Lawmakers and administration officials have begun contemplating the next major addition to Vermont's mental health infrastructure. But they have some big questions to answer before they construct it, and the size of the facility, as well as its location, will be part of a legislative debate in 2016.
Four years ago, Tropical Storm Irene flooded the state-run psychiatric hospital in Waterbury.The catastrophe prompted a wholesale reimagining of the mental health system in Vermont, and the 55-bed hospital has since been replaced with a patchwork of facilities that provide varying levels of care.
"The last three and four years have shown us the continuum of care we're creating. The inpatient capacity, the intensive residential capacity, crisis-bed capacity and then the secure component — they're all part of the system of care," says Frank Reed, the newly appointed commissioner of the Department of Mental Health.
That system, however, continues to suffer from a conspicuous hole. And lawmakers next year will have to decide how many "secure residential recovery beds" Vermont needs to address the shortcomings that continue to plague mental health care.
"The lay of the land for mental health has really changed, even in the last couple years," says Springfield Rep. Alice Emmons, the Democratic chair of the House Committee on Corrections and Institutions. "It seems as if there is much more need."
Emmons and Reed will be key figures in a debate about the number of secure residential beds Vermont needs, and the number it can afford.
"The last three and four years have shown us the continuum of care we're creating. The inpatient capacity, the intensive residential capacity, crisis-bed capacity and then the secure component — they're all part of the system of care." - Frank Reed, Dept. of Mental Health
Last week, the Department of Mental Health issued what's known as a "request for information." The move is intended to solicit proposals from designated agencies, hospitals and other possible vendors who might be interested in constructing and operating a secure residential facility.
Secure residential beds are different from the ones at the new state-run psychiatric hospital in Berlin, which are reserved for patients in the acute stages of mental illness. People placed in secure residential don't need inpatient hospital care, but, due to their conditions, might pose a danger to themselves or others.
Before the state can move forward, however, Emmons says there are still some key decisions to make.
"Where is the best location for the secure residential? What is the number of beds? Is it six beds? Is it 10 beds? Is it 12 beds?" Emmons says.
Earlier this year, Reed's department submitted a proposal to Emmon's committee for 14 beds, at a cost of $11 million. The Legislature responded by asking the department to conduct additional analysis during the off-session, then come back with a new proposal by February of 2016.
Asked how many secure residential beds he would like to bring online if money were no object, Reed says he doesn't have an answer, "because it continues to be evolving."
Julie Tessler, executive director of the Vermont Council of Developmental and Mental Health Services, says the need is pressing. She says she thinks a facility with 14 secure residential beds "is a good place to start."
Tessler says lack of those beds right now is having impacts across the system. Patients at the psychiatric hospital in Berlin, for example, are stuck in inpatient settings longer than they need to be because there are no secure residential beds to send them to.
Tessler says that means fewer inpatient beds for people struggling with acute health crises.
"Individuals who are in mental health crises are getting stuck in hospital emergency rooms where it's not a good environment for someone in that position," Tessler says.
Emmons says the size of the secure residential facility — or facilities, if the state decides they shouldn't all be in one place — will depend in part on how aggressively policymakers want to improve the system.
She says the issue of mental health in the prison population, for example, has the potential to dramatically expand the scope of the proposed new capacity.
"And I think we have an opportunity here to really grapple with the issue: should folks who are suffering from severe mental illness even be incarcerated? Is that the appropriate setting?" Emmons says.
"I think we have an opportunity here to really grapple with the issue: should folks who are suffering from severe mental illness even be incarcerated? Is that the appropriate setting?" - Rep. Alice Emmons (D-Springfield), House Committee on Corrections and Institutions
Emmons, however, says that money will inevitably become a limiting factor when it comes to deciding how to proceed with building the next phase of the system.
"It's expensive," Emmons says. "And I think people will really just kind of shy away from that, because of the expense."
The Department of Mental Health will begin reviewing proposals for new facilities in early November, and Reed says the state hasn't ruled out building a state-run secure-residential facility, as opposed to partnering with a hospital or designated agency.
The new capacity would replace the temporary seven-bed secure residential facility in Middlesex.
Northeast Kingdom Human Services, a nonprofit designated agency that serves residents in Orleans, Essex and Caledonia counties, is expected to submit a plan to the Department of Mental Health for a 16-bed secure residential facility in Essex County.
