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1. As we did last year, we call for rethinking and re-defining the replacement of the Vermont State Hospital with a coherent plan that includes a design for a quality care facility or facilities with a sustainable budget that secures support, a consensus of backing, from the administration, the legislature and from stakeholders including practitioners, parents and families, consumers and advocates.
The final loss of federal certification at the Vermont State Hospital (VSH), which reflected serious administrative, clinical and patient safety shortcomings, has appropriately become a true focal point of attention. Rightfully, state leaders pledged to address these issues and to shore up and improve treatment at our only state psychiatric institution as well create a new blueprint and new design for the treatment of Vermonters with serious mental health problems.
Without federal reimbursement, the VSH must rely on state general fund dollars for its operation. Therefore, there is growing recognition that until there is a plan for life beyond the VSH, the State will have to pour millions of general fund dollars into this antiquated facility. The clock is indeed "running".
While steps have been taken to improve clinical care for seriously ill patients — the relatively new, expanded contract with the Department of Psychiatry at Fletcher Allen Healthcare is a step in the right direction — the treatment model itself is flawed and outdated.
An entire year has passed and yet we still lack a clear, defined and coherent plan, one which has a price-tag that is known and acceptable.
Our yet-to-be completed task is to seek a new partnership and reliance with one or several regional hospitals and to expand a variety of programming whether it be in the area of subacute rehabilitation, consumer-run alternatives, supported employment and/or housing initiatives that might enhance psychiatric services in the state of Vermont.
It is painful, perhaps even embarrassing, to be in a position to quote ourselves from our annual report twelve months ago, October 2004, when we had expectations of considerable progress (expectations that were not realized, when we said:
This is the blueprint for the next twenty-five years and therefore it is a mission worth doing and doing well. The time has come for more precise budget building if we are to translate good intentions to a realistic model, which will include on major new facility with enhanced regional capacity as well.
Any further delay in this task is a potential fiscal disaster, particularly for Vermont's community mental health system. Investing "precious" general fund State dollars in the VSH will be necessary until a new (FUTURES) model can be planned, approved and implemented. With a finite amount of state dollars available, all community mental health services may be the "big losers" in this complicated dilemma.
2. We call for a major reduction on the use of restraints in Vermont's system of care for children and adults for all services within the Agency of Human Services.
A. Unshackle Vermont Kids:
On August 30th of 2005, the Vermont Association for Mental Health, along with other advocacy groups and the Agency of Human Services, announced a new advocacy initiative called "Unshackle Vermont Kids".
The Association made clear that the shackling of Vermont children, teenagers and those younger than thirteen, represents and unacceptable policy and an unacceptable practice. We believe that any restraint process for kids in Vermont should be viewed as a procedure of last resort.
Over many years, the shackling of kids become almost an assumed and customary practice relating to the transporting of Vermont youngsters to and from services within the Health Department, its Divisions of Mental Health and Substance Abuse, and within the Department of Children and Families (DCF) where more than 700 children were handcuffed and leg shackled last year.
State leaders from the Agency of Human Services have pledged their commitment to change this practice. While we embrace the rhetoric, we still know that changing practices "out in the field" is neither simple nor proven. In addition, creating an "alternative system", one that relies on a clinical assessment and a different means of transportation, probably will demand a new funding base.
The Vermont Association for Mental Health, along with other advocacy groups, will monitor this important initiative and will issue an independent report to the Vermont legislature (the House Human Services committee and the Senate Health and Welfare committee) by January 2006 in order to define progress and problems in this initiative.
B. Unshackle Vermont Adults
It is well "past time" that Vermont comes to grip with the issue of restraints in adult services within both the public and private sector of all mental health facilities.
The issue was once again painfully highlighted with harsh criticism by the U S Justice Department, which found that last year, over 90% of the restraint cases involved strapping patients down to a bed and placing them in seclusion. While the issue of patient and staff safety must be part of the discussion, we can and must do better.
In response the division of mental health has initiated steps that seem helpful and appropriate but this issue has plagued our one public mental health institution for years.
The Vermont Association for Mental Health, working with other advocates, the Division of Mental Health and leaders of community services in both the public and private sector, expect to establish new policies and practices in mental health treatment that are not only more consistent with our stated values but represent the best clinical interventions which suggest effective treatment outcomes.
3. We call on Vermont to create access to federal benefits and social supports for inmates in our correctional system as they re-enter community life.
In conjunction with the Bazelon Center for Mental Health Law in Washington, DC, the Vermont Association for Mental Health is introducing a two-year effort, along with the states of Maryland and Minnesota, to create a re-entry system for inmates with mental health and/or substance abuse problems. Our goal is to provide a full range of federal benefits and social supports that will enhance successful re-entry to the community, reduce recidivism and offer access to social services ranging from housing and food stamps to employment and employment training.
The Association will work cooperatively with the Department of Corrections and the Agency of Human Services on this effort.
Our goal is simply not to educate the public about the issue and not simply to achieve consensus on the goals but to actually see the implementation, throughout the state, of a comprehensive re-entry system that works.
4. We call on the State to assess the impact of the "Global Budget" on mental health services and Agency of Human Services programs.
It now appears likely that Vermont will risk building a future on a federal Medicaid agreement that is defined by a "global budget" approach. In doing so, the state will move away from an entitlement program for its most vulnerable populations to a block grant formula. Yet there has been little or no sense of clarity about what its short-term and long-term impact might be within mental health and substance abuse services as well as within the Agency of Human Services.
In specific areas like children's mental health services, which has been largely built on Medicaid dollars, there is growing concern and uncertainty. All we need to know is if the global budget impacts the VSH Futures project.
While there are doubts about the global budget plan, there is considerable risk in doing little or nothing. Vermont faces, like the other 49 states, a major Medicaid shortfall, which reflects the unwillingness of the federal government to maintain the growth pattern in this critical program. The transformation of the Medicaid program may turn out to be one of the most important developments in this decade, either viewed as a creative opportunity or a massive disaster for needy and vulnerable Vermonters.
5. We call for the continued building of a system of care in alcohol and substance abuse services, balancing the needs of treatment, prevention and recovery services.
After decades of neglect, Vermont has made strides over the past three years to shape a "system of care" out of a patchwork of programs and services. Since the passage of Vermont's Parity Bill in 1997, alcohol and substance abuse addictions are being viewed as a health problem rather than simply a moral or personal defect. In turn, this conceptual framework has helped to create a positive environment for change.
One basic reality is that the current treatment system is inadequate to handle the growth and complexity of this problem within Vermont. However, progress has been made. The introduction of Valley Vista in Bradford, Vermont is a significant enhancement and more Vermonters, particularly women, now have access to in-state residential treatment. The expansion of a mobile methadone clinic in the Northeast Kingdom deserves backing and praise. Health Department leadership and that of the Division of Alcohol and Drug Addiction has been impressive. Student assistance programs, another valued service, still are under funded and understaffed. Over several years, Vermont has made strides in creating and supporting a number of "recovery centers" which hold great potential and promise.
However, in the face of this major health issue, Vermont cannot "stand still" or simply maintain what we have. The court and correctional systems already are over-burdened with people, young and old, with addictive disorders and if treatment and recovery supports are not in place, the cost to the state will spiral out of control.
6. We call on the Administration and the Legislature to take credit for the decision to back an agreement with our public community mental health and substance abuse service system, which established a three-year 7.5% budget increase beginning in FY 2006.
Talk is cheap so when the Administration last year proposed and the legislature supported a three year agreement to provide our public community mental health and substance abuse system with an annual rate of increase of 7.5 %, the VAMH applauded this initiative in glowing terms. Indeed, not only are these funds needed and appropriate but the multi-year commitment offers service providers with a better business climate in which to work. Attention to workforce development is one of the greatest challenges facing Vermont's public system and this initiative is indeed a step in the right direction.
The swirl of budgetary pressures however, make is imperative for a careful analysis of the FY'07 budget proposal. There needs to be careful public analysis of impact of this decision on health and welfare of our community treatment system.
7. We call on the Administration and the Legislature to re-establish a commissioner-level post for the public mental health system in Vermont.
The decision to move the Department of Mental Health from Waterbury to the Health Department in Burlington was a proposal that the Vermont Association for Mental Health vigorously opposed. Disconnecting mental health from all the other Agency of Human Service departments in Waterbury, not to mention the Vermont State Hospital, is only a small but not insignificant part of the problem. The real issue is that in implementing this reorganization plan, public mental health leadership position was downgraded from a commissioner level to a deputy commissioner.
The reorganization plan has now been implemented for a year and our opposition is as vigorous as ever.
This transformation of the system may have made conceptual sense to many but in practical terms, it does not work. Public mental health needs and deserves an autonomous, empowered and independent leader and decision-maker. This would be true in the best of times but this is a period of complexity and change for our public system. Clearly Vermont's mental health system is a key component of our state's health care system. It is a system that commands considerable fiscal resources and it is a system that serves more than 15,000 citizens a year. With challenges from within and pressures from a changing federal landscape, this sector needs and deserves a commissioner.
It would take a bold move to re-establish the commissioner's post. However this administration has shown a willingness to make major changes at the highest levels of government and management as it did earlier this year. The precedent is in place; all we need is the resolve.
8. We call on our membership to remember the "lesson learned" from the Fletcher Allen Healthcare Saga, which reaffirmed once again the power of citizen advocates in shaping mental health and physical health care planning.
On September 8th, the new psychiatric unit at Fletcher Allen opened its doors, marking the end to an incredible and improbable advocacy campaign which not only reaffirmed that parity for mental health treatment is indeed a guiding state principle in Vermont but that the arrogance of power is both unwise and unacceptable.
We need to continue to build bridges to institutions like Fletcher Allen Healthcare and other regional hospitals and create a culture of mutual mission and mutual values about patient care.
9. We call on our membership to hold our "feet to the fire" in order to maintain and further expand the design and significance of our landmark mental health and substance abuse parity bill.
This legislation, Vermont's Parity bill, passed in 1997, is still the nation's best example of parity between behavioral and physical health care. Seven years after it was implemented, (January 1st of 1998), there is a need to consider both progress and problems as we work to craft ways of realizing its full purpose and its full potential.