Court ruling exposes broader problems with mental health system

Jan. 04--No one intended for a 13-yearold boy to spend two weeks last spring in an emergency room bed at United General Hospital in Sedro-Woolley. His health crisis wasn't the kind that an ER is set up to handle.

Previously diagnosed with attention deficit hyperactivity disorder and post-traumatic stress disorder, the boy needed psychiatric care. But the hospital had no one to treat him, and no beds were available at a certified psychiatric evaluation and treatment center.

The hospital kept him under the state's Involuntary Treatment Act while awaiting a bed to open.

"The mental health system has failed this young boy," attorney Dennis Scott of Anacortes, who argued for the boy's release, said at the time.

A judge did finally order the boy released, and a bed was found for him later that day. But the issue of what to do with mentally distressed adult and juvenile patients remains largely unanswered.

Each year, hundreds of patients in mental health crisis wait in hospitals ill equipped to treat them until a bed can be found at a mental hospital or in-patient treatment center.

Hospitals don't want to board patients, administrators say. Holding a patient in a mental health crisis can be dangerous for both patient and staff if the facility isn't equipped for it and can't give patients the treatment they need.

But federal law requires hospitals to treat people who need emergency care, leaving hospitals forced to board patients rather than simply turn them away when beds at other facilities aren't available, hospital officials say.

Yet the state Supreme Court ruled this summer that involuntary holds can only occur under specific circumstances.

In September, the court granted a 120-day stay on the ruling after the state attorney general, joined by hospital associations and other groups, asked for time to come up with enough beds for patients who were already held in boarding situations.

That stay has expired.

The state says it is meeting the requirement with Gov. Jay Inslee authorizing $30 million toward the effort and the state adding 140 beds to the mental health system via community hospitals, private psychiatric hospitals and more.

Skagit County has plans for more beds to open at the former Northern State Hospital campus in Sedro-Woolley, though not for several months.

In any case, the state reported in late December that only three patients in the state were boarded due to lack of beds in the week before the stay expired. That's down from 47 in October and 36 in November, according to The Associated Press.

That doesn't mean the problem is solved or that $30 million will fix the problem.

While Inslee is proposing another $37 million in his two-year budget proposal and the re-opening of 30 beds at Western State Hospital, lawmakers deciding how the state's dollars are spent are facing plenty of pressure in the coming session.

Single-bed certifications

Hospitals can hold patients involuntarily through what's called a single-bed certification. The Involuntary Treatment Act allows hospitals to hold patients in dangerous mental crisis until a countydesignated mental health professional can evaluate and decide next steps.

That professional can authorize a 72-hour hold for evaluation and treatment and may ask a court for an additional 14-day hold. If that isn't enough, a 90-day involuntary commitment may follow.

But often, when beds aren't available at certified psychiatric facilities, counties seek a single-bed certification to keep patients in hospital care until space opens.

The trouble is, the court found that state law only allows such holds in a facility qualified to treat the patient.

From 2009 to August 2014, roughly 1,224 singlebed certifications were issued between Island, Skagit Valley, United General and PeaceHealth St. Joseph hospitals, according to data provided by the North Sound Mental Health Administration.

That doesn't include patients who are voluntarily boarded until a certified psychiatric bed can be found, said Carsi Padrnos, director of nursing at PeaceHealth United General Hospital in Sedro-Woolley. Those cases don't require certification.

What's more, no clear legal definition of boarding actually exists, said Joe Valentine, executive director of the North Sound Mental Health Administration.

Limited options

The state Supreme Court's ruling did not ban single-bed certifications, but did ban the use of certifications to hold patients in hospitals that aren't equipped to treat them.

Anyone detained by the state has a constitutional right to treatment that "will give each of them a realistic opportunity to be cured or to improve his or her mental condition," the justices wrote.

The law offers few exceptions -- if the patient needs medical treatment not available at a psychiatric facility or for "continuity of care." But with a shortage of beds and providers for emergency mental health care, hospitals have had few choices.

"Patients who we feel can go home safely, we facilitate that," Padrnos said. "That isn't always an easy option."

Boarding people against their will isn't something hospitals take lightly, said Vince Oliver, Island Hospital CEO. It doesn't result in treatment for the patients, and it sometimes puts hospital staff in danger.

"It's difficult on the patient; it's difficult on the physicians," he said.

It also violates their civil rights, the court ruled. Yet, hospitals are federally mandated to provide emergency care to those who need it, so that conflict puts hospitals in a tough spot, Valentine said.

Some hospitals, such as PeaceHealth St. Joseph in Bellingham, have emergency beds for patients dealing with behavioral health crises. But with the recent ruling, even holding patients may not be permitted. No one seems to know yet.

"This is a whole grey area," Valentine said. "We don't know yet how this is going to play out."

More beds needed

Statewide, a limited number of beds are available at facilities certified for psychiatric treatment.

The only certified beds in Skagit County are at Skagit Valley Hospital, which has 15.

In 2014, such facilities existed in just 13 counties around the state, but most were operating at capacity much of the time, Valentine said.

The largest facility is Western State Hospital in Lakewood, southwest of Tacoma. The hospital serves all 19 Western Washington counties including Skagit for criminal and civil commitments of people with mental illness.

But the 827-bed facility has historically operated at or above capacity -- or at least staff-level capacity, Valentine said.

Western State CEO Ron Adler said 60 beds are "offline" at present, due to a lack of funding from the state. Aside from funding shortages, the hospital, like much of the state, is having trouble recruiting qualified psychiatrists, he said.

"The other issue for us is salary," Adler said. "The salary for our doctors is far below market average. You can't run a hospital without doctors and nurses."

Simply re-opening 30 beds won't be possible without a recurring infusion of money.

Meanwhile, state funding for mental health programs has been cut year after year.

Plans are in the works locally to reopen an evaluation and treatment center at the former Northern State Hospital campus in Sedro-Woolley, Valentine said.

The Skagit County commissioners and the North Sound Mental Health Administration have taken steps toward getting the facility reopened at an estimated cost of $100,000, possibly this summer. The facility would open about 16 beds for short-term holding of patients in crisis.

Another facility at Providence Regional Medical Center Everett recently opened, adding 30 beds. That facility is run by Fairfax Behavioral Health, which also runs a 100-bed psychiatric hospital in Kirkland.

Lawmakers have little doubt that the issue will be one of many that consume the state legislative session, set to begin Jan. 12. But other major issues loom, as well, including another court-ordered fix for education. The McCleary decision requires the state to fully fund education, which pits it against mental health for state dollars.

"Unfortunately, during any recession when the budgets are so hard, people and lawmakers lose sight of the ability to be visionary, and we become reactionary," said Sen. Kevin Ranker, D-Orcas Island. "We get caught up thinking about the immediate solution."

That reactionary thinking is how mental health funding in Washington has been "seriously impacted" in the last five years, he said.

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