BRATTLEBORO — After meetings last week between officials from the Brattleboro Retreat and the state, both sides say they are optimistic that the state's largest mental health facility will stay open.
While it appears that tensions between the Brattleboro Retreat and the state Agency of Human Services (AHS) are simmering down, the factors that created the crisis still remain.
Downsizing of the facility remains on the table as the state and the hospital look at “sustainable long-term solutions.”
“Of course, that would mean the potential for beds not being available when needed,” Konstantin von Krusenstiern, the hospital's vice president for development and communications told The Commons.
Noting that demand for Retreat beds “can fluctuate dramatically from day-to-day, week-to-week, and month-to-month,” von Krusenstiern noted that “it is difficult to plan for changes in need.”
In his State of the State address on Jan. 9, Gov. Phil Scott said the Retreat “is simply too critical for us to let fail, especially without an alternative” and its closure “would have a devastating impact on our mental health system and the region's economy.”
Scott said those in his administration would “do everything we can responsibly do to help.”
Mental Health Commissioner Sarah Squirrell echoed those sentiments but said that while a closure of the Retreat was not imminent, some short-term needs still need to be addressed.
In a statement by the Retreat after the governor's speech, spokesperson Jeffrey Kelliher said that “we are working diligently to refine our partnership with the Agency of Human Services based on shared goals and expectations, and the needs of Vermonters.”
That partnership “presents an exciting opportunity not only to address the short-term problems impacting our hospital, but to arrive at sustainable long-term solutions,” Kelliher wrote.
Part of that process is hiring an independent financial consultant to review the Retreat's finances and come up with a management plan. The goal would be to come up with improvements and efficiencies to improve the admissions process and increase the number of patients.
Currently licensed for 149 beds, the hospital is Vermont's only inpatient psychiatric facility for children and teens, and it has served as the de facto state mental hospital since the Vermont State Hospital in Waterbury was destroyed during Tropical Storm Irene in 2011.
However, the current crisis at the Retreat is just the latest manifestation of the ongoing problem that every hospital in Vermont faces - reimbursements for the treatment of Medicaid and Medicare patients that do not cover the cost of providing care.
Serving as 'the front door'
Steven R. Gordon, president and CEO at Brattleboro Memorial Hospital (BMH), also chairs the board of the Vermont Association of Hospitals and Health Systems (VAHHS).
VAHHS is the statewide advocacy association representing all of Vermont's nonprofit hospitals and health systems. Gordon said the Retreat's troubles dominated VAHHS's monthly board meeting on Jan. 8.
Gordon said in a Jan. 9 interview with The Commons that the Retreat and BMH have a close working relationship.
BMH's emergency department (ED) serves “as the front door to the mental health system,” said Gordon, with an average of three to five patients who have mental heath and/or substance abuse issues arriving daily.
Since the Retreat doesn't have an emergency department, Gordon said it is second only to Dartmouth-Hitchcock Medical Center in Lebanon, N.H., for patient referrals from BMH.
For incoming psychiatric patients - which Gordon said were mostly voluntary referrals - BMH stabilizes them and sends them to the Retreat.
Over the past couple of years, Gordon said, BMH has beefed up its staff to deal with mental health and substance abuse issues, and is working closely with the Retreat on these fronts.
A downsized or closed Retreat would have a significant impact on BMH's operations, he said.
“It is a huge concern of ours that we would have no place to send the voluntary or involuntary patients, that our ED beds would be occupied by patients requiring treatment, and that it would greatly affect our ability to handle medical and surgical patients,” said Gordon.
Gordon said that on occasion in 2019, BMH was close to having to divert patients from the ED because it was at full capacity from having to treat people dealing with mental health or substance abuse issues.
“This is a concern that every hospital has right now,” Gordon said. “It's not just a mental health issue. It is a health-care-system issue. It's not just about the mental health or substance abuse patients.”
“It is about all our patients,” he said - “not just at BMH but all the hospitals in the state.”
Wider impact
Gordon said every hospital in Vermont would be affected if the Retreat cuts services or closes.
“If the Retreat does not exist, it would definitely impact an already strained system,” he said. “If we don't have the ability to transfer patients who require mental health or substance abuse services in a different facility, that is going to further exacerbate the problems we're seeing in emergency departments around the state.”
Then there is the problem of Medicaid and Medicare reimbursements.
Gordon said that Medicaid pays for 70 percent of the patients at the Retreat, and there are not enough patients covered by private insurance to pick up the slack.
Gordon said that private psychiatric hospitals enjoyed prosperity during the 1980s when insurance companies would pay for an average of 21 days of inpatient care. When the insurers cut back on what they were willing to pay, many for-profit psychiatric hospitals either closed their doors or joined larger health-care systems.
“In a rural area, where you have an older population mostly dependent on Medicare and Medicaid, you will not see for-profit health care,” Gordon said, adding the Retreat does not have any entity they can merge or affiliate with.
Collaborations are critical for smaller hospitals such as BMH and Cheshire Medical Center in Keene, N.H., which are affiliated with Dartmouth-Hitchcock. For example, BMH and Cheshire Medical share emergency room doctors.
“Clinical collaboration has helped us survive,” Gordon said. “It has buoyed this hospital and created much more sustainable services in our community.”
Gordon said he, too, was hopeful that the Retreat's crisis can be resolved with a minimum of disruption.
“The Retreat has immediate needs,” he said, “and what they need most is a viable model going forward.”
He praised “some really good people in the Department of Mental Health,” noting that “they're accessible.”
“There's some good expertise to help [Josephson] work on this challenge,” Gordon said. “I am convinced of that.”
He said he was “optimistic that some way, somehow, we will be able to maintain those services.”
“This is Vermont, and people work together here,” Gordon said.