Dawn Tatro, whose daughter Jenna died from an overdose, speaks during a commemoration of International Overdose Awareness Day at City Hall Park in Burlington on Tuesday, August 29. The Tatro family has established Jenna’s Promise to battle opioid addiction. Photo by Glenn Russell/VTDiggerThere’s a pattern that plays out, over and over again, among Vermonters who need treatment for substance use disorder, advocates in the field say. An individual will enter a residential rehabilitation facility, either on their own initiative or through referral by a judge or social services organization. They stay for roughly two weeks. And then, having nowhere else to go, they return to their former home — with all of the temptations and triggers that they just left behind — and relapse.“We have homeless kids who suffer from addiction,” Mark Redmond, the executive director of Burlington’s Spectrum Youth and Family Services, said in an interview. “We send them to (rehab facility) Valley Vista. They’re back a couple of weeks later. It’s just wash, rinse, repeat, wash, rinse, repeat.”That problem, advocates say, is exacerbated — if not outright caused — by the fact that Vermont lacks a crucial piece of the recovery infrastructure puzzle.In other states, residents can access much longer treatment and recovery programs, and pay for them with Medicaid, advocates say. Those programs can involve multiple stages with different levels of treatment, such as detox, rehab, inpatient care and intensive outpatient care. Vermont, however, has a dearth of those less-intensive services, meaning that Vermonters often leave short rehab stints with nowhere else to go but back to the environment that drove them to use drugs in the first place. What’s needed in Vermont, advocates say, are “stepdown” facilities: multi-week or multi-month programs that help clients bridge the gap between inpatient rehabilitation and living independently.In an Aug. 26 letter, a group of advocates and court officials — including Redmond, U.S. District Court Judge Christina Reiss, a federal probation officer and public defenders — urged Scott to invest in such facilities, or to back policy changes to Vermont Medicaid that would allow Vermonters to access programs in neighboring states. Those stepdown facilities are “a critical missing piece in Vermont’s recovery network,” the letter reads.Medicaid limitsOne of the biggest hindrances to such programs in Vermont are limits on Medicaid reimbursements for residential substance use treatment, advocates say.For residents’ first three days at a Vermont rehab facility, like Valley Vista, Medicaid pays a set per diem rate — currently, about $345 a day, according to the Department of Vermont Health Access, which operates the state’s Medicaid program.After those three days, Medicaid pays a lump sum “episodic rate” for the remainder of the patient’s time at the facility, regardless of how long it is. That lump sum depends on what substance a patient has used and whether they have any other complicating factors — such as bipolar disorder, diabetes, or homelessness. Dawn Tatro, whose daughter Jenna died from an overdose, speaks during a commemoration of International Overdose Awareness Day at City Hall Park in Burlington on Tuesday, August 29. The Tatro family has established Jenna’s Promise to battle opioid addiction. Photo by Glenn Russell/VTDiggerFor the most complex patients, that episodic rate tops out at a maximum of roughly $6,900, equal to about 20 days at the per diem rate.“The Vermont Medicaid program does not have any rule or policy limiting the duration of residential treatment,” Alex McCracken, a spokesperson for the Department of Vermont Health Access, said in an interview. He noted that there is also no limit to how many times a Medicaid client may return for another rehab stint, although they must leave for at least three days between treatment episodes.“The intention is that the member would be able to access residential services for as long as is clinically appropriate,” McCracken said.But the state limits mean that Medicaid funds could run out before a patient is ready to leave a facility — something that advocates for those with substance use disorder say occurs frequently — and hinders rehabilitation providers’ ability to offer longer-term programming. “(I’ve) experienced individuals that willingly head on off to our wonderful providers of Serenity and Valley Vista but do return after two weeks,” Rep. Eric Maguire, R-Rutland City, the director of the Rutland Dismas House, which helps people reintegrate into society after incarceration, said in an interview. “I’m seeing relapse occurring within less than a week after their arrival back.”Those Medicaid rules stand in contrast to New York and New Hampshire, according to people who work in the field. Both states’ Medicaid programs allow for longer stays at rehabilitation facilities, some of which offer crucial longer-term stepdown programs that are not available in Vermont, advocates say.‘A failing cycle’Amanda Wheeler, a spokesperson for Gov. Phil Scott, said that the governor has been in communication with Redmond, of Spectrum Youth and Family Services, and Judge Reiss.In response to those communications, the Scott administration has created “an internal working group to discuss the concept of care for longer, more cohesive treatment for addiction, what that could look like for Vermont and how it fits into our larger intervention and treatment strategy,” Wheeler said in an email. “We will continue to develop this throughout our budget and policy development process this fall and leading into January, should the Governor be successful in November,” Wheeler said.Mark Redmond, executive director of Spectrum Youth and Family Services. Courtesy photoDespite the needed investments, stepdown programs would save money in the long term, advocates say, by keeping people out of Vermont’s prisons and emergency departments — where the cost of caring for residents is extremely high.“Treating individuals at the highest level of care for short periods of time again and again is a failing cycle that results in more incarcerated people,” the August letter reads. And, more importantly, advocates say, the programs would save Vermonters’ lives.Dawn Tatro, a founder of Jenna’s Promise in Johnson, which offers sober housing, workforce training and recovery resources, said Vermonters might overdose while searching for help in the state. “A girl called me Friday night, needed to get in (to Jenna’s Promise), needed treatment,” Tatro said in an interview. “I said, ‘Okay, we’ll call Monday.’ And then her sister called me on Monday. She’s like, ‘Don’t worry about it. She died. She overdosed on Sunday.’”Read the story on VTDigger here: Vermont has ‘critical missing piece’ in substance use treatment, advocates say.