Legislators look east for Western State solutions

Maybe an institution that is the target of multiple lawsuits and less than four years removed from a patient-on-patient strangulation can’t be labeled a model.

But by some comparisons, Eastern State Hospital near Spokane has a leg up on its counterpart across the Cascades.

Staffing is less thin there than at Lakewood’s far larger Western State Hospital, where federal inspectors have identified a slew of safety risks caused in part by a lack of trained staff.

And for some reason, it takes patients on the wet side of the mountains roughly three times as long to make their way in and out of state-hospital detention. Those figures have caught the attention of state lawmakers.

“It’s not that I think that Eastern is the perfect model of all mental health care in the world,” said Rep. Laurie Jinkins, D-Tacoma. “But doing some of the things they’re doing, especially with ward size ... if we aim ourselves in that direction, it’s the right way to go.”

MORE STAFF

Wards at Western State Hospital have been filled to the brim — using an average of 98.2 percent of their capacity last month, according to figures compiled by legislative staff. Eastern State Hospital used 79 percent of its wards’ capacity.

Senate budget chairman Andy Hill wants to lower the number of patients per ward at Western State to the levels seen at Eastern State, while keeping the number of employees per ward steady.

“Let’s steal that from Eastern,” Hill, R-Redmond, said.

Hill’s plan calls for freeing up the space by stepping up efforts to find a facility that will take 30 geriatric patients from Western State.

With a smaller load for each employee, he predicts fewer injuries to staff and better care that speeds exits from the hospital.

Last fiscal year, Eastern State had 15 percent more full-time-equivalent employees per patient than Western State, according to a staffing report from the Department of Social and Health Services that manages both hospitals. The report notes the figures predate staffing increases Western State made in response to federal inspections.

“If Western were staffed like Eastern, we’d be spending about $20 million more a biennium on staff,” said Andi Smith, a senior policy adviser to Gov. Jay Inslee.

The staffing gap between the hospitals is roughly the same whether counting budgeted positions or actual spending, so the recent increase in vacancy rates at Western State isn’t necessarily to blame.

Having fewer staff for each patient makes Western State a less costly place to treat a patient and would be a good thing if it simply indicated economies of scale at a larger facility.

But the staffing report shows fewer frontline staff — nurses and nursing assistants — working on a typical Western State ward than one at Eastern State.

The report shows that just three shifts out of 27 at Eastern State have lower target staffing levels than shifts covering similar units at Western State.

Democrat Inslee shares Hill’s goal of reducing the number of patients per employee, but wants to achieve them by adding staff, including more than 50 nurses.

Hill hasn’t ruled out additional staff but points to recent infusions of money after years of cuts. He said he has had difficulty learning reasons from administrators for the differences between the two hospitals.

Inslee wants more than $1 million for a series of studies and planning efforts at the hospitals. Carla Reyes, DSHS assistant secretary for behavioral health, said some of the research would identify industry practices and examine differences between the two hospitals.

Reyes said the staff levels the hospitals target today are based on historical levels rather than some ideal practice.

“We haven’t been able to spend a lot of time analyzing the differences, but it is something that we want to look at,” she said.

LONGER STAYS

Stays at Western State were 3.4 times as long as at Eastern State in fiscal year 2015, according to DSHS figures for civil commitments. Legislative staff calculations for calendar year 2015 — adjusted so they don’t count short-term detentions that happen on the east side at the hospital and on the west side at other facilities — show stays 2.8 times as long.

Depending on the period compared, patients stay 287 days or 354 days at Western State.

“Nobody should be there for more than 180, max,” Hill contends.

While Hill sees higher staff-to-patient ratios as a possible solution because they can provide better care, better staffing at Eastern State doesn’t appear to result in more treatment.

As measured by DSHS, in fact, Eastern provides patients with fewer hours of active treatment per patient per week, state reports show.

Active treatment includes activities that promote recovery, including recreation and “daily living skills” as well as therapy.

Availability of services outside the hospitals is another possible factor, although it’s unclear whether those services are more readily available on the east side.

In some cases, detentions can last years, said Glenn Morrison, a psychiatrist at Western State and doctors union leader.

A tiny fraction of patients are simply inappropriate for discharge, Morrison said, but others languish in the hospital because of inadequate services outside.

“We hear the complaint all the time that we just can’t get people out because there’s nowhere for them to go,” Morrison said.

Lawmakers in recent years have funded services aimed at preventing people from ending up in the hospital and treating them once they are out.

Inslee is calling for more in his budget, including teams that help with housing. House Speaker Frank Chopp said Western State employees have highlighted the need for transitional housing.

DSHS has said vacancies in social worker jobs make it difficult to do the planning that makes discharges possible. Social workers are among the employees who have received a pay raise as the agency tries to improve recruitment and retention.

Hard data on the reasons for discharge difficulties is tough to find because it requires poring over records that aren’t electronic, including patient charts, Smith said.

Not all measures of timely treatment look favorable to Eastern State.

Criminal defendants waiting in jail for Eastern State evaluators to assess their ability to stand trial waited three times as long for in-jail evaluations in December as inmates waiting for Western State staff, according to a court monitor keeping track of progress for a federal judge who has ordered shorter wait times. Waits on the dry side of the mountains averaged more than six weeks.

HOW BIG IS TOO BIG?

Speculation on disparities between the hospitals inevitably runs into the major difference: size. Eastern has space for fewer than 320 patients, Western for 840.

Inslee wants consultants to examine whether Western is simply too big.

“We’re one of the biggest psychiatric hospitals in the country,” Smith said. “Does it make sense for us to regionalize some of these beds?”

 

For a patient from Snohomish County or even farther away from Lakewood, distance makes it more difficult to maintain connections to family and friends and to find housing and employment, Smith said.

House Democrats are thinking along the same lines.

“As a manager of a program, you have to worry about a lot of things, and if it’s too big a place, then that’s a problem,” Chopp, D-Seattle, said. “That stretches management too thin.”

This story was originally published February 17, 2016 at 4:59 AM with the headline "Legislators look east for Western State solutions."