Legislative Update

Rep Anne Donahue

November 24, 2007

Sometimes getting a fresh perspective helps. That appears to be occurring as the Legislature hears back from consultants hired to review plans to replace the decertified Vermont State Hospital.

Seven committees met a few weeks ago to get a chance to question the consultants on their findings. Rep. Maxine Grad, as a member of House Judiciary, and I, as a member of House Human Services, were there.

The report had several core messages:

Throughout its history, VSH has served many different needs. We know those services don’t belong together in a large replacement institution. Now that we have the opportunity to start fresh, we can do better to meet the needs of those currently at VSH.

Short-term, acute care for initial treatment of a serious illness belongs in a medical center. When long term rehabilitation is needed after acute care – just as after a stroke or hip surgery – it needs a different setting and focus.

Most care belongs in the community, through outpatient providers and clinics. Access to all care should be as close to home as possible, where a person’s natural supports are, not in one central location.

I haven’t mentioned the words “mental health” in the summary above. As the Institutes of Medicine said in its series on “Crossing the Quality Chasm,” the same fundamental principles apply to all health care: that it be safe, effective, patient-centered, timely, efficient, and equitable.

What planning model do those core conclusions suggest?

First, strengthening of community supports in prevention and primary mental health care. The last statewide health survey that found that shortages in psychiatry were leading to unnecessary hospitalizations, because it took a crisis for a person to get services. It shouldn’t surprise us, nor can we shirk responsibility, when inflationary pressures for this care equals that of other health care.

There also need to be adequate numbers of longer term residential rehabilitation programs to get folks out of the hospital when they no longer need it. A very limited number of those beds (at most 15, statewide) need to be in a secure setting for those rare situations where the symptoms of an illness could create public safety concerns.

Acute care beds need to be redistributed from Waterbury to general hospitals. While much of Vermont currently meets the state’s Health Resource Allocation Plan for access to inpatient care, that isn’t always true for emergency services when needed at more rural hospitals.

In addition, throughout health care, higher levels of services are being diverted to community hospitals. There must be assurance that there is an appropriate population-based distribution of beds for serious psychiatric illness.

Finally, we don’t want quadruple bypass surgery accessible at every hospital. That tertiary level of care needs to be located where specialized resources and expertise have been gathered. This is equally true for severe, treatment-refractory psychiatric illness.

Meeting these goals – identifying the right types of care in the right numbers and the right places – is the essential planning task remaining. Having the support of the consultant report is a valuable tool towards implementing the Futures plan that was first sketched out in 2005.

One challenging issue remains. How do we address those who do not have the capacity to make their own medical decisions, particularly if it affects where that care can be delivered?

Whether it is your grandfather suffering from dementia and wandering away from home, your seriously developmentally delayed cousin who needs birth control, or your partner on life support, we set standards as a society about how to make choices for and protect the rights of those who cannot make their own decisions.

Money cannot be the driver to limit the right of self-determination. Hitching grandpa to a clothesline would cost less than home care, but that does not make it acceptable.

What the person would have wanted, if able to decide, must be paramount. In our law we affirm that “The state of Vermont recognizes the fundamental right of an adult to determine the extent of health care the individual will receive.” The Institute of Medicine tells us that mental illness, even psychosis, does not necessarily affect decision-making capacity.

The United States and Vermont constitutions require that the state cannot take away one’s rights to freedom or to choose medical treatment without clear proof of lack of capacity as well as strong justification. Finding the right balance for one of the highest levels of invasion of personal autonomy — the involuntary injection of mind-altering drugs — can be challenging, but it is not impossible.

The cards are beginning to fall into place to finally make serious progress on closing the doors of VSH forever. That need is the one issue that has unified the players, and must drive planning forward. We must move ahead firmly without losing sight of our guiding principles of a system that is consumer-directed, trauma-informed and recovery-oriented.