• Please note: Days are attributed to the quarter of admit, though complete numbers may not be reflected until all admits of a quarter have discharged.
• The Alternative Payment Model (APM) began March 1, 2021. Data in Q1 of CY21 includes March only.

This measure is important because the Clinical Integrity Unit (CIU) monitors that services provided are medically necessary, are at the appropriate level of care (LOC) and length of stay (LOS) and are consistent with prevailing professionally recognized standards of Practice. Inpatient authorizations include acute, sub-acute, waiting placement, and variance.

• Acute is authorized when a member is exhibiting acute symptoms/behaviors and is receiving acute interventions. 
• Sub-acute is authorized when the acute LOC is no longer necessary but requires a residential level of care and no discharge placement has been identified or discharge placement has been identified but not available. 
• Waiting placement is authorized when the acute LOC is no longer necessary, and the member is being discharged to a lower LOC (non-residential). 
• Variance days are authorized when a member is meeting acute LOC for either symptoms/behaviors OR interventions but not both therefore not meeting acute LOC.  
• Disposition delays are noted when children/adolescents at the Brattleboro Retreat (BR) are no longer meeting acute LOC but are unable to discharge. In these cases, the BR is not responsible for the delays, rather these are situations such as the member is waiting for residential LOC and can’t return to the community in the interim; the member refuses to return home with the parent/guardian; or the parent/guardian refuses to pick the member up upon discharge. 

The Retreat provides essential capacity to Vermont’s mental health system of care. The Retreat is the only inpatient psychiatric facility that serves children and adolescents in Vermont. When a member is no longer meeting acute LOC criteria, the goal is to discharge the member to a lower LOC to include residential placements, step down (e.g., Hospital Diversion), or to the community with outpatient supports. Representatives from DCF, DMH, DVHA and the Retreat meet weekly to discuss members with potential disposition issues and work to problem solve so that members who are not meeting acute LOC do not remain at the Retreat longer than necessary.   
As seen in the trendline above, there is some variability in the % of days meeting acute level of care. For CY23 Q1 there was a dip due to two outlier situations in which members were admitted in January, were stable and clinically appropriate for discharge, but did not discharge for several months due to disposition issues related to member’s complex presentations. We saw an upward trendline for CY23 Q2 but for Q3 another dip. CY23 Q3 there is an increase in total number of disposition delay days. This is due to an increase in members experiencing delays (14 members in Q2 and 18 members in Q3) Disposition delays continue to be due to members waiting for residential LOC and parents refusing to pick members up upon discharge. For CY23 Q4 we are initially seeing an upward trendline, yet it is important to note that this data is not final until open admissions close and members are discharged. 

Narrative last updated:  04/16/2024

• Brattleboro Retreat 
• Department of Children and Families (DCF)
• Department of Mental Health (DMH) 
• Department of Aging and Independent Living (DAIL)

DVHA, DMH and BR have weekly calls to discuss complex cases including disposition delays. Additionally, there are biweekly Shared Response to Emergency Placements meetings that include AHS partners (DVHA, DMH, DAIL), during which discussions cover specific cases, challenges in the system of care, and how to align the system of care. DVHA has also worked with a Vermont Special Services Agency (SSA) to expand the type of presentation of members that they would accept who need treatment outside of acute stabilization level of care.