The Ban on ‘Boarding’ Mentally Ill Patients Goes Into Effect Soon

Patients no longer held in ER until beds in psychiatric facilities become available

By Celina Kareiva November 18, 2014

mentally-ill

This article originally appeared in the December 2014 issue of Seattle Magazine.

Seattleite Lynn Caldeiro can only remember fragments of her first hospitalization four years ago—a nurse standing over her, her husband crying by her side, her own high-pitched scream above the din of the Overlake emergency room. She was sedated, her wrist and ankle strapped to a gurney. When a bed became available six hours later, she was transferred to the psychiatric unit at Fairfax Hospital in Kirkland.

The first time Caldeiro was involuntarily hospitalized was also the first time, at 37, she was diagnosed with bipolar disorder. What began as a euphoric high had tumbled slowly into delusion. Her racing thoughts turned into sleepless nights, and she began to imagine messages in the music playing on the radio and secret inscriptions on road signs.

Caldeiro’s hospitalization pitched her headfirst into a personal hell that, she believes, ultimately saved her life: “Of course I didn’t want to be there,” she says, “but if I’d tried to get better without the routine or the medicine they force on you in the hospital, and the education and whatnot, I think I’d be worse off today.”

Now, that process—rock bottom for some and a critical juncture for others—is about to change. The practice of holding a mentally ill patient, like Caldeiro, in an ER for hours, sometimes days or weeks, until a bed in a psychiatric facility becomes available is known as “boarding.” In August, the Washington Supreme Court ruled boarding to be in violation of the state’s Involuntary Treatment Act. Starting in December, facilities either have to immediately provide the appropriate resources or release patients.

The historic decision, the first of its kind in the country, stems from a 2013 Pierce County case involving 10 psychiatric patients. At the time of the August ruling, as many as 200 people were being made to wait out their “involuntary holds” at hospitals and acute care centers across the state, because certified psychiatric treatment centers simply didn’t have the space. In some cases, individuals deemed a danger to themselves or others were committed for an initial 72 hours and then released without care because their hold ran out before appropriate space opened.

“It’s a pretty momentous ruling and it’s one that those of us in the community mental health sector applaud,” says David Stone, CEO of Sound Mental Health, a nonprofit behavioral health services provider in King County. “It’s been a real travesty to watch people not get mental health services even when they’re put in hospitals.”

The ruling has forced the state’s mental health system and lawmakers to confront a hard truth: decades of disinvestment in community mental health, created by a series of federal and local budget cuts. Providers and patients caution that a ban on psychiatric boarding is only a first step. Without reinvesting in the system, they say, the ruling could have the unintended consequence of releasing without treatment patients who are potentially harmful to themselves or others.

“What the decision does not do in any way, and what will be the challenge is how are we going to find capacity?” says attorney Linda Worthington of Schroeter Goldmark and Bender. She represents mentally ill patients in administrative hearings as a civil lawyer, and is a board member for the Seattle chapter of the National Alliance of Mental Illness (NAMI).

Amnon Shoenfeld has seen the current boarding crisis climax in slow motion. “I’ve been talking about the bed shortage for some 20 years,” he says. In February, Shoenfeld retired as director of King County’s Mental Health, Chemical Abuse and Dependency Services Division.

Shoenfeld attributes the surge in boarding to the confluence of four main trends: a loosening of commitment laws through the years in response to a handful of isolated but well-publicized crimes (making it easier to involuntarily commit people); a population explosion; a repeated downsizing of available beds; and a disconnect by which money saved from cutting psych wards is not reinvested in community mental health.

Since that August decision, the state Department of Social and Health Services has been working around the clock to expand capacity. Governor Jay Inslee allotted $30 million in emergency funding to create a targeted 145 beds by December 26.

On the day of the state Supreme Court ruling, Navos Mental Health Solutions, a Seattle-based nonprofit organization providing residential treatment and housing for people with mental illness, added two more beds to its 68 psychiatric units. As of the end of October, funds have been used to secure 12 beds at Fairfax Hospital in Kirkland and 18 beds at Cascade Behavioral Health in Tukwila. Thirty more units are expected from Fairfax in Everett. The state anticipates it will have added 117 toward the target by the December 26 deadline. To ease overcrowding, the Washington State Hospital Association has proposed, among other policies, innovations in telemedicine to allow for psychiatric treatment via live video. Many stakeholders are also advocating for greater recruitment incentives for professionals in the mental health workforce to address staffing shortages.

Additional financial help can be found in a two-year waiver from the federal government, which will allow for greater sharing on mental health costs. The waiver went into effect in October and allows free-standing psychiatric facilities with more than 16 beds, such as Navos, to use Medicaid dollars to pay for about half of services. The money saved could free up other funding for the mental health system. It also means for-profit institutions, such as Fairfax, may be more likely to admit Medicaid patients.

With the ban, money is flowing and politicians are scrambling, but there’s a lot of ground to make up in Washington. With just 8.3 hospital psychiatric-care beds for every 100,000 people, the state ranks among the worst in the nation for access to this sort of care, according to a 2014 report by the American College of Emergency Physicians. Between 2006 and 2013, the state lost 250 psychiatric beds, in large part because medical providers found other, more profitable avenues for their money.

Such an entrenched problem leaves many unknowns. Mental health professionals can’t say with certainty what will happen if a patient is involuntarily committed and a bed can’t be secured. Much of that depends on how the public defenders assigned to a patient detained against his or her will decide to argue that client’s case. (There are exceptions to the ban on emergency room stays. Patients with concurrent health concerns, such as dialysis or a heart condition, may still be held and treated for their medical issue.)

“Because no other state has called this unconstitutional, and this practice is happening nationwide, everybody is very interested to see what the consequences [of this ban] will be,” says a mental health professional in King County, who has asked to have her name withheld due to concerns over the potential consequences of speaking publicly.

“There’s no exciting and novel solution, unfortunately,” she says. “People always blame funding. Funding is a part of it. But there’s a real dearth of innovation in mental health…. The time is ripe for something exciting and new and a little risky to try. Because clearly what we’re doing isn’t working.”

She worries that with the ban, hospital ERs will become a revolving door for patients if the state can’t meet capacity needs. Those discharged while in a psychotic episode may face jail or multiple ER readmissions, never meaningfully connecting with the system. Those repeat episodes have financial implications for the state. According to Vollendroff’s estimates, King County alone spent $3.7 million in 2013 on legal services for involuntary patients. That’s the cost of assigning them a lawyer, paying for their appearance before a judge—everything but the actual cost of treatment, where, mental health professionals agree, efforts should be concentrated.

To fix the system, care can’t begin and end with crisis management, Shoenfeld says. Stakeholders and providers have called for greater integration. Otherwise, patients often end up being penalized rather than treated for their symptoms.

Shoreline resident Laura Gillet knows how disruptive that disconnect between systems can be. Gillet spent nine days in jail, during which she was shot with a stun gun and left unmedicated during a psychotic episode, before eventually being delivered to Harborview Medical Center. If the system had worked as intended, Gillet’s diagnosis of bipolar disorder should have saved her the trauma of incarceration. After all, she had had a half-dozen run-ins with police, including when she was arrested on December 26, 2013 for brandishing a shotgun in her front yard in Shoreline.

Gillet was lucky enough to have the support of her family and fiancé. But for many people, jails and ill-equipped ERs have become the de facto psychiatric hospitals. In the weeks Gillet spent in recovery—much of it mandated as a follow-up to her involuntary commitment—she was hardly able to hold down a job, look for housing or maintain any semblance of a normal life.
“The hospital is really just one piece of these individuals’ lives. They are in psychiatric crisis because generally something has been allowed to fall through the cracks,” says Worthington, who represented Gillet. “We [can’t] look at the streets, jail and hospitals as this triangle for addressing problems.”

In that same vein, Shoenfeld says there is a desperate need to look at the bigger picture. Twenty percent of the psychiatric patients who cycle through the emergency room are homeless in King County, which often means any treatment they receive in the hospital is quickly canceled out by their life on the streets. Creating affordable housing to promote self-sufficiency would help defer patients before they ever reach a crisis point.

Jim Vollendroff, director of King County’s Mental Health, Chemical Abuse and Dependency Services Division, says that perhaps the most important piece missing from the conversation is a greater integration of the crisis system. That means recognizing that mental health issues often co-occur with substance abuse, although the two systems currently operate as separate processes and laws.

One step in the direction of greater integration is Senate Bill 6312, which Inslee signed into law earlier this year. It mandates the integration of mental health and chemical dependency services, and integrated Medicaid contracting for physical and behavioral health services. Andi Smith of Governor Inslee’s office calls it a “novel concept to treat the neck up and the neck down, in the same spot.”

Four years after her diagnosis, Caldeiro still wrestles with the peaks and valleys of bipolar disorder. “But I don’t identify that way,” she says. “I know I’m bipolar. I take meds every day. But it’s such a tiny part of me.”
In April, by popular demand, Caldeiro opened her own hairstyling business, called Studio Three, in Ballard. She has her own suggestion for improving the system.

“We need to stop thinking about this issue so academically—as this number, 150 beds,” Caldeiro says. “We’re really talking about 150 people, and there’s a lot more need.”

 

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