process
• These individuals need acute inpatient mental
  health treatment.

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Persons ordered for inpatient evaluation by the
court

• Treatment setting(s) must be able to provide
• Capability to treat co-occurring disorders
  (substance abuse, trauma, intercurrent medical
  conditions)
• Capability to provide the courts with psychiatric
  assessments regarding competency to stand trial
  and sanity or insanity at the time of the alleged
  offense

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Persons ordered for inpatient evaluation by the
court

• Systems issues
• capability to interface with the court system
• active screening system to assure that referrals
  for inpatient evaluation are made only when
  clinically indicated
• If unknown to the community system, it is
  difficult to divert these individuals from
  inpatient care
• Potential Settings
• FAHC
• CVH
• RRMC
• Windham
• Retreat

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Persons with mental illness requiring longer term
inpatient care

• Who are they?
• Individuals with mental illness who require
  intensive multi-disciplinary treatment and whos
  expected psychiatric treatment will take longer
  than 30 days
• May require non-emergency, involuntary medication
• This grouping can be divided into two subgroups
• individuals at high risk for dangerousness
• individuals at low risk for dangerousness

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Persons with mental illness requiring longer term
inpatient care

• High risk treatment setting(s) must be able to
  provide
• Safe environment for patients and staff
• Expertise in medication management
• Expertise in targeted habilitation and
  rehabilitation services
• Potential Settings
• Psychiatric inpatient

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Persons with mental illness requiring longer term
inpatient care

• Low risk treatment systems issues
• It is difficult to maintain ongoing involvement
  of a community treatment team and natural
  supports in the face of longer term stays
• Capability to interface with the legal system
  regarding involuntary medication
• Economy of scale makes more than two sites to
  serve this group unlikely
• If unknown to the community system, it is
  difficult to divert these individuals from
  inpatient care
• Psychiatric services operated by general
  hospitals are currently not arrayed to serve this
  group
• The system of care must be able to move
  individuals between treatment settings
  (inpatient, rehabilitation) as clinically
  indicated

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Persons with mental illness requiring longer term
inpatient care

• Potential low risk treatment settings
• Treatment services for this group could be
  provided in a sub-acute psychiatric
  rehabilitation unit with less medical oversight
  than in an inpatient environment and more
  emphasis on rehabilitation-oriented services
• Intensive rehabilitation programs (Fanny Allen,
  ?)

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Persons requiring enhanced nursing home care

• Who are they?
• Individuals with mental illness requiring long
  term care for whom there is little likelihood of
  regaining significant function and who have or
  are at risk for having behaviors that are
  difficult to manage in long term care settings.
• They have earned the right to comfort care.
• They should not be abandoned.

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Persons requiring enhanced nursing home care

• Treatment setting(s) must be able to provide
• significant assistance with ADLs and lots of
  physical support
• Tolerance for challenging behavior
• aggressively search out new treatment modalities
  that might restore functioning
• Potential settings
• Enhanced nursing home
• Individually supervised wrap-around with
  intensive nursing care

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Persons requiring enhanced nursing home care

• Systems issues
• Vermont is working to reduce the need for nursing
  home care
• Its extremely challenging to not give up on these
  individuals and yet to render compassionate
  comfort care

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Persons with acute illness dangerous behavior,
requiring a short inpatient stay

• Who are they?
• Younger individuals experiencing first break
  psychoses
• Treatment responders
• BPD
• SA psychosis

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Persons with acute illness dangerous behavior,
requiring a short inpatient stay

• Treatment setting(s) must be able to provide
• Staffing pattern robust enough to safely manage
  patients with acute illness
• The clinical emphasis is on acute symptom
  control, followed by movement to rehabilitation
  and/or community aftercare
• Integration of substance abuse and mental health
  treatment
• Integration with general medical assessment and
  care

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Persons with acute illness dangerous behavior,
requiring a short inpatient stay

• Systems issues
• Dangerous behavior may exceed current capacity of
  designated hospitals
• If unknown to the community system, it is
  difficult to divert these individuals from
  inpatient care
• System of care must be able to move individuals
  between treatment settings as clinically indicated

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Point In Time Category Numbers At VSH on 4/6/04
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Point In Time Category Numbers At VSH on 4/6/04
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Our Next Steps Will Be

• Recommendations on Facility and/or Alternatives
  Design
• Program models
• System capacity
• System structural design