Of all the staffing changes announced on Tuesday by Governor Shumlin, the one that caught my eye was the departure of Patrick Flood as Vermont’s Mental Health Commissioner. After only eleven months on the job, he’s being shifted to an unnamed position in state government. And although they haven’t found him a landing spot, he’s leaving his current job right away; Mary Moulton will serve as acting commissioner while the administration searches for a permanent replacement.

It seemed rather abrupt. And at the time, I speculated that Flood may have been shunted aside. That’s apparently not true; I’ve been told that the Shumlin team pressed him to stay on, but he was insistent on leaving.

It’s been a difficult year for Patrick Flood. And if he finally decided that he’d opt for an uncertain posting rather than keep on doing this job, I can’t say I blame him. I think I’d do the same. On multiple levels, this process has been something of a clusterf*ck.

Let me pause for a moment to make something clear: what follows is not based on any inside information or secret sources. This is inference and interpretation based on what I’ve read and observed.

After the jump: the waning of optimism, questions about FEMA delays, and a belated call for clinical experience.

An increasingly cloudy outlook

Flood became Mental Health Commissioner in December 2011 (less than four months after Tropical Storm Irene) in an unusual job-swap: he changed places with Christine Oliver, who became Deputy Secretary of the Agency of Human Services. At the time, Flood expressed enthusiasm for Shumlin’s plan.

Flood said he was impressed by the cooperation and hard work of everyone in the field, though he warned “hard choices” lie ahead.

“Together we will come up with the best choices for Vermonters, I am sure,” he said

The public optimism was unabated through the 2012 legislative session, where the plan was tweaked (25 beds in Berlin) and approved. But over the ensuing months, Flood’s outlook became increasingly cloudy. Here he is in mid-June:

“Basically, things are going pretty well,” said Flood… At the same time, stresses and strains on the system remain, he said, and it will be January before the new system begins to “really turn the corner.”

“We literally spend hours every day making sure somebody can get a bed and we don’t always succeed,” said Flood, with the result that sometimes patients end up being parked in emergency rooms until space is available.

And in mid-August, reacting to continued delays in securing FEMA funds for mental health facilities:

“We are nowhere out of the crisis yet,” and the state could not afford to delay planning for the new hospital, which is on a tight schedule with plans to open in January 2014. Flood said patients are still finding themselves stuck in emergency rooms waiting for beds to open up for treatment.

Then, in mid-October, we got this gloomy outlook:

“It is literally like we’re fixing an airplane while we’re flying,” he told the committee. “It’s going to take time. We’ve been doing business a certain way for a long period of time and now we have to change it all.”

Flood said the current budget environment he’s working through is the most difficult he’s ever encountered.

And now, less than a month later, Patrick Flood is choosing Door Number Three despite the pleas of administration officials that he stay on. Perhaps he grew tired of playing Mechanic In The Sky.  

If things have been tough for Flood, they’ve been worse on the front lines. Anyone who works in a Vermont hospital can tell you that it’s very common for psychiatric patients to be stashed in emergency rooms, sometimes for multiple days. Marginal patients may be discharged sooner than they should, for the sake of opening a bed. Patients are shunted from facility to facility. Patients with different needs are often mixed, leading to dangerous (sometimes violent) situations. Doctors spend a lot of their time shuffling patients and searching for open beds instead of, oh, providing care.

Meanwhile, three things have been happening with the overhaul. Short-term fixes have been delayed, with scheduled openings and deadlines repeatedly pushed back. The long-term plan has been expanded from the original stripped-down version more than once. And, of course, fundamental uncertainties about FEMA funding still remain.

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Whose fault is the FEMA mess?

There’s been a lot of criticism for FEMA’s role in the delays. Mixed messages, changes in personnel, unclear regulations and procedures have all been cited. But it’s been almost a year and a half since Irene, and a decision by FEMA is nowhere in sight.

The Shumlin administration may be part of the problem. There are indications that the state is trying to fudge the rules in order to get more money.

First, there’s the question of whether the Vermont State Hospital was really a total loss. After the flood, there were many who believed that VSH could be refurbished — at least as a temporary hospital, and perhaps as a permanent one. But Governor Shumlin was adamant that the state would never return to VSH.

In early August, we learned that FEMA had issued an initial rejection of the state’s request for replacement of VSH and the Waterbury state office complex. Why?  

Jeb Spaulding, the secretary of the Agency of Administration, said that a contractor used the word “damaged” instead of “destroyed” in a set of recommendations the state filed with the Federal Emergency Management Agency.

This was depicted as a sort of clerical error on steroids. But what if the contractor meant what he said? What if VSH can’t be classified as “destroyed”? In that case, FEMA’s initial rejection may become permanent, or Vermont may get a lot less money than it had hoped. FEMA is responsible for restoring losses, not building new stuff. If VSH could have been repaired and reopened, then why should FEMA pay for a brand-new facility in Berlin?

A second problem area came to light in mid-October. This time, it’s the difference between “temporary” and “permanent” facilities.

Flood and Spaulding said the Middlesex and Morrisville facilities should have no problem receiving FEMA funding for construction costs because they are temporary facilities that are being built as a result of a disaster. But, said Flood, nothing is definite.

“They usually pay for the temporary ones and not the permanent ones,” said Flood.

The harder sell, they conceded, is convincing FEMA that the Rutland and Brattleboro units are both “temporary and permanent,” as they put it.

Which would seem to be a deliberate stretching of FEMA regulations. Rather than simply repairing what was lost in Irene, the Shumlin administration is trying to get FEMA to underwrite the cost of an overhauled mental health care system. Again, that doesn’t seem to be FEMA’s mission.

The state is having the same problem with FEMA over the rebuilding of highway culverts. The state wants larger culverts with more capacity to handle future floods; FEMA wants to restore the culverts to their pre-Irene state.

If Vermont is trying to game the system to prop up Shumlin’s vision, then (a) it would explain the lengthy delays, and (b) it raises the possibility that the administration will get nothing like the federal money it’s hoping for. And the blame would fall on state officials, not the feds.

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A need for clinical experience

After Tuesday’s news conference announcing the staff reshuffle, reports VTDigger, “Flood said that it’s time for a person with clinical mental health experience to run the Department of Mental Health.”  

Well, that would certainly be a change of direction. The entire process, from its very beginning, has had little or no clinical input. Executives, administrators, and politicians have held sway throughout. The advice of actual clinicians has been ignored.  

Let’s go back to December 2011, and the announcement of the Shumlin plan.

The unveiling of Shumlin’s proposal came on the same day a top mental health psychiatrist called for almost the exact opposite of what the governor proposed. Dr. Jay Batra, medical director of the state hospital since 2009 and a professor at UVM, told lawmakers at a hearing on Tuesday that the state should have one central mental health facility serving 48 to 50 patients in order to provide the best clinical treatment and best staffing model.

…Dr. Batra, who was questioned closely by lawmakers, said that a central facility works best because staff can train together and gain the expertise to deal with severely ill patients and patients can get peer support. He also said he felt there was a demonstrated need for 48-50 inpatients state hospital beds.

A few days later, Dr. Batra said that he “was not consulted on the governor’s proposal.”

The head of the Vermont State Hospital, presumably the most qualified person in the state on caring for the severely mentally ill, was “not consulted.” Does that seem curious to anyone besides me?

In January, three of Vermont’s top psychiatrists echoed Dr. Batra’s views.

Take psychiatrist Terry Rabinowitz of Fletcher Allen Health Care in Burlington, who said the state’s plan for acute mental health care falls short and marginalizes the state’s most vulnerable population. He called it “not only a disservice but a dishonor.”

…Dr. Peter Thomashow, medical director of Central Vermont Medical Center… said the governor’s plan simply underestimates the difficulty of the patients who were sent to the state hospital, many involuntarily. Professionals in the wards and emergency rooms see things differently, he said.

“We’re talking about the most difficult population in psychiatry,” he said.

And, at an early January hearing…

[The House Human Services Committee] got a front row seat on the central disagreement over the plan when they were told via speakerphone by the head of Fletcher Allen Health Care’s psychiatric unit, Dr. Robert Pierattini, that the state cannot get by without a 30-40 bed state hospital staffed to handle patients needing intensive mental health care.

…Pierattini said the state needed a “Level 1” intensive care mental health facility with 30 to 40 beds to replace the Waterbury State Hospital, and the facility absolutely needs to be in a medical center and provide the full range of medical care.

When the Legislature was pondering the Shumlin plan, the views of clinicians were not heeded. Now, says Flood, after a very difficult year, “it’s time for someone with clinical mental health experience.” Ya think?

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Stresses and strains

The Brattleboro Retreat is a centerpiece of the Shumlin plan. With 14 inpatient beds, it would be the second-largest facility in the mental health care system. And now the Retreat is having labor unrest and budget troubles. On Monday, unionized workers held an informational picket to spotlight the lack of progress in contract talks, and what it sees as “demoralizing” requests for concessions by Retreat management — at a time when the Retreat has gained a measure of financial health, and when workers have been stretched to meet post-Irene demands.

Then, two days later, the Retreat announced a total of 31 layoffs. citing “projected deficits in 2012 and 2013.”

These may be simple bumps in the road. But the Retreat has had more than its share of fiscal and managerial problems in the past. Under the Shumlin plan, the state will be relying on the privately-run Retreat to take the place of a state-run facility. Can the Retreat be counted on to consistently deliver what it has promised?

Also, with planned multiple facilities to replace a single VSH, the chances for NIMBYistic delays are multiplied. This is already happening in Middlesex, where a homeowner is trying to block construction of a small secure facility next to his property. The dispute may end up in court.  

What’s worse are the real problems with staffing and supplying multiple facilities. The initial cost of a new VSH would have been higher, but would have allowed long-term savings from economies of scale. Even worse, as Dr. Batra said last December, is the dilution of expertise that may permanently degrade the quality of care. And since the new system will have fewer beds spread around the state, there will be an ongoing need to shuffle patients around the system. That can’t be a good thing.

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Conclusion

If there are answers to some of the questions I’ve raised, I’m happy to hear them and report back in this space. But looking back over the course of this issue from last December through today, there are a lot of warning signs. And I’ve been told that where there’s smoke, there’s usually fire.

Generally speaking, I give the Shumlin Administration very high marks for meeting the challenges of post-Irene reconstruction. But I have serious doubts about the wisdom of its mental health care plan, which has been bedeviled by delays and uncertainties and may have been ill-conceived from the start. In the meantime, people with significant mental illnesses are getting much less than the treatment they need. And even after the ongoing crisis is resolved, we may be left with a misconceived and underfunded system.