Ready or not, Vermont is on its way to a decentralized mental health care system that will spread inpatient services around the state and place more of the burden on community-based treatment programs. More resources have been promised, so that these programs can provide better services to more people.

A couple of recent news items raise serious questions about the plan. The first reveals that Vermont routinely violates its own law on transporting severely mentally ill people by putting them in handcuffs and shackles. The second regards the death of a young man who’d been living in a small — ahem, community-based — mental health treatment facility.

Details after the jump.  

1. Vermont AP: Vermont Routinely Violates Law on Moving Mentally Ill.

In 2003, the Legislature passed a law requiring “the least restrictive means necessary” when transporting mentally ill people who are involuntarily under the state’s care. The law was updated two years later. Since then, it’s been pretty much ignored.

A very small percentage of patients are combative or are deemed to present a threat of violence, psychologists, sheriffs and others said. But about two-thirds of patients being moved by sheriffs or police are in handcuffs and ankle chains, data compiled by the state Department of Mental Health show.

The post-Irene closure of the Vermont State Hospital, and the increased use of the Brattleboro Retreat, has meant more transports over longer distances. Hence, more shackle time. How therapeutic.

Deputy Mental Health Commissioner Mary Moulton acknowledged the mental health system was not living up to the terms of the law… Moulton said her goal is to see, within a year, at least 60 percent of Vermont’s transports of mental health patients done without law enforcement involvement or the use of restraints.

It’s difficult to see how she’ll do that. Over the past five years, about three-quarters of such transports were done by sheriffs’ deputies or police — who lack the expertise to evaluate a patient’s potential for violent behavior. Their first concern, understandably, is security.

It might seem strange… counterproductive… unhealthy… for patients to be shackled and transported via police cruiser. Why not an ambulance? Two guesses, and the first one don’t count.

A ride with a sheriff is cheaper than one in an ambulance. And Jim Finger, president of the Vermont Ambulance Association, said some ambulance services balk at long-distance transports of patients covered by Medicaid because reimbursements from that government health insurance program are too low to cover the ambulance crew’s costs.

There’s also a numbers issue: if ambulances take over the transport duties, we’ll need more ambulances and EMTs. This will be a perpetual problem in a decentralized mental health care system, for two reasons:  

a. The balancing act. It’s easy to assign patients to beds in a single facility. But if, say, Brattleboro is full and Rutland has open beds, then some patients will be transported to Rutland. The entire system is designed to maximize use of available beds, so all facilities will be operating near capacity. Which will lead to frequent transports to get patients to available beds.  

b. Different patients, different issues. Some patients are violent, some are highly vulnerable. There are women and men, children, youths, adults, seniors. In the Shumlin system, patients will have to be moved to keep them away from incompatible patients, or to get the specialized care they need.  

So the question is this: if Vermont has been knowingly breaking its own law in order to save some bucks on patient transport, is it going to foot an ongoing and potentially larger bill in the future?

2. Vermont Digger: Patient’s Death at Eagle Eye Farm Leads to State Probe.

This story concerns the January death of Justin Ponzio, who was under the care of Eagle Eye Farm, a Northeast Kingdom residential facility for “traumatic brain injured survivors as well as other ‘at-risk’ populations,” acceding to its website. Ponzio walked away from the Farm on the night of January 5; his body was found the next morning. He’d apparently frozen to death.

The case has prompted two state investigations, and opened concerns about state oversight of community-based treatment facilities — which are about to become a more central part of our mental health care system, and are likely to see a larger and more demanding patient population.

VTDigger has learned that Eagle Eye Farm was cited for a number of serious deficiencies in two unannounced inspections by the Division of Licensing and Protection, which conducts inspections and oversight for the federal Medicaid program.

The deficiencies included a lack of training for staff, no background checks for most of its employees, and outdated and incomplete records for its patients. It was also providing custodial rather than therapeutic care. After the first inspection, Eagle Eye’s administrator provided a detailed action plan. But six months later — and about four weeks before Ponzio’s death — a second inspection found that Eagle Eye had failed to correct some of the violations.

A key issue in extensive legislative discussions on the new statute implementing the overhaul was assuring “the highest quality of care” in the new system through a broad array of reports and metrics, as well as creating an oversight system for patients under the “custody of the commissioner of mental health.”

If the Eagle Eye Farm case is anything to judge by, the state has a long way to go before it can assure high-quality care in the new system. For those who welcome the shift to community-based care, this should be a huge area of concern.

I’ve had my own experience searching for a good placement for a close relative, and I can tell you from bitter experience that it’s really difficult. A lot of places look good at first glance, and the deficiencies only become obvious over time. Almost every facility falls short of its promises — most often, providing care that’s more custodial than therapeutic. Under the Shumlin plan, we’ll be placing a greater burden on a licensing and regulatory system that seems incapable of handling its current responsibilities.

I’m not saying the Shumlin plan can’t work. But it will face significant obstacles, most of which have to do with resources. And to judge by these two news stories, the system already has big problems in that area. Given the fact that Shumlin wanted a 16-bed hospital because that was the best way to maximize federal dollars, can we trust him — and his future successors — to increase and then maintain the state’s financial commitment to mental health care? If not, his plan may turn out to be a slow-motion disaster.