Nearly three months after the launch of new rules banning the warehousing of mentally ill patients in Washington state and after millions in new spending to boost care, experts in psychiatric evaluation and those on the front lines say the revamped system is off to an uncertain start.
The state Supreme Court ruled last August that it is unconstitutional to detain and hold psychiatric patients in settings such as emergency rooms without providing appropriate treatment. In the wake of that decision, critics charge that some detained patients are receiving only “Band-Aid” mental-health care — while others who should be held are being turned away, even when they might pose a danger to themselves or others.
“I haven’t seen a bad outcome yet, but it’s an inevitability,” said Robby Pellett, a designated mental health professional in Thurston and Mason counties, who said he’s heard reports of 10 to 20 mentally ill patients released without care. “It’s only a matter of time.”
Designated mental health professionals are the front-line professionals who assess psychiatric patients at hospitals and other facilities.
Other observers, however, say the changes enacted Dec. 26 by the state — after the court agreed to a delay — have gone as smoothly as possible, considering they’re a first step toward solving longstanding problems in Washington’s troubled mental-health system.
“We think it’s going much better than it was before the Supreme Court case,” said Chelene Whiteaker, director of advocacy and policy at the Washington State Hospital Association. “It’s gone better because they’ve added capacity.”
There are 160 more psychiatric beds in the state than in August, with an additional 60 expected by July, according to the state Department of Social and Health Services.
After the state Supreme Court ruling, Gov. Jay Inslee authorized $30 million to help stop the boarding, though the state wound up spending only $14 million because of a change in the way Medicaid beds are reimbursed. The governor has proposed $37 million in the 2015-2017 budget plan to continue to address the issue; Whiteaker and others said they were anxiously waiting to see what the Legislature approves.
Critics note that an estimated 300 to 400 mentally ill patients were being boarded each month as of last summer, and that there’s still a gap between beds needed and those available.
But Jane Beyer, DSHS assistant secretary for behavioral health and service integration, said that on any given day, only about 65 psychiatric beds are required to deal with the most critically mentally ill patients.
“We have brought the beds online that we committed to bring online — actually more than we committed to,” Beyer said. “I do think we are on the right track.”
In addition, there’s better cooperation among mental-health agencies, giving patients appropriate care faster than before, said Nate Hinrichs, a DMHP crisis supervisor for Pierce County, whose testimony about the problems of boarding was cited by the Supreme Court justices in their decision.
“I would say that things are much better than they were,” Hinrichs said. “It’s the most focused change in the state in decades.”
That sentiment is echoed by Jim Vollendroff, director for King County’s mental-health and substance-abuse division. County officials, hospital officials and directors of the five local evaluation and treatment centers are now constantly in touch about patients who need placement, Vollendroff said. There’s even a phone tree of the executive directors who step in personally to resolve problems with hard-to-place patients.
“At least one time it made it up to me,” said Vollendroff, who said he couldn’t discuss the specific case because of privacy rules.
State ruling
The state Supreme Court ruling took aim at the practice known as psychiatric boarding, in which authorities forcibly detained mentally ill people to treat them — but had no evaluation and treatment beds available for proper care. Rates of psychiatric boarding in Washington quintupled between 2009 and 2012, a Seattle Times analysis found.
The opinion delivered by Justice Steven C. González found patients could be held in hospitals under so-called “single-bed certifications” for recognized reasons, “but not merely because there is a generalized lack of room at certified facilities.”
Up-to-date figures on single-bed certification aren’t available, DSHS officials said. But in January, the first month after the court ruling took effect, single-bed certifications were accepted 290 times, DSHS figures show. That’s down from 430 in August 2014.
The January data included 158 patients who couldn’t find space in evaluation and treatment centers and instead were sent to hospitals with psychiatric units, to psychiatric hospitals — or to hospitals that attested they were “willing and able” to provide designated mental-health treatment, as required by the court ruling. That includes psychiatric evaluation, appropriate medication and a treatment plan.
It’s that last category that most worries psychiatrists such as Dr. Arpan Waghray, medical director for behavioral health at Swedish Medical Center. Such care is treatment in name only, he said. Psychiatric patients may still be confined in emergency or medical units and deprived of the full range of care they need.
“Nothing has changed, nothing has changed,” Waghray said. “They’re doing what they did before, but they’re not calling it boarding. It’s not the evidence-based medical care that I would want for my family.”
At the same time, DSHS’ new rule bans designated mental health professionals from accepting mentally ill patients when there are no authorized beds, said Ian Harrell, program director for Behavioral Health Resources in Olympia and a past president of the state DMHP association.
Both Harrell and Pellett — who has just left his post in Thurston and Mason counties — said they have received reports of DMHPs releasing detainable mentally ill patients for lack of space. Neither would identify the patients or the providers involved, citing federal privacy rules. Neither said they knew of incidents when such patients caused harm to themselves or others. Both, however, said the possibility was very real.
“The only way we’re going to know is if somebody shoots a place up,” Harrell said. “We’re not going to know if they suicide. The DMHPs are freaking out about it.”
Beyer, of DSHS, said the proportion of people coming in and being evaluated and the number of detentions has not changed since the court ruling, and the agency has received no reports of patients who meet criteria for detention being released for lack of beds.
“We have not had hospitals contacting us saying this is a problem,” she said.
Some positive results
Overall, the impact of the court ruling has been positive, even as problems remain, said King County’s Vollendroff. There won’t be a quick fix in a mental-health system that ranked 48th in the nation for access to care in a recent report by the nonprofit Mental Health America.
“I would completely agree that it’s a Band-Aid situation,” Vollendroff said. “People are getting care, but we need more psychiatric beds.”
At the same time, there is a great appetite for finding solutions to the problem sooner. In King County, the Community Alternatives to Boarding Task Force has been focused on meeting mental-health needs before they become a crisis, said Mike De Felice, civil commitment supervisor for King County.
“The trend has to be in the opposite direction, not to increase involuntary treatment beds, but to increase community mental-health intervention,” he said.
Such interventions include mental-health mobile units, where trained providers go directly to the scene of a problem to try to help defuse the crisis and arrange future help. The King County Crisis Solutions Center also provides care outside of involuntary commitment, De Felice said.
There are still unmet needs in the state’s rural communities, where many hospitals don’t have psychiatrists on staff and can’t fulfill the requirement of being willing and able to provide appropriate treatment, said Whiteaker, of the Washington State Hospital Association.
But for the first time in years, there’s progress, she added.
“There’s a hope that wasn’t there before,” Whiteaker said. “It was in such bad crisis that people had almost given up on the solutions.”
