Thurston County's mental health triage center isn't functioning as planned. Why not?

Aug. 25--When the Thurston-Mason Mental Health Triage Center in Tumwater opened in August 2016, The Olympian ran a story with the headline "Relief could be in sight for Thurston County's mentally ill."

Stakeholders' vision for the triage facility, located next to the Thurston County Jail, was a place where people experiencing mental health crises picked up by law enforcement could land temporarily. They would be evaluated and diverted to mental health services, rather than jail. People already in jail, too, could be assessed and diverted to the treatment they needed.

But over the last three years, county officials say shortages of treatment beds and funding within a rapidly changing system have prevented them from fully realizing that vision. They say the 10-bed facility has served some of the law enforcement- and jail-involved population it was created to serve, but the beds are almost always full, and patients are staying in those beds much longer than intended.

Meanwhile, the number of people who use behavioral health and substance abuse services provided by the regional agency is expected to be double in 2019 what it was just two years ago.

The original vision

The triage center is operated by the Thurston-Mason Behavioral Health Organization (TMBHO), which manages state-funded mental health and substance use disorder programs in Thurston and Mason counties.

Joe Avalos, TMBHO's Chief Operating Officer, told The Olympian the triage center is licensed as an Evaluation and Treatment inpatient facility.

So-called E&Ts are meant for people suffering acute mental health crises, who are typically admitted through places such as hospital emergency rooms. At the triage center, though, referrals were intended to come from law enforcement and the Thurston County Jail.

The diversion process -- away from jail and into mental health services -- takes several steps.

To be involuntarily admitted, Avalos said, a person has to meet at least one of three conditions: They must be an imminent danger to themselves, an imminent danger to others, or gravely disabled due to a mental health condition.

Chief Deputy of Corrections Todd Thoma said when someone experiencing a mental health crisis is arrested and brought into the jail, if they seem to meet one of the three conditions, his staff will reach out to an on-call prosecutor.

The prosecutor will then decide whether to consider diversion to the mental health system. If the answer is yes, the prosecutor will call a Designated Crisis Responder. That responder then comes in and determines if the person can be involuntarily detained. If so, the responder then finds the person a bed at a facility.

The original intent, Avalos said, was to then bring that person directly to the triage next door.

"What we want to be in a position to be able to do is to identify someone early on with an acute mental illness that's been arrested for, say, a nonviolent offense and be able to refer them to the triage rather than proceed with the criminal prosecution," said Patrick O'Connor, director of Thurston County Public Defense.

The triage center was supposed to hold people for a maximum of 72 hours, before releasing them either to the community with appropriate supports or to another level of care.

TMBHO operates another E&T in the region: a 15-bed facility on Mary Elder Road Northeast. Services at both are provided by Telecare, a California-based company. However, the Tumwater triage center's original emphasis on the jail- and law enforcement-involved population and 72-hour stays was unique, according to Avalos.

The reality

"When there's a bed available, it works great," Avalos said. But beds are rarely available. When they do open up, they're typically filled the same day.

What was meant to be a 72-hour facility quickly turned longer-term, according to Avalos.

"Primarily, it was because we have too much volume and nowhere to send folks afterward," Avalos said. "That is where we are at today."

Thurston County Prosecutor Jon Tunheim told The Olympian that early on he expressed concern that there wouldn't be enough capacity in the mental health system beyond the triage center to accommodate the flow of people from the 10-bed facility. He worried there would be a backup.

He's heard about success stories of diversion from jail, Tunheim said. But he's also concerned that, if law enforcement officers are turned away enough times because the triage center is full, they'll stop calling it altogether.

Lt. Ray Brady said the Thurston County Sheriff's Office has not stopped calling, but agrees it's a possibility. And when officers are turned away because the triage facility is full, they usually take people to Providence St. Peter Hospital in Olympia.

"The long and short of that is I feel like my concern I was expressing then actually came true," Tunheim said. "There still is not enough capacity in our mental health system to let that triage do what it was intended to do."

Thurston County Board of County Commissioners chair John Hutchings also chairs TMBHO's governing board, which also includes Thurston County Commissioner Tye Menser and Mason County Commissioner Kevin Shutty.

Hutchings said that, between 2016 and today, the vision for the triage hasn't changed.

"Are we meeting the goal? I think we are," Hutchings said. "However, the confounding issue is the beds are full."

'There's nowhere to go'

Data from the TMBHO shows the number of people receiving behavioral health services -- and people experiencing mental health crises -- in the region is steadily increasing. Meanwhile, the number of people served in these E&T facilities has remained pretty much the same.

According to data provided by Avalos:

* In 2017, TMBHO served a total of 11,772 clients for all behavioral health inpatient and outpatient services through its local and regional provider network, including substance use services. The organization primarily serves Medicaid and low-income clientele.

* More than 1,600 of those people in 2017 were in crisis -- they needed to be evaluated for involuntary treatment or required a response in the field. The organization sent 410 of them to the E&Ts.

* The total number of clients TMBHO served grew by more than 2,000 from 2017 to 2018; the number of people who needed crisis services went up by about 1,000.

* In just the first half of 2019, Avalos said the organization served more than 10,000 people and over 1,600 were in crisis. At that pace, 2019 numbers will be double what they were in 2017.

* And yet, 418 people were served at the E&Ts in 2018. And this year, the number of people served at the facilities is on pace to be lower than the last two years.

About 60 percent of people in crisis who are found to need involuntary commitment in the Thurston-Mason area, Avalos said, are sent out-of-region -- to King, Pierce, or Clark counties, and sometimes as far as Spokane -- due to a lack of acute-care beds here.

When people are sent out of the region, Avalos said it becomes difficult to connect them to resources and make discharge plans. And the more places people are sent, the harder it is to coordinate.

Avalos offered two examples where clients were discharged from out-of-region facilities with a bus ticket to a hotel and no plan to connect them with outpatient services.

In one case, the TMBHO medical director just happened to be at the Ramada Inn on Martin Way East when he recognized a client who had been discharged in Everett and sent there by bus.

"We ended up having to detain her again," Avalos said.

While a shortage of local acute-care beds creates a bottleneck to get into the triage, there's another bottleneck on the back end, according to Avalos.

"The primary reason we're going to serve less people, actually, in our E&Ts, is because they're staying longer and there's nowhere to go," Avalos said.

Holly Borso, regional director of operations for Telecare, told The Olympian that, traditionally, if an individual who is held past the initial 72-hour period doesn't "return to functioning" within a 14-day period, service providers would go to court and ask for a longer stay. If granted, that person would go to either Western State Hospital or Eastern State. But those facilities also have a backlog.

With no place for people who need longer-term care to land, Borso said the state started giving E&Ts permission to serve those people.

"Typically, at any given point, 10 to 20 percent of the E&T short-term beds are taken up by people waiting to go to Western (State)," Avalos said.

According to a spokesperson at the state Department of Social and Health Services, there was a backlog of 58 people as of Friday who were waiting for a civil bed -- the kind that a person coming out of the triage facility would need -- at Western State.

Avalos said there's one client at a TMBHO E&T who's been there for more than 200 days, waiting for a judge-ordered spot at Western State.

Avalos and Borso say there's a bottleneck coming out of Western State, as well. Those discharged need resources such as supported housing, crisis stabilization units, and step-down facilities.

"That's a big missing piece," Borso said. "The wait list to get into an adult family home is huge. The wait list to get into community protection or to supported living for our folks with intellectual disabilities? Huge," Borso said.

Even when there's money to get facilities up and running, Borso said a workforce shortage looms. A quick search on Indeed.com for job opportunities in behavioral health in Thurston County brought up more than 600 results.

An advocate's take on navigating the system

Karri Phillips is intimately familiar with the mental health care system in Washington state, and specifically in the Thurston-Mason region. Two of her family members, she said, have been admitted to the local E&Ts run by Telecare, and she's become an active advocate for those family members as they navigate the system.

Phillips said she felt the triage facility lacked proper staffing to respond to her son Brian, who went there voluntarily after a law enforcement officer identified he was having a mental health crisis. She said Brian was turned over to the jail from the triage center, and deputies then took him to St. Peter Hospital.

Ultimately, the state brought charges against Brian for his behavior at St. Peter. Court documents describe Brian threatening to harm staff.

"They're being ping-ponged all over the place," Phillips told The Olympian. "And each facility has their shortcomings."

Phillips sees fundamental statewide issues with the system and she's pushing for change at that level. Locally, based on her experience with another loved one at a local E&T facility, she went so far as to ask TMBHO to conduct an investigation into whether staff was following protocol.

When The Olympian asked Avalos about that investigation, he couldn't give specific details due to confidentiality regulations. He did detail TMBHO's investigative process, which involves a review by TMBHO's medical director and opportunities to appeal to higher levels, up to the state Health Care Authority.

"At this time, we've had no grievances or concerns that needed to be elevated to the state Health Care Authority for resolution," Avalos wrote in an email to The Olympian.

Looking to a complicated, hopeful future

At the county level, the general consensus among officials seems to be that the state is aware of the issues its mental health system faces, that it has momentum toward solutions, and that meaningful work groups are in place.

The state's goal is to close nearly all civil commitment beds at the state hospitals by 2023, and to bring clients closer to home with 16-bed, community facilities.

Right now, though, is a transition period. By 2020, 32 beds are coming online at two new facilities in Mason County, 16 of which are intended to be long-term community placement beds, according to Avalos.

More beds are opening at the new South Sound Behavioral Hospital in Lacey. And Recovery Innovations was awarded a state grant to open a 16-bed E&T facility near Olympia, though the time table for those beds coming online is unclear.

In the interim, Avalos said, TMBHO is "spinning its wheels."

"The need is here now, and we're dealing with an issue now with a lot of band-aids," Avalos said. "And it's going to be some time before we see any of the state solutions realized in our region."

Even with new facilities opening, Commissioner Hutchings pointed out that ongoing funding is an issue.

The county, he said, pays for the court services and staff that are attached to the E&Ts. Hutchings said just under $1 million, in early estimates, is currently being requested for staffing the court at South Sound Behavioral Hospital.

Hutchings' goal for the future is to "go knee-to-knee" with state legislators, advocating for more money locally.

"What's heart-wrenching is ... those folks that need this I don't believe sufficiently get the help that they need," Hutchings said. "All because of money. The intent is there. The goal is there. You've got people that really give a flip."

In the midst of all this, another big change is coming in January.

That's when, Avalos said, all BHOs across the state will no longer be tasked with providing Medicaid-funded behavioral health services. Instead, managed care organizations ?-- which, in this region, will all be for-profit ?-- will take over. It's a transition that's already happened in other parts of the state.

Maybe the future will include a discussion about changing the way the triage facility is used, as TMBHO CEO Mark Freedman mentioned in a recent Board of County Commissioners meeting, in order to bring it closer to its original intentions.

Despite the challenges, county leaders in the field seem optimistic about the potential for facilities like the Tumwater triage center.

"I'm still hopeful, we're still going to work toward that," Prosecutor Tunheim said. "There are a lot of barriers. ... I still see the facility as having a critical role in getting people diverted from the criminal justice system and into the mental health system.

"If we had the resources we need, I think it could actually be used to its full capacity."

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