WATERBURY — Projects intended to keep Vermonters out of emergency departments during mental health crises are coming to nearly every part of the state.
Of the 12 submissions generated last year by the Department of Mental Health’s request for proposals for mental health urgent care services, eight will receive funding, including seven brand-new programs.
Iterations of three different models of crisis care will move forward: psychiatric urgent care clinics (“PUC” or “PUCK”), community crisis centers (“Living Room”), and crisis response teams (“CAHOOTS”).
Using time-limited federal dollars, DMH has awarded grants to six of Vermont’s community mental health centers – Counseling Service of Addison County, Washington County Mental Health Services, Health Care & Rehabilitation Services of Southeastern Vermont, Lamoille County Mental Health Services, United Counseling Service, and Howard Center – and to the Burlington Police Department.
There is no clear plan yet as to how the programs will be sustained after the two-year federal grants expire in 2025.
Per city documents, BPD’s CAHOOTS-style crisis team will allow mental health clinicians and EMTs to “intervene in crisis situations where armed law enforcement is not necessary.” Burlington allocated $400,000 for the program in its municipal budget for fiscal year 2023 and subsequently applied to DMH for funds to cover the difference between that sum and the estimated annual cost, between $800,000 and $950,000 in total.
The concept comes from Eugene, Oregon, which called it Crisis Assistance Helping Out On the Streets. Now labeled “Burlington CARES,” the model does not involve peers.
“After this two years, the city intends to fund this on their own, so we kept the model as it was as a whole,” DMH Deputy Commissioner Allison Krompf said.
Last year, the city’s plan included references to “qualified mental health professionals empowered to require emergency evaluations,” which serve to begin the process of involuntary hospitalization. At the time, Burlington expected to contract Howard Center, which employs QMHPs, to run the program. More recently, however, the city decided to manage the program in-house instead. That led DMH to “go back” and look at the proposal again, Krompf related.
“We want the person who’s responding to know what the threshold is for involuntary hospitalization, but we are not going so far now as to say that… they on their own could go out to the community and involuntarily hospitalize somebody,” she clarified. “So we did [tell] the Burlington PD that we wouldn’t authorize them in this program to be doing that.”
PUC stands for Psychiatric Urgent Care, and PUCK stands for Psychiatric Urgent Care for Kids. These programs provide assessments by Masters-level clinicians, crisis de- escalation, and access to psychiatric consultation, according to Krompf.
They can also treat co-occurring medical needs of mild to moderate severity. Despite the model’s “clinical” focus, it “still comes with a space that’s much more well suited for people in a mental health crisis” than an emergency room, Krompf said.
DMH “has asked and required that there be peer supports” at each clinic, she noted, and those accepting pediatric patients will have “sensory spaces.”
“If you have a child or even an adolescent who’s really having a difficult time, putting them in a space where they can’t touch anything, and if they do, they can get in trouble… it’s just really tough,” Krompf said.
UCS has run a PUCK clinic in Bennington since 2019. Its DMH grant will support the hiring of full-time staff and expanded operating hours, including evenings and possibly Saturdays, likely by July or sooner, per UCS.
According to UCS Executive Director Lorna Mattern, PUCK has “decreased emergency room
utilization for children between 33% and 40%” in its catchment area.
“When kids would get picked up, often from school, by the police, they didn’t have anywhere else to go, and so they would often, if not always, end up in the emergency department. And I think what PUCK showed the state and funders and others is that we can create alternatives,” Mattern said. “We can provide trauma-informed, family-friendly, kid-friendly environments and still respond to a mental health crisis and help stabilize and keep them in the community.”
Howard Center’s PUC clinic in Burlington will serve adults only. Krompf characterized the proposal as a collaboration that also included the University of Vermont Medical Center and the Community Health Centers of Burlington.
UVMMC may be contributing about $2.4 million toward needed additional funds for renovating a site as well as toward three years of operating costs to fill a funding gap beyond the DMH grant.
That money is part of a proposal for reuse of $18 million in reserved funds that still needs approval by the Green Mountain Care Board. The DMH grant is for $1.6 million over two years, and the 3-year full cost is a little over $3.6, according to the submission to the GMCB.
Pathways Vermont submitted a response to DMH to create a peer-run respite center but Krompf said that it didn’t meet the federal criteria for funding.
“We are really interested in finding a way to move that forward. We couldn’t use this bucket of money,” she said.
The Living Room model, coming to Addison County and Washington County, intends to create a warm, homelike environment for patients. In DMH’s vision, this works to promote “autonomy, respect, hope, empowerment, and social inclusion.”
Psychiatrists and peers will work together in what Krompf called a “multidisciplinary team approach” for “person-centered care.”
“When someone enters that space, there isn’t some prescription of, ‘Oh, you get exactly this,’” she described. “There’s a peer involvement that says, ‘What are you looking for? What are your goals, and how can we support you?’”
Launch dates for the new urgent care services may vary by program.
“Each proposal has a different timeline,” Krompf told the House Committee on Health Care in May. “But the money that we have to spend on this needs to be expended by 2025. So, if that gives you an indication – we aren’t looking for a two-years-out implementation. These are things that had dates within six months, nine months.”
Anticipating a future need for state dollars, legislators asked whether DMH had a plan in mind for how to pay for the programs in the long term.
Krompf told them that “the leaders on this, in terms of funding, are well aware that they’re putting things in motion to serve the population for mental health urgent care that don’t have sustainable funding, and I do think some of this is going to be a need for CMS and Medicaid to acknowledge that.” But “Medicaid can’t pay for all services for everyone,” she added.
Northeast Kingdom Human Services’ project did not qualify for the special federal funding because it proposed to offer patient stays longer than 24 hours, so DMH asked the legislature for an allocation from the state’s general fund.
Its proposed Front Porch Crisis Care treatment center will offer four to six crisis beds in the region of the state that has fewer than any other. Stays will range from two to ten days.
For same-day services, NKHS Executive Director Kelsey Stavseth described a plan that would incorporate aspects of both PUC(K) and the Living Room, with “access to nursing, psychiatric, and medication management services” on a “walk-in” basis within a “therapeutic environment” featuring peer support.
NKHS will need to buy a building to house the program, which it will develop in a phased approach that will, however, allow some components to start up within its existing facilities. Stavseth noted in February that a realtor had already identified some potential candidates for a new property, which, “for staffing access,” would preferably lie within the I-91 corridor, no more than an hour’s drive for patients from Orleans, Essex, or Caledonia County.