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The medical treatment and rehabilitation services most commonly available to people with serious mental illness are provided by the "public mental health system." This term is noted in quotes because the services are largely provided by private mental health agencies but paid for by public money, in a manner somewhat more independently than one might expect in a true public system. People with serious mental illness may also be patients of private practice psychiatrists and psychologists, but the impoverishment and severity of disability of most clients limits their selection of treatment providers to those willing and eligible to be paid by state-controlled Medicaid. With some exceptions, only the public mental health system provides the community support programs so important for rehabilitation and recovery from long-term mental illness.
Since 1986, the Vermont Department of Mental Health and Mental Retardation has been involved in an innovative project known as ‘regionalization,’ or ‘deinstitutionalization,’ whereby state resources have been shifted from inpatient care at the state hospital to less restricted, community-based care, even for individuals with the most severe mental illnesses. The State continues to manage and operate the state hospital facility in Waterbury, but the institution, which at one time had a patient population of about 1,300, now maintains an average of about 60 people. The Vermont State Hospital (VSH) is used exclusively for involuntary admissions of people with mental illness who are of danger to themselves or others. All others with mental illness live in the communities and receive their treatments and services from Community Mental Health Centers (CMHCs). The services of the CMHCs are contracted for by the Vermont Department of Mental Health and Mental Retardation. Under the contract provisions, most of the agencies provide services to the ‘priority populations,’ established by state statute: 1) adults with serious and persistent mental illness, 2) children with severe emotional disturbance and their families, and 3) individuals with mental retardation. Some also offer substance abuse treatment and services on a contract with the state Office of Drug and Alcohol Prevention, and adolescent behavioral counseling on contracts with school districts.
There are ten private, nonprofit CMHCs in Vermont, each with an independent identity, a chief executive officer, and a staff of psychiatrists, mental health clinicians, and case managers. Each agency is governed by volunteer community members who serve on the board of directors; board members are normally local business people who may or may not have an understanding of mental illnesses, mental retardation, clinical treatments, support services or the strategic direction of the Vermont mental health system. The role of CMHC board members is to hire and oversee an effective executive director and establish policies to maintain the integrity and financial stability of the agency. The clinical staff (service providers) of each agency is responsible for determining treatment plans and necessary support services, under the supervision of the agency executive director.
Each agency has a preferred provider status with the State, which means it has the right to provide clinical and support services on behalf of the State in a given geographical region, and receive compensation via state-controlled Medicaid, federal mental health block grant funds and state government general funds. Each agency has a direct linkage with the Vermont State Hospital, and a responsibility to provide services to patients who are released from the hospital after becoming stabilized from an acute episode. Most, but not all, agencies have group homes and contracts with community care homes to help individuals make the transition from hospitalization to independent community living.
The agencies are currently paid on a fee-for-service basis, and generate additional revenue from private insurance and local service contracts. All of the agencies, like other health care providers, are restructuring to accommodate the managed care concept currently embraced by government and private industry efforts to achieve health care reform.
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