Waterbury, Vt. - Among the casualties of the flooding that ravaged Vermont during Tropical Storm Irene was a faded brick hospital that housed the state's most seriously ill psychiatric patients.

Eight feet of water from the Winooski River inundated the century-old building Aug. 28, forcing the 51 residents, most of whom had been sent there involuntarily, to the upper floors. The next day, they were evacuated by bus to temporary placements around the state.

Two months later, the Vermont State Hospital remains closed - for good, Gov. Peter Shumlin says - and the state is grappling with how to care for acutely mentally ill residents.

"We really have kind of an unprecedented situation on our hands," said Jill Olson, a vice president of the Vermont Association of Hospitals and Health Systems, an advocacy group, "where the highest level of care for a mental health situation in Vermont just washed away."

In a strange way, the disaster presented an opportunity that many state officials and mental health advocates had been seeking for years. The state hospital had so many problems that the federal government decertified it in 2003; state leaders had been vowing to close it ever since but were stalled by indecision about what to build in its place.

"All of us thought that it was so shabby and so old and so difficult to make safe that it was time to replace it," said Dr. Robert Pierattini, chief of psychiatry at Fletcher Allen Health System in Burlington, the state's teaching hospital. "But I don't see any evidence that we can get by without a state hospital."

While other states have shuttered psychiatric hospitals and sharply reduced inpatient beds in an effort over the decades to place the mentally ill in less restrictive environments, virtually all have kept at least one open, according to the National Association of State Mental Health Program Directors Research Institute. And none have had such an abrupt closure as Vermont's hospital, which has forced the state to create alternatives at breakneck speed instead of the years it usually takes. The short-term result is patients requiring intensive care scattered at facilities not equipped to handle the newcomers.

Fletcher Allen and the Rutland Regional Medical Center agreed to temporarily take some patients who would otherwise have gone to Vermont State Hospital, but they question how long they can continue.

"It comes with an unacceptable level of risk," Pierattini said. "We will make do for now, but what is our plan for creating a new system of intensive mental health care?"

Thomas W. Huebner, president and chief executive of Rutland Regional, said his hospital has needed to use emergency medication or restraints on agitated patients seven times more often in the 10 weeks since the floods than it normally does in a year.

One challenge, he said, is that Vermont's legal standard for allowing involuntary medication is among the strictest in the nation. And while every patient who refused treatment used to go to the state hospital, some are now at Rutland Regional and Fletcher Allen, where providers are not used to handling them.

"Much of the stress is just constantly monitoring the level of chaos versus calm and gauging what people can tolerate," Pierattini said.

One thing seems certain: Vermont will have fewer acute-care beds for the mentally ill from now on. While the old hospital had 54, state officials want to cut the number to roughly 30 and expand community-based services.

For now, the Brattleboro Retreat, a private psychiatric hospital, has agreed to devote 14 beds to patients who would otherwise have gone to the state hospital, with the state pledging $3.5 million for required renovations.

A handful of patients who were involved in criminal cases have been at a state prison in Springfield since the storm because they require more security than other temporary quarters can provide, said Patrick Flood, deputy secretary for the Vermont Agency of Human Services. The state will likely move them to a "more appropriate" building on the grounds of another prison in Windsor, he added.

The state is also seeking a temporary location for roughly 15 beds, possibly at a former school for the disabled outside Burlington.

In the meantime, Flood said, the state was moving quickly to expand the kind of community-based programs that advocates say have been lacking in Vermont. They include housing for the mentally ill, transitional facilities for those who no longer need to be hospitalized but still need care, and so-called wraparound services to prevent hospital stays in the first place.

"It's stuff we know how to do, but now we're going to invest more money in it," Flood said. "We have an opportunity now to build a system that will actually meet our needs and work well."

He added, "Community services can't totally replace the need for inpatient services, but it can bring down the demand quite a bit."

But advocates for the mentally ill say that while the plan sounds good, they fear Vermont will not be able to guarantee the financing needed to sustain it year after year.

"If you look at the history of the state, whenever there's a budget crisis we cut community mental health," said state Rep. Anne Donahue, co-chairwoman of the State Legislature's Mental Health Oversight Committee.

Flood said Vermont spent about $24 million a year on the state psychiatric hospital - money that could now be invested in community-based care. The total amount will actually be more, he said, because many of the community programs will get federal matching funds that the state hospital had not qualified for after it was decertified in 2003.

"State funding goes up and down all the time," he said, "but I believe we have no choice but to make sure whatever system we put in place now is stably funded."

Money aside, some mental health providers are worried that 30 beds will not be enough to meet even a small state's needs. Under the worst-case scenario, Donahue said, acutely mentally ill people could quietly be diverted into the corrections system, a frequent occurrence in populous states like California and Florida but not, so far, in Vermont.

Donahue fears that a permanent, albeit smaller, replacement for the state hospital will never be built; Flood said there was no "definite plan" yet to do so.

"I just don't want to see pieces put into place that are going to shape the status of mental health care for the next 50 years in Vermont that are bad policy decisions," Donahue said, "simply because we have an emergency right now."

Mental health workers hope that the 14 beds at the Brattleboro Retreat and roughly 15 at Fletcher Allen and Rutland Regional will suffice for the winter, when demand for psychiatric care often rises.

"What if suddenly we don't have enough capability in the system?" said Dr. Robert E. Simpson Jr., president and chief executive of the Brattleboro Retreat. "Right now we're just poised with anxiety because not all the capable pieces are in place."

At Rutland Regional, Huebner said that disruptive patients who would otherwise be at the state hospital were "driving out" others who needed treatment but could not tolerate the environment. They included an 18-year-old college student suffering from depression who decided to leave after one night in Rutland Regional's psychiatric unit, he said.

"If a concrete plan emerges soon we can hold on," Huebner said. "We've got everyone's attention now, but there's still a lot to be figured out."