Fletcher Allen Health Care (FAHC) and the University of Vermont Medical Center (UVM) in Burlington want to build a new inpatient psychiatric unit. At a cost of more than $10 million, they plan to build 31 private rooms in a new building offering office space and treatment and therapy rooms—as long as the new facility is not located on the main campus with the rest of the hospital’s medical-surgical services.
"On the surface, how could you not support their plan?," asked Anne Donahue, editor of Counterpoint, a newspaper published by Vermont Psychiatric Survivors (VPS), a patient advocacy group. "And OK, by the way, its several miles down the road, and OK, by the way, we are going to restigmatize all of psychiatry."
The dramatically growing opposition to the plan by Burlington’s only hospital has spread beyond those intimately involved with the hospital to include numerous patient advocacy groups; professional societies, including the Vermont Psychiatric Association (VPA); state legislators; and members of the U.S. Senate and House of Representatives.
The fracas includes allegations of coverups, intimidation, and even false testimony before government planning committees. And now some psychiatrists on the faculty of the University of Vermont Medical School fear for their jobs and hospital privileges should they speak out in opposition to the hospital’s plan.
The Fletcher Allen Health Care— University of Vermont Medical Center (FAHC/UMC) campus, like many academic medical centers across the country, is a hodgepodge of aging buildings, appended to each other without any formal master planning. The newest of the buildings on campus are roughly 10 years beyond their original projected life. That, together with substantial growth in local requirements for the medical center’s services, led to FAHC’s "Renaissance Project"—a 10-year, nearly $300-million plan to redesign and rebuild the patient care facilities as well as research and office space on campus.
The existing psychiatric unit has 30 inpatient beds: a 14-bed locked unit and an open 16-bed unit, all in semiprivate rooms on two floors within the hospital complex. The building in which the unit is located is scheduled to be demolished by 2004.
The unit serves about 700 psychiatric inpatients a year, according to L. Ragon Willmuth, M.D., an associate professor and chair of psychiatry at FAHC/UVM. The locked unit serves some involuntary patients, but they are kept only for 72 hours before being sent to Vermont State Hospital. On the unsecured unit, the majority of patients are admitted with serious psychoses and suicidal depressions.
"We, like everywhere else," Willmuth told Psychiatric News, "have seen our population become more acute and of increased years." Willmuth also noted that comorbidity is "absolutely increasing."
Willmuth and FAHC Chief Medical Officer John Brumsted, M.D., said that they’ve been left with no options except moving the psychiatry service to a separate campus, known as Fanny Allen, some three and a half miles away, while most of the hospital’s other clinical services will be worked into newly constructed replacement space on the main campus over the next 10 years.
The Fanny Allen campus is currently composed of a walk-in care center, which sees about 18,000 patients a year, an inpatient rehabilitation unit with 34 beds, an outpatient rehabilitation center, and several clinics.
Gail Barton, M.D., president of the Vermont Psychiatric Association, has had extensive discussions with FAHC representatives as well as members of the psychiatry faculty at UVM and numerous patient advocacy groups regarding the proposed move.
"We are very much with the consumers in opposition to this one [FAHC’s plan]," Barton said. "There doesn’t appear to be any community input, including [from] the psychiatric community, patient community, or the people at large. This seems to be an administrative concoction that they’re very happy with."
The community’s concerns with the project center on the new psychiatric unit’s isolation from the rest of the medical center’s medical and surgical services. Quality-of-care issues have been raised involving care of patients who need integrated medical care for what FAHC’s Willmuth acknowledged is "increasing comorbidity." How, opponents ask, will consultations with other services be obtained?
Questions have been raised as to how a patient with psychosis, for example, would receive emergency care if the patient became seriously injured during a violent episode at Fanny Allen or was having chest pain that could be a signal of an acute heart attack.
"Those are specific staffing issues that we will address in the usual fashion," FAHC’s Brumsted told Psychiatric News. "We actually have the capacity right now with ambulances on site to transport people—there obviously would be transport involved at this point," Brumsted acknowledged, "but no different from coming from a home situation."
However, even Willmuth has been quoted as saying, "Some of the operational difficulties have kept me up at night."
"Yes, I did say that," Willmuth told Psychiatric News. "But clearly this is an issue of just not knowing what it’s going to be like in terms of the number of residents available, the number of psychiatrists and coverage schedules, efficiencies of consultations, et cetera at this new facility. But these are not insurmountable operational problems."
"We obviously don’t plan anything out there," added Brumsted, "that has any high likelihood of needing intensive inpatient medical or surgical services."
"They just don’t get it," Barton remarked. "They are not paying attention to the fact that psychiatric patients have physical problems too."
The physical layout of the new facility, which has been presented in preliminary architectural drawings, is also being questioned. Patient advocacy groups are outraged that the entire new unit will have the capacity to be locked down.
This "means it will be the last hospital in Vermont that has no option of any unlocked unit for voluntary patients," said Donahue, who has a copy of the plans. "That’s a big issue."
"What they seem to be doing," said Barton, who has also seen the plans, "is sort of reinventing the state hospital. They even have an exercise yard planned with fencing around it. I was just so startled—the doors are all locked, and the exercise area fenced! Safety seems to be Fletcher Allen’s only concern, and to them segregation means safety. They are not listening to the fact that effective, appropriate treatment means safety."
Barton has coordinated with a number of groups representing mental health professionals and patients who have come together as a coalition to fight the proposed plan (see box). All of the groups have expressed great concern that segregating psychiatric patients, in direct opposition to the national trend of fully integrated care, will result in a restigmatization of patients and psychiatry on the whole. Some have even expressed concern that nonpsychiatric patients having appointments at the Fanny Allen campus may feel uncomfortable going to the facility because it will quickly become known as "the mental hospital."
The concerns of the community seem to be falling on deaf ears at FAHC. Both Barton and Donahue told Psychiatric News that their attempts to discuss their concerns with FAHC administrators, including Brumsted and Willmuth, have met with polite but firm resistance.
Several of the members of the University of Vermont department of psychiatry and FAHC faculty told Psychiatric News that they have also been quietly working to get the plan modified. Initially they discussed their opposition to the planned move openly, but those who did so early in the dispute were threatened with what faculty members have termed "an effective gag order."
One faculty member familiar with the development of the hospital’s plan, who did not want to be named, told Psychiatric News, "If I continued to speak out against the plan, I could start looking for a new job and a new hospital to admit to." Other faculty members told Psychiatric News that they either witnessed the comment or similar statements were made to them by FAHC administrators.
Although the dean of the School of Medicine denied the existence of a "gag order" to the Burlington Free Press and to Counterpoint and publicly encouraged faculty to share their concerns, FAHC officials have been silent on the concern. However, Brumsted told Psychiatric News that "any faculty member who openly expressed opposition to the mission of the hospital would be considered insubordinate."
Brumsted acknowledged that many faculty members remain steadfastly opposed to the plan despite his previous testimony to the contrary before state Senate and House of Representatives committees looking into the proposal. In fact, both the House and Senate committees wrote to FAHC CEO William Boettcher seeking a correction of the discrepancy in Brumsted’s testimony after faculty members alerted committee members that opposition was still very strong, not "starting to turn around with several faculty members now on board," as Brumsted had testified.
FAHC has filed a certificate of need with the state of Vermont for approval of the proposed move of psychiatric services. In late March, the state’s Division of Health Care Administration responded to the filing with a list of 25 questions it had regarding the project. Many of the questions mirror the concerns of the psychiatrists, mental health professionals, and patient advocacy groups.
Once the state has received what it deems to be adequate answers to its questions, public hearings will be scheduled to review the certificate of need. Several of the coalition members have written state regulators expressing the desire to be designated as "parties of interest" during those hearings, including VPA, VPS, and others.
"The decision has been made to site this facility on the Fanny Allen campus," Brumsted told Psychiatric News, acknowledging that FAHC considers the proposed move its only option and "a done deal." He did acknowledge, however, that FAHC will have to go through the public-approval process.
"It’s an objective and political process," he said, "so there is a possibility that we’d be told that we couldn’t do this."
VPA’s Barton and VPS’s Donahue are just two of a growing number of people who certainly hope that will occur. And most of those opposing the plan believe the hospital had other options. "To the extent that they are locked in," said Donahue, "it is because they planned it that way."
FAHC has posted detailed information on its Renaissance Project at www.fahc.org. ▪