NAMIGrading the States: A Report on America's Health Care System for Serious Mental Illness
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Grading the States 2006: Vermont - Narrative

Vermont stands at a critical juncture.

Traditionally, Vermont has excelled in clinical community care, integrating science into service, and adopting new models of care, as well as weaving consumer and family involvement into every level of the system. Its mental health insurance parity law is a national model that includes coverage of substance abuse. The state has a culture of rehabilitation and recovery.

It's an admirable record. The glaring exception has been the Vermont State Hospital (VSH) in Waterbury. The century-old hospital has lost federal certification twice, and a U.S. Department of Justice (DOJ) report in 2005 called the facility "dehumanizing" and "prison-like," in the course of cataloguing deficiencies in staff, psychiatric assessments, and risk- and quality-management systems, all of which translated into major safety concerns.

The DOJ report also exposed overuse of restraints and seclusion. Frequently, they were used for "staff convenience" or "punishment," as well as an intervention of "first resort," representing "gross departures" from good care. 

To its credit, Vermont adopted an attitude of collaboration with DOJ to address the problems that were uncovered - in contrast to California, which has faced a similar challenge to one of its state hospitals. The state has contracted with Fletcher Allen Health Center at the University of Vermont to improve staff training, staffing levels, supervision, and quality of care.

Nonetheless, the VSH problems represented a failure of leadership at high levels, with consequences that are still unfolding.

The state is poised to develop a new facility on the campus of the Fletcher Allen Health Center in Burlington, which has potential to integrate medical services and reduce the stigmatizing isolation that marked VSH. Going from one state hospital to none, however, and working with a private hospital, brings potential risks as well as benefits. Co-location with an academic center offers opportunities for collaboration and workforce development, but many pieces will need to mesh to make it work - including common vision, community alternatives, and institutional cultures. It also requires the state legislature to make a long-term financial commitment.

An ominous sign recently arose when the City of Vergennes defeated a proposal by the Howard Center for Human Services and Addison County Counseling Service to run a former nursing home as a 10-bed sub-acute care facility under contract with the state. The proposal was part of the plan for satellite intermediate care facilities to supplement the new Fletcher Allen facility. The Vergennes city manager claimed no confidence in the state's commitment to the Fletcher Allen plan, although other major factors were involved, including the stigma that often attaches to mental illness.

Unfortunately, the Vergennes action was the second notable controversy involving stigma within a year to mar Vermont's reputation. In 2005, the Vermont Teddy Bear Company marketed a "Crazy for You" bear wrapped in a straitjacket, with "commitment papers" listing symptoms of mental illness, as a Valentine's Day gift. It sparked a national debate over stigma and trivialization of mental illness in popular culture. The company no longer manufactures or sells the bear, but its CEO was forced to resign from the Fletcher Allen board as a result of the controversy.

Reorganization of the state system comes at a time when Dr. Susan Wehry has left the Department of Health to become the Medical Director of the Department of Corrections. There is some irony in the move, if only as a warning.

If the Fletcher Allen reorganization doesn't work, many people with serious mental illnesses may end up in the corrections system - a tragic, cost-shifting phenomenon that occurs nationwide, but is nonetheless a sign of failure.

People expect better of Vermont.

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