State Hospitals. There are three state hospitals in Washington: Western State Hospital in Lakewood, Eastern State Hospital in Medical Lake, and the Child Study & Treatment Center in Lakewood. The first two serve adults and the third serves children. The state hospitals primarily serve patients who are committed for involuntary treatment by a civil or forensic court process. They are operated by chief executive officers and fall under the administration of the Department of Social and Health Services (DSHS). The state hospitals specialize in long-term care, but at times in their history have accepted short-term involuntary patients.
Civil Commitment for Behavioral Health. A person may be detained for involuntary treatment under the Involuntary Treatment Act if, in response to a crisis line call, a designated crisis responder (DCR) determines that the person has a behavioral health disorder that causes them to present a likelihood of serious harm or to be gravely disabled.
Likelihood of serious harm means:
Gravely disabled means the person is:
Civil Commitment Options. A DCR may cause the person to be placed in initial detention for up to 12 hours for a civil commitment investigation. Initial detention may occur at an emergency room, triage facility, crisis stabilization unit, evaluation and treatment facility (E&T), or secure withdrawal management and stabilization facility (SWMS). If the DCR determines further detention is needed after the 12-hour initial detention period, the DCR must detain the person to an E&T for treatment of a mental disorder, to a SWMS for treatment of a substance use disorder, or, if neither is available, to a voluntary treatment facility which is willing and able to provide treatment through a temporary authorization known as a single-bed certification. This period of treatment may last for up to 120 hours, excluding weekends and holidays. A court hearing is required in order to extend treatment for an additional 14-day period, which continues at an E&T, SWMS, or single-bed certification facility.
Detention beyond this 14-day period requires a civil trial. If the court or jury authorizes treatment beyond this 14-day period, the patient becomes eligible for transfer either to a state hospital or to a community facility certified for long-term civil commitment. The first extension period is for 90 days, followed by renewable periods of 180 days until the person is discharged by the treatment facility or the court. Prior to about 2016, long-term civil commitment generally occurred in a state hospital, although there could be long waits for state hospital admission, during which patients would continue to receive treatment in community facilities. Since 2016, the state has invested in creating long-term civil commitment facility options in communities across Washington.
Single-Bed Certifications. The Health Care Authority (HCA) may issue a single-bed certification authorizing a voluntary treatment facility to treat an involuntary patient if the facility is willing and able to provide timely and effective mental health services to the person. A single bed certification lasts for 30 days and is specific to the patient. A single-bed certification may be requested for a number of reasons, including to provide medical services not available in a certified facility, to facilitate continuity of care, and to allow a person to receive treatment closer to their home community.
No-Bed Reports. When a DCR is unable to find a placement for a person who meets detention criteria in an E&T, SWMS, or single-bed certification, the DCR must release the person at the end of the initial detention period and file a no-bed report. The report goes to HCA and must be filed within 24 hours. When HCA receives a no-bed report, it must promptly notify the Medicaid managed care organization (MCO) or behavioral health administrative services organization (BH-ASO) responsible for the cost of the person's community behavioral health care. The MCO or BH-ASO must attempt to engage the person in appropriate services and report back to HCA within seven days.
The bill as referred to committee not considered.
Each adult state hospital must establish and maintain capacity to provide treatment for patients who are initially detained for civil commitment, or who are committed for 14 days of involuntary treatment. The priority use of this capacity must be for patients who experience difficulty obtaining placement in local E&Ts or SWMS.
DSHS must develop guidelines for obtaining admission for initial detention or 14-day commitment at the adult state hospitals, in consultation with stakeholders including the HCA, the Washington State Hospital Association, designated crisis responders, BH-ASOs, King County, Spokane County, individuals with lived experience, impacted family members, the Attorney General's Office, prosecuting attorneys, public defenders, and the state's largest forensic service provider. DSHS must distribute the guidelines to DCR agencies. The guidelines must address acceptable procedures for obtaining medical clearance, including a goal of reducing or avoiding use of emergency departments. The guidelines must discuss factors that may be used to determine admission priorities, such as:
DSHS must bill the patient's insurance for the cost of treatment under initial detention or a 14-day commitment order, based on a rate to determined by DSHS, which reflects the full expected cost for short-term involuntary treatment at the state hospital. If the person has no health insurance coverage and does not qualify for enrollment in Medicaid, DSHS must bill the BH-ASO that serves the region where the patient resides.
PRO: The reality is a small subset of the population is being failed by the Involuntary Treatment Act (ITA) system. These are some of the largest users of emergency services, who may have a history of violence or involvement in the criminal justice system. There is no blame, everyone is trying to do the best we can, but we must change practices to take better care of citizens with mental illness. When the ITA system fails these individuals, they decompensate further and go on to commit felonies and get pulled into the forensic system. Folks should not have to destabilize to this degree. They are repeat customers, we know who they are, and we should serve them in the civil system. Acuity levels are growing in jails and hospitals. A woman I encountered received no help from the civil system, no help after being charged with a misdemeanor, and a year later she stabbed her own father. Passage of this bill would provide a big relief to hospital emergency departments, which have seen big surges of mental health patients since the start of the pandemic. Patients who are hard to place in E&Ts end up boarding in emergency departments. They need access to the higher level of care available in state hospitals. These patients present an assault risk for staff.
CON: Western State Hospital has not operated a short term civil admission ward for decades. The wait list for admission for forensic services at the state hospitals is months long. Patients wait for discharge at Western State Hospital for an average of 230 days after they have been determined to be ready, and over 100 days at Eastern State Hospital. Single bed certifications and no-bed reports are a big problem, but this is not the solution. Our mental health system is in crisis, but this is not an effective answer.
OTHER: We respect the intent of this bill, and agree this population could be better served. This bill runs contrary to the direction the state hospitals are going to move the care of civil patients into the community. State hospital admission severs connections to local communities and local resources. Western State Hospital has challenges with physical space, since it is in the process of closing down wards to make room for demolition and construction of a new, modernized hospital. It would have to choose who else not to serve. Staffing challenges and safety concerns held in the community are shared by the state hospitals.