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King County mental health facilities still reject a quarter of patients, report shows
Seattle Times - 9/5/2023
Sep. 5—People in a mental or behavioral health crisis were turned away from treatment at facilities in the Seattle region 1,173 times last year, according to a new report from King County'sBehavioral Health and Recovery Division.
The reason people are denied treatment isn't a lack of available beds, the report shows. It's frequently a slew of other causes like being too acute or sick, having a history of aggression or use of restraints, or having autism or other cognitive or developmental disabilities.
Ultimately, the data demonstrates how the most vulnerable patients in the system also struggle the most in accessing care — and few facilities and staff are equipped or willing to take on the most complicated and difficult-to-place patients.
The report found that facilities on average decline people 25% of the time, though the person could later be accepted at a second or third facility after an initial decline. This rate is similar to the decline rate for 2021.
"[Facilities are] just not staffed or oriented towards taking care of people with complex needs," said Paul Getzel, the director with the local Seattle chapter of the National Alliance on Mental Illness, an advocacy nonprofit that supports family members and people living with mental illness and substance use.
Often he hears from parents of adult children who have a hard time finding the right facility for their loved one in crisis and are fighting to keep them from falling into the criminal-legal system.
"What we're concerned about is getting folks into care and not jail," Getzel said.
The county's annual report analyzed how often people are turned away at nine local facilities, including residential treatment facilities like Telecare and Recovery Place; free-standing psychiatric hospitals like Navos, Fairfax and Cascade; and traditional hospitals that provide crisis care like Swedish Ballard, MultiCare, Harborview Medical Center and the Geropsychiatric Center at the UW Medical Center.
To get a bed at one of these facilities, a person must go through a lengthy process, starting with an evaluation from a designated crisis responder. If they find that a person in crisis meets the threshold for involuntary treatment because they are a danger to themselves or others, or are so sick they cannot care for themselves, they will be detained for up to five days. A judge will then order their civil commitment for an additional 14 days, with additional extensions if that person has not stabilized.
Once they arrive at a facility, people typically receive medication for their mental illness and intensive group and individual therapy.
However, those who don't get accepted to a facility generally stay in a hospital emergency department or medical unit under what's known as a single-bed certification, a temporary license that allows them to hold someone for up to 30 days while a proper bed is found. Critics of this practice argue it is a far cry from adequate treatment, and sometimes staff in those more generalized departments lack training or expertise in caring for psychiatric patients with severe illnesses or substance use disorders. If the patient in crisis doesn't get a placement on time, they are ultimately released without treatment.
While King County's data doesn't indicate whether a person who was declined at one facility was ultimately accepted by another, it's clear that many people are having trouble finding a placement: According to a Seattle Times analysis of data from the Washington Health Care Authority, an average of 443 people a month in King County were held on a single-bed certificate last year. Statewide, an average of 80 reports were filed each month when beds were not available for people.
Facilities like Harborview are the most accepting of patients with complex backgrounds, declining just two people last year. Compare that to Cascade in Tukwila and MultiCare in Auburn, which declined people 44% and 40% of the time, respectively.
Laurel Kelso, the director of hospital operations for Navos (which is owned by MultiCare) explained that as a free-standing psychiatric facility, they aren't able to deal with certain needs like wounds, dialysis treatment or mobility issues.
"If we can't manage those individuals when they're referred, then we have to decline," Kelso said. "That is for the best interest of the patient."
She also points out that the facility does not have single rooms — so anyone who needs private space if they're being aggressive or volatile due to their untreated mental illness will not be accepted by Navos.
Staffing likewise remains an issue. Currently the facility is at 50% staffing levels and relies on travel nurses and mental health techs to keep providing services.
Recovery Place, one of the facilities that improved their decline rate from 43% in 2021 to 30%, opened up their acceptance criteria to take more patients. For instance, they'll now accept someone who is medically detoxing but using methadone, said Richard Geiger, chief of inpatient and residential services at Valley Cities Behavioral Health Care, which owns Recovery Place.
He credited their new director, Teresa Hardy, who championed this change.
"If she gets somebody that doesn't fit in the specific box, she makes sure that we can adjust the box a little bit," he said.
Harborview, on the other hand, is able to accept a high percentage of patients because they're specially equipped to handle people with more complex needs, a spokesperson explained. They have access to medical services to care for someone with a physical injury or illness, for example, and can consult with neurology or surgical specialists.
Staff at the Swedish Ballard campus, which hosts 22 psychiatric beds, likewise pointed to their high staffing levels, which allow the facility to take patients who have higher acuity. Swedish Ballard also recently opened a new partial hospitalization program that helps people transition from inpatient to outpatient settings.
Telecare declined to comment and Fairfax did not respond to multiple requests for comment.
The 2022 King County report also cites a particular need for specialized units that can care for people with traumatic brain injuries and intellectual and developmental disabilities.
Meanwhile, fewer psychiatric beds are available to begin with: The report notes the recent closure of Cascade Behavioral Health Hospital in Tukwila, which used to make up about 13% of beds for patients committed to involuntary treatment in King County. The hospital was recently bought by the Department of Social and Health Services, but the state currently plans to use it for a different population of patients.
"We are of course deeply concerned about the closure," said Isabel Jones, the interim behavioral health director with King County.
Officials will be tracking how this affects the decline rates at the remaining eight facilities to see whether more people are turned away next year.
But the landscape of crisis care in King County is likely to shift in the coming years anyway.
In April, voters overwhelmingly passed a property tax to build five new walk-in crisis facilities that would be capable of taking people in a mental or behavioral crisis, regardless of insurance.
The centers represent a new opportunity to stabilize people in crisis before they need involuntary treatment — though it's not yet clear whether that will help the most complex patients access the types of specialized treatment they're denied today.
Construction for the centers wouldn't start till 2026, but Michael Reading, chief of crisis systems and services for King County, said now is the time to start thinking about how that future system will interact with the current one.
At the future walk-in crisis centers, both law enforcement and families can bring in a person for care. Though the facilities are voluntary, county officials have said that the walk-in crisis centers will operate under a "no wrong door" policy.
The centers may also house designated crisis responders, who would be able to kick-start the involuntary care system if necessary. At that point, patients would be rerouted to another psychiatric locale like an evaluation and treatment facility.
King County is not alone. Communities across the country have struggled to care for people with complex needs.
"As a society, we have created such profound challenges and simply don't have the resources to safely or appropriately place people with those histories," said Robert Trestman, chair of psychiatry and behavioral medicine at the Virginia Tech Carilion School of Medicine.
Patients with the most severe needs are often the ones most likely to be bounced through the system, he said.
Besides having a hard time during a crisis, people with sex offenses, substance use disorders or criminal histories will then face an uphill battle to stabilize with appropriate housing or employment.
"Our patients typically are at the back of the line," Trestman said. "And there are very few advocates and very few legislators who are willing to take a broader social perspective."
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