On May 11, 2018, Gov. Jay Inslee announced a five-year plan to move nearly all mental health patients who are admitted to the big state hospitals through civil commitments into smaller facilities around the state.
“Large institutions were popular in 1918, but in 2018 we know smaller hospitals closer to home are far more effective,” said Inslee, who spoke outside Western State Hospital in Lakewood, joined by state lawmakers from the Tacoma area.
Nearly a year later, the Legislature capped off its 105-day session by approving a plan rooted in Inslee’s ambitious strategy, but with some significant changes.
The Legislature opted to treat civil patients in hospitals and other nonprofit facilities instead of state-run buildings. Civil commitments occur after a mental health professional determines a person is dangerous to themselves or others due to a mental disorder.
Lawmakers also predict it will take longer than five years to move most of the civilly committed patients out of Western State and Eastern State Hospital near Spokane. Given the number of mental health facilities that need to be renovated or built, a more realistic timetable is by 2026, they say.
What’s not in dispute is that lawmakers used Inslee’s blueprint to craft a bi-partisan plan that offers the promise of modernizing the state’s troubled mental health system.
The state has increased spending on mental health from $1.1 billion in 2015-2017 to $1.9 billion in the upcoming two-year operating budget, according to preliminary figures from the Office of Financial Management.
Lawmakers have more than doubled mental health spending in the capital budget in that same period, from $105 million to $224 million.
“Our citizens can expect a much better behavioral health system that will be closer to them in their communities and will also have well-staffed professionals to care for them,” Inslee said shortly after the legislative session ended on April 28.
The question now is whether that promise can be fulfilled.
State officials say they are determined to overcome the challenges to executing the plan from Inslee and the Legislature, which is to use a variety of facilities around the state so that those who are civilly committed because of mental illnesses don’t have to be admitted to the state hospitals.
“You can build it, but can you actually operate it with enough staff and finances?” said MaryAnne Lindeblad, the Medicaid director for the state Health Care Authority. “We’re certainly doing things to help address that, but will everything come together at the same time?”
In many respects, the state’s strategy revolves around Western State, where the federal government last year pulled annual funding of $53 million after the facility failed an inspection. Infractions included the restraint of patients for hours without cause and an insufficient number of sprinklers in parts of the hospital.
As of May 1, there were 470 civil patients and 311 forensic ones at Western State.
By 2026, the state’ s mental-health strategy should dramatically change that, with nearly all of the patients being forensic ones.
“Our plan over the next several years as we move people out into the community is we will keep wards open at Western that will primarily be for (people not guilty by reason of insanity) and those who are in a specialized higher-risk category,” said Rep. Laurie Jinkins, D-Tacoma. “We always want to balance public safety with making sure we move people back into the community.”
Forensic patients at Western State are awaiting an evaluation to determine if they are competent to stand trial or those who need treatment to become competent. If their competency can’t be restored, their criminal charges can be dropped, and they can be civilly committed to the hospital. People who are found not guilty by reason of insanity can stay at Western State for a time up to what would have been the maximum sentence for their crime.
The state capital budget includes $1 million for predesign of a new Western State on the grounds of the existing hospital.
WHERE TO HOUSE CIVIL PATIENTS
Building a new Western State with 250 to 350 beds almost exclusively for forensic patients requires facilities for civilly-committed ones.
Inslee’s plan called for building state-run facilities all around Washington — four each with 16 beds, two with 48 each and three with 150 each.
Sen. Steve O’Ban, R-University Place, was among the large majority of legislators who said it would be better to use nonprofit entities to provide more long-term beds, which are used by those who are committed involuntarily for 90 or 180 days.
“The whole premise of this policy shift is to keep people in their communities. We’re more likely to achieve that if we are relying on private facilities scattered around the state,” he said.
The state capital budget has $120 million in grants for that purpose and a long list of specific projects throughout the state.
That includes $20 million to help the MultiCare hospital system open a psychiatric care facility in Auburn. It would consist of 12 to 18 beds for patients who are in crisis and need to be stabilized, 60 beds for those who are civilly committed for short-term stays and 60 long-term beds.
The bricks-and-mortar budget also earmarks $4.7 million for a 24-bed psychiatric unit at Providence Regional Medical Center in Everett. Six of those would be long-term beds and 18 would be for mental health patients with medical needs along with those who are admitted voluntarily.
As the mental health crisis has increased in Snohomish County, some free-standing psychiatric hospitals have opened, but those have not taken much pressure off 530-bed Providence to care for the mentally ill in need of treatment, said Kim Williams, chief executive officer for Providence Health and Services Northwest Washington.
Williams said the state funds from the capital budget will enable the 24-bed unit to open in 2021.
The six long-term beds fit the state’s strategy to enable civil patients to avoid being admitted to Western State, she said.
The strategy released by Inslee in 2018 and revised by the Legislature this year goes far beyond beds.
Lawmakers approved a bill to prevent mentally ill people facing criminal charges from being warehoused in jail as they await treatment to become competent to stand trial. The legislation put key provisions into the state code from last year’s legal settlement of a lawsuit between a nonprofit advocacy group, Disability Rights Washington, and the state.
In 2015, a federal judge ruled in favor of a class of criminal defendants suffering from mental illness who were held in county jails as they waited to be evaluated to determine if they could assist in their defense. Many of the defendants had to wait for weeks or months to get into either Western State or Eastern State.
The state plans to help people get outpatient mental health treatment so their competency can be restored and they can learn how to assist in their defense as they prepare for trial.
Beyond that, the state is using several projects to help those with mental illness — who are more likely to be victims of crime than perpetrators — avoid getting arrested. The effort is needed in part because of the criminalization of homeless people who also have mental illnesses, said Melodie Pazolt, section manager in the state Health Authority’s Division of Behavioral Health and Recovery.
Legislators set aside $35 million in the state’s Housing Trust Fund for development of housing for those with behavioral or chronic mental illness. The funds are tied to case management, which helps mentally ill people set goals for independent living and learn about housing, education, health care services and employment.
Other programs include training mentally ill people who have stable lives to help people before their mental health issues spiral into a crisis. Expanded service facilities will help elderly patients at Western State and Eastern State move into an adult family home or assisted living facility.
The $33.2 million for predesign, siting and design costs for a behavioral health teaching hospital at the University of Washington will provide at least 50 long-term civil commitment beds, 50 geriatric psychiatric beds and 50 licensed medical/surgery beds with the ability to treat patients with psychiatric diagnoses and/or substance abuse disorders.
The teaching hospital also will help address the shortage of mental health workers, said Lindeblad, the Medicaid director for the state Health Care Authority.
“It’s really going to help us in terms of expanding the workforce. It’s not just psychiatrists. It’s at all levels — psychiatrists, nurse practitioners, nurses and mental health specialists who can serve individuals with substance abuse. It won’t solve a problem in five years, but it will really create an opportunity to train more individuals,” she said.
Adoption of the state’s mental health strategy has created hope among many residents whose lives have been touched by mental illness.
In March, Patti Egbert attended a meeting of the legislative subcommittee that crafted much of the legislation that accompanied the spending on mental health in the state’s operating and capital budgets.
As she fought back tears, Egbert told lawmakers that her 25-year-old son was in a psychiatric hospital in Kirkland. When he was 17, he was diagnosed with bipolar disorder. Since then, he has been hospitalized three times. Most recently, it was because his medications had stopped working, Egbert said.
There were no beds available in the Vancouver area. Despite the three-hour drive to Kirkland, Egbert said she and her husband felt lucky to get a bed for her son.
“It is critical that there are enough beds available for every person with a severe mental illness in crisis. It is terrifying to think about the possible outcomes had our son not been able to get the treatment necessary for his illness. Without a bed, our situation would have become very tenuous. Without treatment, mental health deteriorates and many times leads to self-harm, homelessness, violence and suicide. These are all avoidable outcomes,” she said.
Egbert said in a recent interview that her son returned home about six weeks ago, and he hopes to resume working after undergoing intensive outpatient care.
She welcomed the mental health reforms that the Legislature passed. Echoing the message from lawmakers, she said the changes to the system would take time.
“There are so many barriers to mental health care, and so I am just thankful whenever a step is made in the right direction,” Egbert said.