Act No. 79 (H.630). Health; mental health care reform

An act relating to reforming Vermont's mental health system

This act strengthens Vermont's existing mental health care system by providing a continuum of flexible and recovery-oriented treatment opportunities, which are fully integrated with substance abuse, public health, and health care reform initiatives, consistent with the goals of parity. A clinical resource management system is established to coordinate the movement of individuals to appropriate services throughout the continuum of care and to perform ongoing evaluations and improvements of the mental health system. The clinical resource management system shall facilitate an array of functions, including the use of coordinators to assist emergency service clinicians in the field, the use of an electronic bed board to track available bed space, the coordination of patient transport services, access by individuals to a mental health patient representative, and the periodic review of individuals' clinical progress. The overall effectiveness of the mental health care system shall be the subject of an annual report by the department of mental health (DMH), which shall focus on the utilization of services within the system, the adequacy of the system's capacity, individual experience, and the performance of the system as compared to national standards.

This act establishes a geographically-diverse system of mental health care with treatment opportunities that vary in degree of intensity. Peer services, provided by individuals with personal experience of living with a mental health condition or psychiatric disability, are at one end of this spectrum. This act empowers the commissioner of mental health to contract for peer services that are aimed at helping individuals with mental illness achieve recovery through improved physical and mental health, increased social and community supports, and avoidance of crises and hospitalizations. More specifically, the commissioner is authorized to develop peer-run transportation services and a nonemergency telephone response line.

This act also expands and strengthens Vermont's network of community mental health services. Designated agencies, with support from the DMH, shall improve emergency responses, noncategorical case management, mobile support teams, adult outpatient services, and alternative residential opportunities. In addition, the DMH is authorized to contract for at least four short-term crisis beds in designated agencies to prevent or divert individuals from hospitalization when clinically appropriate, as well as a voluntary five-bed residence for individuals experiencing an initial episode of psychosis or seeking to avoid or reduce reliance on medication. Other community services authorized in this act include housing subsidies for individuals living with or recovering from mental illness.

The commissioner of mental health is authorized to contract for intensive residential recovery facilities, meaning licensed programs providing safe, therapeutic, recovery-oriented residential environments to care for individuals in need of intensive clinical interventions in anticipation of returning to the community. Fifteen intensive residential recovery facility beds shall be located in northwestern Vermont, eight beds shall be located in southeastern Vermont, and eight beds shall be located in either central or southwestern Vermont. This act requires that the placement of these facilities be subject to a certificate of approval process, which shall take into consideration recommendations from a panel of stakeholders.

For the purpose of replacing those services provided by the former Vermont State Hospital (VSH), this act empowers the DMH to oversee the delivery of emergency examinations and involuntary inpatient treatment services at several acute inpatient hospitals throughout the state. The DMH shall establish by contract a 14-bed unit and a six-bed unit within existing hospitals in southeastern and southwestern Vermont, respectively. It is the intent of the general assembly that these units be located at the Brattleboro Retreat and Rutland Regional Medical Center. The establishment of these two units shall be contingent upon the hospitals' receipt of certificates of need pursuant to 18 V.S.A. chapter 221, subchapter 5. In addition, the initial contract terms for these hospital units require participation in the no refusal system for four years, meaning that the hospitals shall be required to admit any individual for care if the individual meets the eligibility criteria established by the commissioner in contract. Contracts for these two hospital units shall contain a number of conditions, including specifications that funding shall be based on hospitals' ability to treat patients with high acuity levels, reimbursement by the state shall cover reasonable actual costs, hospitals shall maintain a stakeholder advisory group with nonexclusionary membership, and the state shall retain the option to renew the contract upon the expiration of the initial term.

This act also requires the construction of an acute inpatient hospital in central Vermont containing 25 beds, which shall be owned and operated by the state and proximate to an existing hospital. The commissioner of mental health shall have jurisdiction over the new hospital's operations. The hospital shall maintain adequate capacity for individuals receiving a court order of hospitalization, as well as a private room that shall be used for the purpose of judicial proceedings. Using expeditious methodology, the department of buildings and general services (BGS) is responsible for supervising the construction of this hospital with a goal of completing the project in 24 months. The commissioner of BGS may purchase, lease for a period of up to 99 years, or enter into a lease-purchase agreement for the property on which the new facility is to be built. The commissioner of BGS must inform the senate committee on institutions and house committee on corrections and institutions when any substantial steps in furtherance of the hospital's completion are taken.

In the event the new hospital is not eligible for federal matching funds after December 31, 2013, the commissioner of mental health shall be required to cease use of nine beds within a time frame set by the Centers for Medicare and Medicaid Services and reduce the hospital's license from 25 to 16 beds. The commissioner shall develop a transition plan that both addresses the nine-bed acute inpatient bed deficiency by expanding capacity elsewhere in the system if necessary and repurposes the nine decommissioned beds in a manner that does not jeopardize federal matching funds for the hospital's remaining 16 beds. If federal matching funds are lost or denied while the general assembly is in session, the commissioner shall notify and seek approval of the plan from the senate committees on health and welfare and on institutions and the house committees on human services and on corrections and institutions. If federal matching funds are lost or denied while the general assembly is not in session, the commissioner shall notify and seek approval of the transition plan from a special committee composed of members of the joint fiscal committee and the chairs and vice chairs of the senate committees on health and welfare and on institutions and the house committees on human services and on corrections and institutions.

Lastly, the commissioner of mental health is authorized to contract on a short-term basis for seven to 12 acute inpatient hospital beds at Fletcher Allen Health Care until the state-owned and -operated hospital becomes operational. In addition, if a viable setting is identified by the commissioner and licensed by the Vermont department of health, the commissioner may use that setting temporarily for the purpose of providing acute inpatient services. If the temporary facility is located in Morrisville, acute inpatient services shall be discontinued when the state-owned and -operated hospital is operational, but no later than September 1, 2015. Any temporary facility in Morrisville shall initially be licensed for eight beds with expansion necessitating permission from the host community.

As part of the mental health care system, this act also authorizes the commissioner to establish and oversee a secure seven-bed residential recovery facility owned and operated by the state for individuals no longer requiring acute inpatient care, but who remain in need of treatment within a secure setting for an extended period of time.

For the purpose of evaluating and improving the state's mental health care system, acute inpatient hospitals, designated agencies, and secure residential facilities are required to report to the DMH instances of death or serious bodily injury to individuals receiving treatment who are within the custody of the commissioner. Similarly, this act requires the DMH to establish a system to review any death or serious bodily injury occurring outside an acute inpatient hospital when the individual causing or victimized by the death or serious bodily injury is or recently has been within the custody of the commissioner.

This act imposes a number of one-time reporting requirements on the DMH. First, the department shall report to the senate committee on health and welfare and the house committees on human services and on judiciary regarding the decentralization of inpatient mental health care, including any statutory changes needed to preserve rights afforded to patients at the former state hospital, the development of a process to ensure public involvement with policy matters, the development of consistent definitions of seclusion and restraint, and the efficacy of housing subsidy programs. Second, the DMH must also report to the senate committee on health and welfare and the house committee on human services regarding the department's efforts to plan for implementation of and its recommendations to improve the new mental health system, based on an assessment of outcome and financial measures. Third, the department shall report on its plan to streamline overlapping state and federal reporting requirements for providers in the mental health care system. Lastly, the DMH shall report to the joint fiscal committee by September 2012 regarding a fiscal review determination as to whether the department's hospital cost reimbursement methodology reflects reasonable actual costs.

The DMH shall also be required to initiate a rulemaking process that establishes standards for the use and reporting of seclusion or restraint on individuals within the custody of the commissioner, as well as requirements pertaining to the training and certification of personnel performing emergency involuntary procedures.

A special committee composed of members of the joint fiscal committee and the chairs and vice chairs of the senate committees on health and welfare and the house committee on human services, in consultation with the commissioner of mental health, shall contract with an independent consultant who has expertise in the field of mental health and psychiatric hospital services to evaluate the structure, services, and financial implications of Vermont's mental health care system. This act requires the consultant to submit a report to the general assembly by December 2012. The report shall first address whether the proposed mental health system serves the needs of Vermonters, and if there are any needs unmet by the system, how they should be addressed. Second, the report shall establish a list of data and evaluation mechanisms necessary to manage and improve the quality of care and outcomes for individuals with a mental health condition.

This act stipulates that former VSH employees subject to a reduction in force (RIF) on or after February 6, 2012, who have not been reemployed by the state during the two-year RIF period, shall be granted RIF rights to vacant classified bargaining unit positions at the new state hospital. Those former VSH employees subject to a RIF on or after February 6, 2012 who have been reemployed by the state during the two-year RIF period shall be eligible to receive one mandatory offer of reemployment at the new state hospital to the job classification the employee last occupied at VSH. Where an employee who accepts a mandatory offer of reemployment fails the associated working test period, the employee shall be separated from employment and granted full RIF reemployment rights. Hospitals participating in the no refusal system and designated agencies providing acute inpatient, intensive residential recovery, or secure residential services are required to give the department of human resources (DHR) a description of the minimum qualifications for open positions related to caring for individuals with mental health conditions. These hospitals and agencies are encouraged to hire former state employees meeting the minimum requirements or who have equivalent experience. The DHR shall notify former VSH employees about these posted openings. With regard to retirement incentives, former VSH employees who participated in a defined benefit or defined contribution plan and who did not initiate the purchase of any additional service credit are eligible for state payment of up to 80 percent of the cost of premium health insurance if certain other criteria are met.

Multiple effective dates, beginning April 4, 2012