A February plan in which Dartmouth-Hitchcock Medical Center and Dartmouth Medical School would license a psychiatric facility at the White River Junction Veterans Hospital is now "in limbo" after Medicaid licensing conflicts and funding requirements halted the proposal, Vermont Mental Health Commissioner Michael Hartman told The Dartmouth.
The Vermont State Hospital Futures Master Plan called for the Vermont state government to open a 33-bed facility at the Veterans Hospital using $15 million from a one-time allocation of federal Medicaid funding. A technicality in the Medicaid bill is now causing the funds to be withheld, leaving DMS's role in the facility's expansion unclear, according to Hartman.
Under the licensing agreement, DHMC and DMS would have run and provided staff for the facility, as well as assumed liability for its operations.
A variety of significant regulatory issues, including oversight of licensing for hospitals and the construction of new beds, arose after the possibility of DHMC licensing the facility at White River Junction emerged, Hartman said.
Deeper analysis by administrators at DHMC revealed that using any portion of the license in New Hampshire for an expanded hospital in White River Junction was not a viable option, DHMC governmental relations vice president Frank McDougall said.
Recent licensing problems and specifications for funding determined by Medicaid mean the details of the construction and operation of the psychiatric facility need to be "properly defined" so that the "boundaries of [DMS's] involvement" are clear, McDougall said.
"We want to help within the parameters we have outlined because the [Vermont State Hospital] has been outdated for many, many years," he said. "The answer really lies with the Veterans Administration in the state of Vermont."
The state Senate Institutions Committee invited McDougall and DMS psychiatry department chair Alan Green, who have been working with administrators at the Veterans Affairs Medical Center in White River Junction and at the Vermont Department of Mental Health, to speak with the committee, McDougall said.
McDougall and Green "let the state know" that the extent of DHMC's involvement must be properly defined to proceed because of the currently "unsustainable" situation, McDougall said.
The Futures Plan originally proposed to open three new facilities by 2012 to replace the outdated Vermont State Hospital facilities, The Dartmouth previously reported. The plan proposed to build a secure facility on federally-donated land adjacent to the Veterans Affairs Medical Center, which would serve psychiatric in-patients at the hospital.
However, the facility does not qualify for participation in the Medicaid program because of specifications in the original Medicaid bill passed 1965, Hartman said.
"If you are a freestanding psychiatric facility with 17 or more beds not part of a general hospital and serving a population in the age group of 19 to 64, you are considered an Institute for Mental Disease' by the Medicaid bill," Hartman said.
IMDs do not qualify for federal funding through Medicaid, Hartman added.
According to the Futures Plan, DHMC would license the psychiatric unit as part of a "general hospital" to avoid the designation of IMD for funding purposes, according to Hartman. But because the VA hospitals are in a different system from state general hospital facilities, the facility at White River Junction would have to be licensed not by the VA which has a different set of regulations but by a standalone hospital, Hartman said.
The Futures Plan recommended dedicating $61.4 million of one-time funds from the 2009 American Reinvestment and Recovery Act toward the capital costs of securing residential and in-patient facilities. These funds rested on congressional approval of a six-month extension of a higher federal contribution matched to state-provided Medicaid funds, McDougall said in an interview with The Dartmouth last February.
Several potential changes, including budget adjustments at the outset of the legislature next January, may make approximately $12 million available for the construction of another part of the Vermont State Hospital. If the facility remains under 17 beds, it may also qualify for one-time funds through the ARRA, totaling up to $15 million in federal funding, Hartman said.
"There are about $30 million dollars that could be used, but nobody has clearly labeled it as such," he said. "There is a possibility here that we are setting up to have the money necessary by next January, although I would regard the place we are now as more ideal if all of this was clearly labeled."
The Vermont State Hospital is structurally and operationally outdated, Hartman said. Since his appointment as commissioner, Hartman said that he has overseen the opening of many community recovery residential programs and plans to make 30 to 40 more inpatient beds available in the state.
By exploring the facility at White River Junction as a possible resource for neuropsychiatry, the sub-specialty dealing with veterans with head injuries, the Vermont Department of Mental Health hopes to link the psychiatric services of the new facility with services at the Veterans Administration, Hartman said.
"We are looking for a way to create a unit to respond to that level of need that could also be beneficial to the Veterans Administration, since it is on their property, as well as the people of Vermont and New Hampshire," Hartman said. "Dealing with the significant mental and physical needs of patients is in line with our mission in integrating general and mental health care."
