No vacancy is no excuse for denying treatment to the mentally ill.
That idea, the core of a legal ruling issued Wednesday by Pierce County Superior Court Commissioner Craig Adams, throws an inconvenient wrench into the gears of the state’s ailing mental-health system and forces a public debate over a practice known as psychiatric boarding.
In essence, Adams ruled that parking the mentally ill in hospital emergency rooms without appropriate treatment violates state and federal law.
“I don’t think you can do psychiatric boarding just because there is no room at the inn,” Adams said. “The remedies for this really lie with the state Legislature or a higher court.”
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The argument started Feb. 27 when 11 mental patients on gurneys rolled into the involuntary commitment court, seeking beds at Western State Hospital or one of the county’s evaluation and treatment centers. Most rolled right back to the hospitals.
One was a shaggy, middle-age man from Gig Harbor diagnosed as psychotic, possibly unbalanced by a new type of medication. Another was a 19-year-old boy from Puyallup recovering from a drug habit – he jumped through a window of his house.
They came from hospital emergency rooms around the county. There was no other place to put them: none of Pierce County’s allocated 102 beds at Western State or the 44 inpatient beds shared among the county’s evaluation and treatment centers designated for the mentally ill were available.
That meant no therapy and no mental-health treatment, a requirement of state law.
The spectacle is increasingly common these days at the Western State court. Another recent day saw 14 patients come in from local emergency rooms, according to court records.
In bureaucratic jargon, psychiatric boarding is known as “single-bed certification.” A patient needs a bed at a certified mental-health facility but nothing is available. To park at an area hospital requires permission from Western State officials. Permission, typically granted by fax, is virtually automatic. Taxpayers generally foot the bill through state funds or federal Medicaid insurance.
The practice is spreading across the state. A series of state budget cuts have reduced the number of state-certified beds for the mentally ill from 777 to 517 at Western State during the past five years. Overall, the state ranks 51st – last – in rates of staffed psychiatric beds, according to a 2011 study by the Washington State Institute for Public Policy.
While beds have vanished, the mentally ill haven’t disappeared. Instead, they’re spilling into emergency rooms (and jails, if they’ve committed criminal acts).
That trend dates to 2008, and it’s mushrooming.
“It’s pretty much exploded,” said David Reed, a state official who oversees mental-health programs for the state Department of Social and Health Services.
Official numbers are scarce, but 189 Pierce County patients languished in hospital rooms for a total of 910 days during a 10-month period last year, according to statistics from OptumHealth, the for-profit company that provides mental-health services for Pierce County.
The numbers were greater in King County where 653 patients spent 2,200 days waiting for mental-health beds.
“It should not be a surprise to anyone,” said Amnon Shoenfeld, director of King County mental health and substance abuse services. “We should not be surprised that we have a boarding crisis.”
Tim Holmes, vice president of behavioral health for the Multicare Health System, could not provide specific numbers, but he said the number of mental patients in Pierce County emergency rooms doubled between 2011 and 2012. Hospitals do their best, but they’re not the ideal place for mental-health care. Patients receive medical care if needed, but no treatment for their underlying mental issues.
“We believe that the right thing for these patients is to be treated at an appropriate psychiatric facility that has the necessary support structure to help them deal with their individual situations,” Holmes said.
Adams’ ruling emerged against a fitting backdrop. On Feb. 27, the day he heard arguments on the issue, the hearing had to stop to make way for patients arriving from area hospitals for involuntary commitment hearings.
“I think it’s important that we handle the people who are here on hospital gurneys,” he said.
The delay drew a sardonic remark from Stanford Opdyke, an assigned defense attorney who filed the original motion arguing against psychiatric boarding.
“That’s really ironic – the number of single-bed certs (certifications) screwing up the hearing about single-bed certs,” Opdyke said.
Opdyke has argued against psychiatric boarding in the past. In one of his legal briefs, he called it “a class-action suit waiting to happen.”
Under state law, any person facing involuntary commitment has the right to adequate care and individual treatment. Mental patients don’t receive that required care in emergency rooms.
The commitment process starts when an individual showing signs of “imminent risk” (danger to self or others) is detained on a 72-hour hold. Within those 72 hours, a mental-health professional must evaluate the person for potential civil commitment and schedule a hearing on the matter.
Ideally, the person is detained at a certified mental-health facility, where appropriate treatment is available – but more often, those facilities are full. In such cases, the patient goes to a local hospital to wait for an evaluation or a free bed. Psychiatric boarding has begun. The patients wait – and wait.
The argument that led to Adams’ ruling featured three attorneys arguing from different angles: a defense attorney representing the patients; a county attorney representing the county’s interests and a state assistant attorney general defending the state’s practices.
The state is involved because Pierce County, alone in the state, hands off its local mental-health obligations to OptumHealth, which contracts with DSHS.
Nathan Hinrichs, a Multicare employee, also supervises the county’s contracted team of designated mental-health professionals: the people who evaluate the patients facing involuntary commitment. A typical evaluation might take two hours. On Feb. 27, Hinrichs testified that the volume of patients in emergency rooms is so great that patients sometimes wait more than 72 hours for a psychiatric assessment.
“It’s becoming a very significant challenge for our staff. The volume has exceeded what we can actually accommodate,” he said. “In an emergency room or a medical hospital, (patients) are confined primarily to a room. They might get meds, but they’re missing out on counseling.”
Before Adams issued his ruling, assistant attorney general Sarah Coates argued that while psychiatric boarding might not be ideal, it’s better than nothing.
“The alternative to the single-bed certifications is to turn the respondents back out on the street, where they might pose a threat of harm to themselves or others,” she wrote in a legal brief.
The state also argued that Adams, whose duties are limited to involuntary commitment hearings, lacked the legal authority to decide whether psychiatric boarding violated the law.
Adams agreed in part but waved off arguments he shouldn’t rule at all. In the end, he sided with the mental-health professionals faced with the Hobson’s choice of deciding the fate of too many patients needing care.
“It grates on me,” he said. “The choice is violate the person’s rights or let that person go. Psychiatric boarding is problematic. I think that’s an understatement.”
His ruling won’t take effect immediately. After a request from county attorneys for a 30-day stay, the debate is headed for Superior Court where a judge will weigh the merits of the competing arguments. A hearing date has not been set.
“The Superior Court judge may say I’m full of baloney,” Adams said Wednesday. “But the longer this issue festers, the more patients will suffer.”
Sean Robinson: 253-597-8486