Small hospitals given big job: treating sometimes-violent psychiatric patients

MIDDLEBURY — Porter Hospital’s Emergency Department is used to dealing with people with serious cuts, broken bones and other physical ailments.
But for the past few years, Porter’s ED has been asked to accommodate patients suffering from ailments that can’t be sutured, splinted or even seen.
Porter and the state’s other community hospitals are now routinely housing psychiatric patients who require residential placements but cannot find such an opening with Vermont’s stressed mental health system. It is a service that has required the small hospitals to establish safe rooms and provide enough oversight to ensure the patients do not harm themselves and/or others as they wait to be sent to a facility that can deliver the services they need.
It’s a service that is taking a financial and emotional toll on the hospital and its Emergency Department staff, who must juggle the new service in concert with their regular duties.
“It is a burden on our staff not just because they’re not necessarily accustomed to having a patient in their unit for days and weeks at a time, but these patients are more than occasionally disruptive, and sometimes violent,” said Porter spokesman Ron Hallman. “I have seen that it is emotionally taxing on these employees and staff members, to be in an environment with someone for weeks who is trying to hurt themselves, or trying to hurt you … I say this from a place of sympathy, because these people are in situations they shouldn’t be in.”
Jennifer Peasley is a registered nurse assigned to Porter’s Emergency Department, and she is on the front lines of providing care to patients assigned to the safe room. She said the new service has proved a challenge for the department, though like Hallman and Dr. Fred Kniffin, chief medical officer at Porter Hospital, she is most concerned about the impacts on the patient occupying the safe room.
“The biggest challenge is seeing the patient not getting the treatment they need to get better,” she said.
Counseling Service of Addison County (CSAC) officials point to Tropical Storm Irene as the genesis of the current quandary. It was on Aug. 28, 2011, that a swollen Winooski River spilled over its banks and flooded the Vermont State Hospital in Waterbury. The hospital’s 51 mentally ill patients were evacuated to temporary locations throughout the state.
Community hospitals were asked to step up in a pinch to provide temporary beds to local mental health patients needing to be involuntarily committed, but for whom no psychiatric beds, like the ones formerly available in Waterbury, could be found.
“Before Irene, we never boarded psychiatric patients; it just didn’t happen,” Dr. Kniffin said. “(Psychiatric patients) would come in, they would be evaluated, and they would go to the psychiatric facility that met their needs. Maybe someone stayed eight or 10 or 12 hours, maybe overnight, but it worked.”
That all changed after Irene destroyed the Vermont State Hospital and its more than 50 beds dedicated for patients with severe mental illness.
“Since (Irene), we are always boarding patients,” Kniffin said.
Porter Medical Center last spring spent more than $30,000 to make one of its Emergency Department single-occupancy rooms safe for involuntarily committed patients who might pose harm to themselves and others. The 9- by-11-foot, windowless “safe room” consists of essentially four plywood-reinforced walls and a bed. There is no glass, cords or sharp instruments that a patient might use in an effort to commit suicide or to wield against others. There are no vents that might provide an avenue of escape. The electrical outlet can only be activated from outside the room. There is no interior doorknob on the lone door.
The accommodations sound Spartan, but the extreme measures have proved necessary, according to Porter officials. Kniffin recalled one of the initial safe room patients who requested, and was given, a family photo. That patient ended up breaking the frame and using the glass to hurt herself and also cut a staff member, according to Kniffin. Other staff members have sustained cuts, bruises, scrapes — but nothing that has left anyone with a long-term injury, he said.
“You have to be thoughtful about it,” Kniffin said.
Patients have been confined to the Porter Hospital room for periods ranging from a few days to three weeks, as they wait for a bed vacancy within the state’s mental health system that can meet their significant needs. Kniffin estimated the room is occupied around half the year.
And whenever that room is occupied, there are at least two paid people on duty: an Addison County Sheriff’s Department deputy to ensure security, and a clinician to tend to the patient’s basic needs, such as trips to the restroom and occasional walks outdoors.
The sheriff’s deputies’ wages for this round-the-clock supervision are paid through a contract with the Vermont Agency of Human Services. Addison County Sheriff Don Keeler said there are times he has had to assign two of his deputies to the Porter safe room when it is hosting a particularly violent patient.
“It depends on the circumstances; it depends on the violence,” Keeler said, noting his department has worked with Chittenden County to make sure there are enough deputies to do the job. “It’s been a tough haul, and it doesn’t look like it’s going to end soon.”
Porter Medical Center must pay the clinician’s wages. Porter receives no reimbursement from the state for the clinician’s wages.
“They are not being treated for an emergency,” Hallman explained. “We’re holding them. Our understanding is there’s no real source of reimbursement for that type of ‘holding.’”
Community hospitals routinely house a combined total of nine to 10 psychiatric patients in any given month, according to Vermont Department of Mental Health officials.
The patients in question are either local residents or folks who suffer a mental health crisis while traveling through Addison County, Kniffin explained.
“They come to us from police, or from rescue,” Kniffin said.
These patients are evaluated by a crisis team that can recommend involuntary committal. It is then up to Vermont Department of Mental Health officials to find a bed for the patient in one of the state’s psychiatric programs that best meets his or her needs. But if there are no vacancies, the patient may be confined to the Porter Hospital room for a lengthy period. Porter recently accommodated a patient for 21 days.
Hallman said Porter only receives reimbursement if the patient requires some sort of medical treatment.
“The reimbursement for these types of patients is extremely limited — nowhere near the resources we put into caring for them,” Hallman said.
Porter officials said they feel frustrated that patients who use the safe room are not receiving the intensive mental health care they need, but are rather in a holding pattern. Kniffin credited the CSAC personnel for visiting the safe room multiple times each day, but said there is only so much they can do for the patient within the confines of the small room.
“What makes people the most frustrated, is that the patient isn’t getting what they need. That’s what we should all feel a collective shame about. These are patients who are sick and not getting what they need,” Kniffin said. “We’re doing what we can, but we’re really holding; we’re not really treating.”
The safe room has also changed some of the dynamics of the Emergency Department, according to hospital officials. The department is set up as a place where patients come and go, and not for overnight care. Having a patient confined to one room under constant supervision has been “a complete game-changer for (the department),” Kniffin said.
“It’s a big, big strain,” Kniffin added. “It just wears (the staff) down.”
He praised the Emergency Department personnel for adjusting to the new service, in some cases taking special training to ensure mental health patients receive proper care.
At the same time that it is building a new state hospital, the state is reorganizing its delivery of mental heath care.
In 2012, Vermont passed Act 79, “An Act Relating to Reforming Vermont’s Mental Health System.” The goal of the new law was to create a new system of care placing less emphasis on institutionalization and more of a premium on integrating patients, whenever possible, in their communities with the supports they need to live more independently. Those supports — also referred to as “community enhancements” — include housing and various prevention programs aimed at counseling people with mental illness before they reach a point where they might need to be involuntarily committed to a residential facility.
“(The state) decided, ‘OK, we’re not going to build another big state hospital, we’re going to enhance services in communities,’” CSAC Executive Director Robert Thorn said. “The idea was to keep people close to home, in communities.”
This strategy and related funding allowed CSAC to introduce two new beds for patients in crisis; a day program providing group counseling and therapy for people suffering with mental illness; and various peer services. CSAC also has two group homes with 15 beds and two “crisis” beds for patients.
“Statewide, since the community enhancements were initiated, the number of people who have needed to be hospitalized in that population has decreased by 27 percent,” Thorn said. “That’s really, to me, a good indicator that these community enhancements work. Do we get everybody to divert hospitalization? Not necessarily … But clearly, on some levels, there are some good things going on.”
Since a premium is now being placed on treating mental illness within the communities, the severity threshold for residential placements has become greater, according to Greg Mairs, CSAC’s operational director.
The goal for the state’s mental health system, Mairs explained, is to get to a point where “only those who really as a last resort need an in-patient referral, make it to that referral process. Prior to (Irene), that wasn’t the case.”
With that in mind, Vermont mental health officials set a goal of having a smaller state hospital than existed in Waterbury. The new, 25-bed “Vermont Psychiatric Care Hospital” is under construction in Berlin and is scheduled to open July 1.
While work on the new Berlin hospital is under way, the state is contracting with several nonprofits to provide a combined total of 35 “Level One”beds for mentally ill patients requiring residential placements. Those beds and treatment programs are provided through Rutland Regional Medical Center (6); the Brattleboro Retreat (14); Green Mountain Psychiatric Care Center in Morrisville (8); and Fletcher Allen Health Care in Burlington (7).
Many of these patients, as they show improvements, are eventually diverted to other facilities or programs requiring less intensive services. But there are, of course, times when all of those level one beds are full. That’s when community hospitals like Porter are called upon to house patients until a spot opens up.
“A big part of the problem is length of stay. Over 60 percent of the people in those (14) beds at the Brattleboro Retreat have been there for more than a year,” Thorn said of the system. “Movement is critical.”
State and local mental health officials added there is no guarantee that community hospitals like Porter will be relieved of accommodating psychiatric patients when the Berlin hospital opens. When that facility opens in July, the Green Mountain Psychiatric Care Center in Morrisville will close, resulting in the immediate transfer of those eight patients to Berlin.
“We are not going to end up with a lot of new beds,” said Sen. Claire Ayer, D-Addison, and chairwoman of the Senate Health and Welfare Committee. “But we are hoping (psychiatric placements at community hospitals) become a rare event, rather than a common event.”
Thorn said a large part of the solution lies in “more housing,” and building up the community mental health system.
“We need to have the crisis beds empty so that people can come in there rather than go to a hospital when that level of care warrants, and we need something for people to go to to get out of the crisis beds, so that we open up the crisis beds,” Thorn said. “And we need something for people to go to when they’re ready to leave these (level one) beds.”
Prior to Irene, CSAC’s Mairs said the Vermont State Hospital would be asked to make room in an emergency for new patients.
“Before, the Vermont State Hospital was a catch-all,” Mairs said. “Once we called and got denials at every designated hospital in the state, VSH would have to find a way to house them in Waterbury, whether it was an extra bed in a room or a cot in a hallway … Now that capacity has been removed by the hurricane, hence the ERs have been assigned the task of having to support them as they await placement.”
A core team has been created by the state to evaluate each psychiatric patient’s needs as they are triaged to where they need to receive services. A “care management team” meets Monday through Friday and gets three updates per day from hospitals on bed availability, according to Thorn.
CSAC officials acknowledged that psychiatric patients are unfortunately not getting the mental health care they need while being temporarily housed in the community hospital emergency departments. It is a setting, officials noted, that does not lend itself to psychiatric treatment.
“Picture an individual who unfortunately ends up in a position of being held on involuntary status at Porter — it’s largely someone who is non-medication compliant and who is in a manic state,” Mairs said. “Therefore, they are not in a position to really be open and receptive to clinical interventions and supports.”
When the patient is willing to be cooperative and open to treatment, that’s when CSAC can be there, Mairs noted.
A bill is working its way through the Legislature, S.287, that could allow the state to treat and medicate some mentally ill patients against their will. House and Senate conferees will soon meet to try and resolve their respective differences on the bill.
Community hospitals continue to struggle on the front lines of society’s effort to deal with members of the community who are mentally ill.
CSAC officials credited Porter Hospital for the manner in which it is caring for the psychiatric patients.
“These difficult times have brought us closer together, I think,” Mairs said. “Porter Hospital has made huge strides in accommodating these patients.”
Reporter John Flowers is at [email protected].

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