Proposal for Six-bed Psychiatric Intensive Care Unit

                 December 7, 2011
        The Rutland Regional Medical Center proposes to create and license an additional 6-bed
inpatient psychiatric unit to serve as a ‘Psychiatric Intensive Care Unit (PICU)’ that would be
fully integrated with the existing milieus described below. This program is anticipated to operate
at 90% capacity with an average daily census (ADC) of 5.4 patients. Rutland Regional’s current
program has an ADC of 13.5. The addition of the PICU would provide a level of care
commensurate with that previously provided at the Vermont State Hospital (VSH). These 6
additional beds will also serve as a critical component of the statewide “VSH Replacement”
system that is currently being developed by various stakeholders to in response to services lost
due to tropical storm Irene. The PICU would provide for the highest level of care and be
categorized as ‘no-reject’ beds. It will have the ability to admit patients 27/7, 365 days/year, in a
setting staffed by an experienced, multidisciplinary team working in an environment meeting
JCAHO and CMS standards.

        It is important to note that although patients admitted to the new PICU would have
previously been served at VSH, it is intended that the populations will be integrated and the level
of service will be dictated by the needs of the patients. Said another way, there will not be
“Rutland patients” and “State patients”; there will only be patients requiring an appropriate level
of care. The clinical program is described in Section 3, below.

        The proposed PICU will be able to admit patients 24/7/365 from every part of the state.
We will seek to maximize the utilization of the PICU by transferring patients to lower levels of
care when intensive services are no longer required. Involuntary patients on our existing unit
have an average length of stay of 28 days, but we believe that we will be able use the integrated
nature of the new combined units to manage the PICU component of the stay with an average of
21 days. With these assumptions we predict that the 6-bed PICU would serve an additional 90 to
100 patients per year.

        Currently, the Psychiatric Inpatient Unit at RRMC serves patients from across the entire
state of Vermont. Approximately 50% of our patients come from Rutland County with Addison
and Bennington Counties combining for an additional 25% of the patients served. The
remaining 25% come from every other county in the state. This geographic mix of patients is
driven largely by the volume of referrals we receive from any particular area of the state. We
expect referral demand to continue to drive the geographic mix of patients we serve. Admission
decisions to the PICU will be made based on clinical criteria and bed availability without regard
for county of residence.

        Taken together the proposed 6-bed PICU and the 17-bed inpatient general psychiatric
unit will provide services to three different levels of care within a single milieu. The levels of
care will be organized into separate wings, but will share much of the common space. The two
lower levels of care (General and Specialized) are comparable to the levels of care currently
provided at RRMC. The highest level of care (Intensive Care) was previously only provided at
VSH and will represent a higher level of care then RRMC has provided to this date. The PICU
will have an entirely separate treatment, group, common and dining spaces. However, as PICU
patients stabilize it is anticipated that they will increasingly take part in groups and activities
outside of the PICU area until they are eventually transferred completely to a lower level of
intensity. Likewise, patients may also progress during their stay from specialized to a general
level of care. Below is a brief description of each level of care.
Intensive Care Unit (6 Beds)
        Patients within the Psychiatric Intensive Care Unit generally present with imminent risk
of harm to self or others and require the highest level of supervision to maintain safety. Patients
on this unit will be those who are unable to reliably contract for safety. Staffing at this level of
care will maintain a minimum of 2:1 patient to staff ratio with the ability to provide 1:1 as
necessary. This unit will be separated from the General and Specialized units via locked set of

Specialized Inpatient Psychiatric Services (10 Beds)
        Patients within the Specialized level of care are generally those who are at increased risk
for harm to self or others, but have the ability to maintain safety with staff support. Staffing at
this level of care will maintain a minimum of 6:1 patient to staff ratio with the ability to provide
1:1 as necessary. Patients in this area will likely be a mix of voluntary and involuntary patients.

General Inpatient Unit (7 Beds)
        This level of care is for patients who meet acute care criteria but whose level of imminent
risk of harm to self or others is minimal. Patients on this unit typically demonstrate a high
degree of behavioral stability and impulse control. It is anticipated that many of the patients on
this level of care will be very close to meeting discharge criteria. Staffing within this level of
care will maintain a minimum 7:1 patient to staff ratio. Common space for this level of care will
have a fair amount of overlap with the Specialized level. Currently this level o care is served
within the same locked unit as the specialized level of care and with similar limitation son
freedom of movement on and off the unit. We are very hopeful with the renovation of space on
as part of the new PICU that we will be able to accommodate a patient controlled access to and
from the unit for this level of care.

Integration of programming
        PICU beds will function within an integrated 23-bed unit with three levels of care:
general, secure, and PICU. The architectural design will allow for safely sharing treatment and
common space across all three levels of care It will minimize restrictions on patient flow from
the Specialized and General levels of Care and allow for shared common and outdoor space
necessitated by a single point of entry onto the psychiatric floor. Given that the goal of this
program is to provide the greatest degree of autonomy in an environment which ensures patient
safety at a level that meets both best practice and regulatory (e.g., CMS, Joint Commission)
standards the point of entry onto the psychiatric floor will be locked. Optimally a separate,
unlocked, entrance/exit would be available to those patients at the General level of care,
however, the physical structure of the existing space combined with the desire to maximize all
patient’s access to common and outdoor space do not allow for access to an unlocked
entrance/exit by subset of patients. Programmatic planning will partially mitigate this restriction
through off-unit, outdoor, activities as appropriate to clinical state.

       As a result of the ability to transfer patients to the level of care that most appropriately
meets their needs, the integrated design will reduce PICU lengths of stay and ensure maximum
availability of new admission capacity. The design will also allow staffing support available
between wings as needed. Additionally, the integration of psychiatric services within the larger
hospital systems allows for excellent and immediate response to all medical needs that patients
might experience during their stay.
         In order to create the new PICU, extensive renovation of an existing medical inpatient
area is required. Attached (Attachment A) is floor plan sketch which identifies the scope of
renovation required to achieve six new ICU beds and one additional general psychiatric bed.
The PICU will be adjacent to our other 17-bed unit. Relocation of offices on the existing unit
will allow for the creation of an additional patient room within our existing space providing for a
total of 23 inpatient psychiatric beds. Furthermore, the proposed renovations will result in a
significant expansion of common areas and create new outdoor space, that will be shared by all
patients. This plan was developed to support client-directed, trauma informed care.

Elements of the preliminary space design include the following:
    Large rooms – would allow patients the ability to self-regulate their exposure to noise and
      other stimuli
    Nursing station that allows for excellent line of sight into corridors and all common areas
    Highest level of environmental safety (NAPHS and ASI standards)
    Ample secure access to outdoor space – the proposal is to create a large outdoor
      recreation area on the rooftop of the floor below.
    Additional indoor activity space that will serve the new and existing levels of care
    Large common areas which allow patients many options for activities
    Designated family/visitor meeting space
    Allows for the creative use of space to reduce the need for emergency interventions


        The table below represents the minimum staffing pattern for nursing and total direct care
for each unit of the proposed program. This level of staffing does not include patients who are
on 1:1 supervision. The table indicates the minimum number of nursing staff and the total
number of staff on each shift for each level of care.

 Core Staffing Levels
 Unit / Bed Capacity           Day                    Evening                  Night
                         Nursing   All           Nursing     All         Nursing        All
 General / 7               1        2              1          2            1             2
 Specialized / 10          2        5              2          5            2             4
 PICU / 6                  2        2              2          2            1             3
 Total Unit                5        9              5          9            4             9

        We anticipate that the new PICU program will require the recruitment and hiring of an
additional full-time psychiatrist, additional on-call psychiatrists, and approximately 20 direct
care staff at various professional levels. Applications for newly created positions would be
welcomed from current VSH staff and physicians. Over the past two years we have had
significant success in recruiting and retaining new psychiatrists to participate on employed staff
and to participate in our call system. And, we expect that we will be able to sustain this level of
physician engagement with the addition of the new PICU. Additionally, a plan to on-board and
train new staff prior to opening the new unit will be developed once agreements to move forward
are reached.
        The proposed staffing model includes a limited ability to accompany patients to offsite
appointments or meetings. It is our intent to continue to work with DMH to develop systems that
minimize the need for this capacity. However based on data provided by DMH regarding the
frequency of patients requiring 1:1 supervision, we anticipate having sufficient trained staff to
provide 1:1 care for up to 25% of the patients being served in the PICU without drawing staff
from other areas. If needed, additional trained staff could be accessed from other levels of care.
Additionally, management will actively maintain a list of qualified and trained per diem staff to
provide additional 1:1 coverage to meet peak demand, including the possibility that all six
patients within the PICU may require the 1:1 supervision.

       Physician, nurse and support staffing will be maintained at a level to ensure that there is
capacity to admit patients 24 hours a day, 365 days a year. The program will be staffed by
psychiatry staff 24 hours a day. Only patients meeting acute care criteria will be admitted to the

        The proposed program will be directly fully integrated into the Rutland Regional Medical
Center hospital and have full access to all the medical services and facilities offered by Rutland
Regional Medical Center. This connectedness between the psychiatric unit and other medical
units is fully implemented within the current systems at RRMC and will continue under the
proposed program. Patients with emergent, urgent and co-existing medical conditions are
attended to as anywhere else within the hospital. All patients will be medically evaluated as part
of the admission process and then evaluated daily by an attending psychiatrist. Based on the
physician assessment specialized medical consultations can be ordered to address both urgent
and routine medical needs of patients. In addition, the program will participate in the hospital
wide Rapid Response Team which provides a multidisciplinary response within minutes to
patients within the hospital. The Rapid Response Team (RRT) assesses, treats, and stabilizes a
patient whose medical condition is deteriorating. The RRT also educates and supports staff
nurses, assists with physician communication, and transfers patients to the appropriate medical
level of care, if necessary. For patients whose medical needs require transfer from the Psychiatric
Unit, supervision of the patient will be provided by a combination of staff from medical units
and the psychiatric unit, as necessary.

        Treatment for patients admitted to the PICU will be individualized based on the acute
needs of each patient. The Recovery Model is, and will continue, to be implemented to the fullest
extent possible across all levels of care at RRMC Psychiatric Services. This includes psycho-
social programming designed to treat patients with treatment refractory mental illness, patients
with a slow response to medical and psychosocial interventions, patients who are involuntary and
who may be extremely reluctant to engage in recovery, and patients with complex co-occurring
conditions (for instance developmental delay, head injury, dementia, and substance use).

        RRMC has significant experience providing treatment to a diverse array of patients’
varied clinical presentations. Prior to tropical storm Irene, approximately 20% of the patients
currently served by the psychiatric services at RRMC were on involuntary status for some
portion of their stay (this number has dramatically increased with the unintended closure of
VSH). While hospitalization may be mandated in these cases, specific treatment is not. Patients
are encouraged to participate in the groups and milieu activities, but never mandated or coerced.
Groups and milieu activities are flexible and responsive to needs of patients. For example, while
some patients may be unwilling to participative in group psychotherapy, they may be willing to
participate in a crafts or cooking group lead by an occupational therapist. The focus of treatment
for patients unwilling to engage in traditional therapies is on developing the patient’s ability to
trust staff and feel safe while in the hospital. Individual therapy and activities are provided on a
daily basis for patients who are unwilling to participate in the larger group.

        Within the proposed program there will frequently be multiple groups/activities occurring
at the same time across the three levels of care on the unit with > 20 hours/week of active
treatment. Groups and therapies on the unit will include individual therapy, recovery groups,
CBT and DBT programmatic therapy as well as life skills and recreation groups. Patients will be
encouraged to choose groups and activities that are most appropriate for their needs, their
recovery process and their preference. Programming will take reflect the perspective that people
with mental health issues can have hope, control over their lives, develop self-directed wellness
plans, and achieve recovery, working toward meeting their own life dreams and goals.

       In addition, the psychiatric service at RRMC has worked closely with peer support
through Vermont Psychiatric Survivors. Peers, advocates, and other community supports are
always welcome on the unit. While at this time the inclusion of peer supports has not been
formalized into the treatment planning it is an area we continue to explore.

        RRMC has substantial experience in discharge planning for patients who reside in all
corners of the State. Currently, fully 50% of patients admitted to our current psychiatric unit
come from outside Rutland County. We work closely with CRT programs, outpatient mental
health providers, primary care physicians, all levels of skilled nursing facilities and other
community resources to develop step down plans for patients with complex needs. Patients
themselves, along with their families and other natural supports are always at the center of our
discharge planning efforts, focusing on implementing plans they have helped develop.

        The proposed program will work closely with DMH and other partners to coordinate
admissions into the program and to facilitate appropriate discharges to lower levels of care. The
ability of the program to accept new admissions is directly connected to our ability to arrange
clinically appropriate step down for patients.

        Our ability to accept new patients will be limited by the availability of a bed within an
appropriate level of care. RRMC will strive to stabilize patients such that they will transition
from higher to lower levels of treatment (i.e., Intensive to Specialized and Specialized to
General). However, in rare circumstances a patient requiring a higher level of care may be
denied admission even though there are beds available at a lower level of care. For example, if a
patient requiring an intensive level of service is presented for admission when there are six
existing PICU patients with none appropriate for step down to the specialized level due to the
risk they pose to other patients or themselves, the new admission would necessarily be denied.
Unit leadership will actively participate in statewide discussions on each case presented for
admission to the PICU to ensure the appropriate level of care is available to individuals across
the state.

        In our role as a Designated Hospital we maintain a close working relationship with the
DMH legal unit. RRMC has substantial experience with preparing for commitment hearings,
participating in development of applications for involuntary treatment, development of orders on
non-hospitalization, and providing testimony at hearings. Applications for non-emergency
involuntary mediation are a relatively new aspect of care undertaken by RRMC since the
unforeseen closure of VSH. Staff and leadership have been working closely with the DMH Legal
Unit to ensure the appropriate education and training for our physicians and staff has been in
place for these situations.

       More generally, being integrated into a general hospital, staff on the psychiatric unit are
well versed, and undergo regular training, on issues such as understanding of patient rights, duty
to warn, mandated reporting and HIPAA compliance. We have also begun initial discussions
with Rutland District Court regarding the development of on-site courtroom capacity. By having
hearings for involuntary patients held on-site, we would eliminate the need to transport patients
by sheriff.

        RRMC has ongoing systems in place to continue to evaluate and measure quality of care
and program outcomes. The RRMC Psychiatric Services has monthly section meetings in which
quality measures are identified and tracked by the Medical Director, Director, staff psychiatrists
and nursing leadership. Through this practice quality improvement is an ongoing process and
would continue to be so with the proposed expansion. Moreover, RRMC Psychiatric Services
would work closely with DMH and other state agencies to track elements identified as critical to
measuring and improving outcomes for the population served by the PICU as well as the other
levels of care provided at this institution.

        In November 2007 RRMC Psychiatric Services established a Community Advisory
Committee that has met monthly since that time. Participants include patients, family members,
advocates, providers and Department staff. The committee has been fully involved in the
development of several key policies. The meeting agenda for these open meetings is set by
consensus with opportunity at each meeting for any committee member or community member
to raise issues they would like to see the committee address. This information will be routinely
shared through this Community Advisory Committee to illicit insights and feedback, allowing us
to modify and streamline our quality measures which, in turn, will allow program modifications
as deemed necessary to improve outcomes for clients

       As indicated above the unit will be licensed as part of the Rutland Regional Medical
Center and will be overseen by its Board of Directors.

        In addition, in November 2007 RRMC Psychiatric Services established a Community
Advisory Committee that has met monthly since that time. Participants include patients, family
members, advocates, providers and Department staff. The committee has been fully involved in
the development of several key policies. The meeting agenda for these open meetings is set by
consensus with opportunity at each meeting for any committee member or community member
to raise issues they would like to see the committee address.

        Capital costs include those associated with renovation of the space to be occupied by the
PICU as well as those needing to be renovated to accommodate the programs being displaced by
the PICU. The initial rough estimate of construction costs for the renovations to our space to
create (1) the 6-bed PICU, (2) additional common areas, (3) outdoor space in the form of a roof
terrace, and (4) alterations to the existing necessitated by the programmatic changes is $6.35
million (See Attachment B).

        We anticipate that staffing and operating the new PICU at the level and capacity
described will result in a base cost of $1,152 per patient per day. We believe that the staffing
model and unit design will minimize but not eliminate the need for dedicated 1:1 staffing. For
patients that require dedicated 1:1 supervision, our base costs rise to $1,680 per patient per day.
We will work with the State to refine our assumptions regarding the number of patients that
might require 1:1 supervision. The new PICU would be immediately eligible for reimbursement
through Medicaid and Medicare, allowing for a substantial reduction net cost to the State
compared to operation of VSH over the past many years.

        Rutland Regional Medical Center strongly believes that hospital level alternatives to
VSH beds must be found to ensure treatment is available to individuals requiring the highest, or
most acute, level of psychiatric care. RRMC believes that expansion of our existing psychiatric
services to include an intensive level of care fits well within our mission to provide the best
possible care for our community. We have received tremendous support from our staff, our
Board, and our community for the proposal we are putting forth.
        We anticipate that RRMC could bring this new bed capacity online in approximately 6
months from the point that capital and operating agreements are reached required State and
regulatory approvals are obtained. Some elements of construction (e.g., creation of an outdoor
porch area) may continue past this initial time frame, but would not impede the opening of the
new PICU. Building on the existing strengths within RRMC Psychiatric Services, both people
and programs, we believe that we can provide high quality care to patients with the most
intensive needs along with all the benefits of being integrated within other levels of care and
within the hospital.
Attachment A: Scope of PICU Renovation
Attachment B: Capital Costs

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