BRATTLEBORO — Sustainability. That's the key word repeated in conversations about the Brattleboro Retreat's recent announcement that it would close approximately six outpatient programs and lay off 85 employees.
The announcement from the Retreat did not happen in a vacuum and will likely affect multiple layers of the Windham County community, mental-health system, workforce, and economy.
What will the loss of the programs mean for other service providers who will likely fill the service gaps left by the closing programs? Where will the 85 employees find work?
What about the Retreat's clients, including the state? And are the state's expectations for its contractors reasonable, given the level of funding it provides in its contracts?
The question arises: what will sustainability look like for the Retreat and in the long-term, Windham County, and the Retreat's hometown of Brattleboro?
'The state is our best customer'
According to the psychiatric hospital's president and CEO, Louis Josephson, these downsizings - while painful and made with heavy hearts - align with the state Department of Mental Health's 10-year sustainability plan.
Work on the plan, “Vision 2030: A 10-year plan for an Integrated and Holistic System of Care,” was conducted last year, and the DMH presented the plan to the Legislature in January. The pandemic has delayed implementing areas of the plan that were scheduled to launch in the fall through a Mental Health Integration Council.
“Though this is an important step in assuring the Retreat's long-term survivability, it will no doubt have a tremendous impact on many of our valued colleagues, their families, and our broader community,” Josephson wrote in an Oct. 23 letter to employees.
The alternative, said Josephson, would have been the hospital's eventual closure.
The Retreat provides approximately half of the inpatient psychiatric beds available in Vermont.
According to Josephson, the average number of patients hospitalized involuntarily is 25 to 30 - more than in any other hospital in the state. Clients with these greater needs require more staff and incur higher costs for their treatment, he said.
The Retreat offers the only inpatient psychiatric services for children and adolescents in the state.
“The state is our best customer,” Josephson said. “We've been on shaky financial ground, and we want to work with our best customer - and it aligns with our mission, too, of course.”
At the end of this year, the hospital will eliminate two substance-use disorder outpatient treatment programs: the medication-assisted therapy Hub program and Starting Now, which treats individuals and groups. The hospital's Mind Body Pain Management Program will also close.
The hospital's education programs, serving children from infancy through 12th grade, will close: Mulberry Bush Independent School, Meadows School, and BRIDGES (Brattleboro Retreat Individually Developed & Guided Education Services), a therapeutic day school program.
Services that remain include the inpatient beds for children, adolescents, and adults. The youth residential programs and the Anna Marsh Clinic will stay open. So, too, will the community programs, such as the partnership with Groundworks Collaborative where a Retreat clinician serves clients of the nonprofit's shelter.
In Montpelier, a different perspective
During his two terms as governor, Phil Scott has often cited a goal of “making Vermont more affordable.” It's a tricky phrase. Many might agree that living in the Green Mountains is economically tough despite positive indicators, like an increase in the gross state product in recent years.
Yet not everyone agrees on which changes actually make the state affordable. Tax cuts to businesses? Paid family and medical leave?
In the case of the Retreat closing programs, sustainability could come with the same complexity and contradiction.
The Retreat and the Agency of Human Services have been working to create a sustainability plan for the hospital. Two pieces of legislation enacted in recent months have put firm conditions on the hospital and reference the plan, due to Senate Committee on Health and Welfare and to the House Committee on Health Care by Feb. 1, 2021.
The hospital is taking the actions to align with the state's financial goals - and, arguably, the Retreat's own needs - to right-size its financial situation.
One of Windham County's lawmakers, Rep. Emilie Kornheiser, D-Brattleboro, said that, in the long term, the changes at the Retreat might be what's best for Vermont's overall health-care systems.
In the short term, however, the retrenchment risks are hurting the employees, the people served by the hospital, and the community, said Kornheiser, who believes that some of the issues between the Retreat and the state might be a matter of perspective.
Unlike in other areas of Vermont that don't rely as heavily on these types of community-based services, in Windham County, these services are essential, and the Retreat's outpatient programs are a part of this service network, she said.
But in Montpelier, the Retreat is about inpatient and residential programs, Kornheiser said.
“The reality on the ground looks quite different than what [the Agency of Human Services] or Retreat leadership might be describing,” Kornheiser said.
“While I do agree that changes at the Retreat might be in the long-term interests of patients and the service system, what this looks like on the ground is the elimination of most community-based services and the retention of services that serve the state,” she noted.
Not happening in a vacuum
Josephson attributed the program closures first to the state and hospital's sustainability plan, which he referred to as the “driving document” behind the Oct. 23 announcement.
The pandemic, too, has made things difficult and uncertain, he said. For example, if a client shows COVID-like symptoms, the hospital must freeze admissions.
“We felt we had to take steps sooner rather than later to shore ourselves up because the future is uncertain in regard to the pandemic anyway,” he said.
There are still questions to answer - within two short months - about transitioning clients to other programs. Josephson pledged that these “warm hand-offs” will happen.
Kornheiser also raised issues of accountability.
According to her, many of the funding sources, contracts, and licenses attached to the Retreat's soon-to-close programs sit with a variety of state agencies and departments. The Meadows School is overseen by the Agency of Education, multiple supervisory unions, and the Department for Children and Families.
With so many agencies involved, which, if any, is ultimately responsible for ensuring the Retreat's clients' needs are met?
“Who exactly in the administration will be responsible for ensuring that the incredibly vulnerable populations served in each of these contracts will not experience any more adverse impacts?” Kornheiser asked.
Over the years, the Retreat has taken on providing more state-funded services - inpatient and outpatient - which are not reimbursed at a level that reflects the “true cost of care,” she said. Instead, hospitals fund raise to make up the difference.
In her opinion, in the case of the Retreat, the Scott administration “never admitted [its] culpability” for how this gap has contributed to its deficit.
She continued, “Additionally, if the Retreat was not able to run these programs or contracts sustainably, why would another community partner want to try, and why would they succeed?”
If the program closings and client or employee transition plans are mishandled, Kornheiser said, the results could be dire - even life-threatening.
“We're all in this together,” she said. “No one here is an enemy.”
Kornheiser and fellow Rep. Tristan Toleno, D-Brattleboro, both pledged to hold the Scott administration and Retreat accountable for planning transitions for the laid-off employees and clients.
Toleno, whose district includes the hospital, echoed Kornheiser's concerns. He placed a lot of responsibility on the Scott administration, whose agencies have been very involved in building the Retreat's sustainability plan.
The Retreat is not entirely accountable for its funding situation, he said. Toleno added that in some cases, for-profit mental health businesses have attracted easier-to-serve clients, leaving hospitals like the Retreat to care for people with more complex needs.
A shift toward community-based programs, but a focus on inpatient services
The state has provided the Retreat with additional funding to help it through some financial challenges as well as issues fueled by the pandemic.
For example, a year ago, the Retreat and the state Agency of Human Services (AHS) signed a Memorandum of Understanding for $16 million in funding. In April, the hospital received additional funding to fill budget gaps - such as a decline in the number of patients - created by the pandemic.
The takeaway of that collaboration thus far is that, to reach sustainability, the hospital needs to cut $8 million from its annual budget. The Retreat would also shift, or “re-focus,” according to Josephson, on inpatient psychiatric care.
“This is both consistent with our history, current state needs, and alignment with the Department of Mental Health's 10-year plan for service delivery,” wrote Josephson.
The 10-year plan emphasizes a lifelong approach that incorporates mental health into a person's routine health care, a model that could make the Retreat's outpatient programming redundant.
The plan also encourages patient-led services through community-based programming as well as peer services.
“While driven by financial necessity and the healthcare needs of Vermonters,” said Josephson, “our focus has been to assure the continuity of our mission and maintain critical mental health services that only the Retreat has the infrastructure, capacity, and willingness to provide.”
Josephson said that approximately 150 clients are served by the programs set to close at the end of the year. He said that staff is finding new programs or placements for them.
“I can't deny the impact,” he said. “But as everybody knows, we've really had our financial struggles in the last couple of years and so, like any business, we've had to make tough decisions.”
Unlike other businesses, Josephson added, the Retreat doesn't manufacture widgets no one will miss. Instead, the hospital cares for people.
The program closures are “very aligned” with the state's 10-year sustainability plan and the Retreat's need to strengthen its finances, he said.
“We were asked by the state to work on a sustainability plan,” Josephson said. “The first goal in that plan was to essentially double down on the Retreat as an inpatient psychiatric resource for the state and to grow that capacity.”
According to Josephson, even though the state's plan focuses on shifting to more community-based services, the state's mental-health system also needs more inpatient services - and this is the role the Retreat will fill, he said.
The sacrifice of the programs will help ensure that the unique programs the Retreat offers, such as child and adolescent inpatient services, will continue to exist, Josephson noted.
He added that not all of the program decisions were only about the bottom line. For example, the Hub program had once served 160 clients but now serves 70. The school, especially during the pandemic, has seen a drop in student enrollment.
To Josephson, these drops in numbers demonstrate that clients are looking for different programs.
Focusing on the inpatient programs will bring the Retreat back to its roots and its mission, he said.
Josephson said he wouldn't “sugar coat” the loss that also accompanies the closures for the community, employees, and clients.
Regarding the Mulberry Bush child care programs, which serve approximately 30 children, Josephson said that he is working with local providers to take over the program and rent space from the hospital.
Winston Prouty Executive Director Chloe Learey confirmed the conversations are ongoing. She said multiple child-care advocates and providers are investigating the possibility of taking over the program and operating it at the Retreat.
If such plans do not emerge, the loss of the program would come at a time when the pandemic has highlighted the crucial role early child care plays in parents' or guardians' ability to participate in the workforce.
According to advocacy group Let's Grow Kids, for Windham County to meet its demand for quality child care, providers would have to create 377 more spots for infants, 52 more for toddlers, and 225 for preschoolers.
“We don't have the capacity in the community right now to absorb all these [Mulberry] kids,” Learey said. “This is a big blow.”
Learey's comments point to the ripple effects already felt in the community from the Retreat's program changes.
Rhianna Kendrick, director of operations for Groundworks Collaborative, said the organization is still evaluating how it will respond to the Retreat's program closures.
Kendrick said that the programs will close during the holiday season, already a traditionally stressful time of year for many people.
How clients are expected to transition to new programs and how those transitions will actually unfold will probably be two different things, she said.
For example, said Kendrick, several of Groundwork's clients have connected to the Retreat's outgoing Hub program more easily than they have connected to the community-based spoke programs. She added that the Hub medication-assisted treatment program has offered buprenorphine, while the local spoke providers, such as Habit OPCO, offer only methadone.
Most mental health providers face the complicated question of how to create truly accessible programming that not only meets clients where they are, but also is also fully funded, she said.
As is the case at the Retreat, the federal and/or state reimbursements aren't sufficient to cover costs for many mental health providers.
Groundworks Executive Director Josh Davis - also a member of the Retreat's board of directors - added that in a wider context of mental health services, part of the issue facing community-based providers is one of investment.
Current clients have at Groundworks have many of the unmet needs, which are an offshoot of deinstitutionalization of inpatient facilities in the 1970s, he said.
Davis supports community-based services as an alternative to the centralized asylums they replaced. Yet, he continued, the federal and state governments have failed to make comparable investments in community programs. The system as a whole is playing catch-up, he said.
Rep. Laura Sibilia, I-Dover, said that she wants to see a transition plan for clients.
The Retreat is just one struggling hospital in a struggling national health-care system, she added.
“We are not solving this issue on our own,” she said. “This is a wicked game of Jenga.”