HOUSE BILL REPORT

2SSB 5732

As Passed House - Amended:

April 16, 2013

Title: An act relating to improving behavioral health services provided to adults in Washington state.

Brief Description: Concerning the adult behavioral health system in Washington state.

Sponsors: Senate Committee on Ways & Means (originally sponsored by Senators Carrell, Darneille, Keiser and Pearson).

Brief History:

Committee Activity:

Health Care & Wellness: 3/19/13, 3/26/13 [DPA];

Appropriations: 4/1/13, 4/8/13 [DPA(APP w/o HCW)].

Floor Activity:

Passed House - Amended: 4/16/13, 93-3.

Majority Report: Do pass as amended. Signed by 16 members: Representatives Cody, Chair; Jinkins, Vice Chair; Schmick, Ranking Minority Member; Angel, Clibborn, Green, Harris, Manweller, Moeller, Morrell, Riccelli, Rodne, Ross, Short, Tharinger and Van De Wege.

Staff: Chris Blake (786-7392).

Majority Report: Do pass as amended by Committee on Appropriations and without amendment by Committee on Health Care & Wellness. Signed by 29 members: Representatives Hunter, Chair; Ormsby, Vice Chair; Alexander, Ranking Minority Member; Chandler, Assistant Ranking Minority Member; Wilcox, Assistant Ranking Minority Member; Buys, Carlyle, Cody, Dahlquist, Dunshee, Fagan, Green, Haler, Harris, Hudgins, Hunt, Jinkins, Kagi, Maxwell, Morrell, Parker, Pedersen, Pettigrew, Pike, Ross, Schmick, Seaquist, Springer and Sullivan.

Minority Report: Do not pass. Signed by 1 member: Representative Taylor.

Staff: Andy Toulon (786-7178).

Background:

Community Mental Health System.

The Department of Social and Health Services (DSHS) contracts with Regional Support Networks (RSNs) to oversee the delivery of mental health services for adults and children who suffer from mental illness or severe emotional disturbance. The RSNs contract with local providers to provide an array of mental health services, monitor the activities of local providers, and oversee the distribution of funds under the state managed care plan. An RSN may be a county, group of counties, or a nonprofit or for-profit entity.

The declared intent of the community mental health system is to help people with mental illness through programs that focus on resilience and recovery and practices that are evidence-based, research-based, consensus-based, or promising or emerging practices. It is further intended that RSNs have flexibility in designing services for people within their geographic boundaries and they are encouraged to use evidence-based practices to reduce or eliminate the use of institutions for mental diseases.

Enhanced Services Facilities.

Enhanced services facilities are facilities that provide treatment and services to persons who do not need acute inpatient treatment and have been determined by the DSHS to be inappropriate for placement in other facilities due to complex needs that present a behavioral and security issue. These facilities were established in statute in 2005, but were never funded. These facilities are intended to serve individuals with: (1) complex needs; (2) certain qualifying behaviors; and (3) a mental disorder, chemical dependency disorder, organic or traumatic brain disorder, or cognitive impairment requiring supervision and facility services.

Discharge Planning.

The RSNs must establish discharge procedures for transitioning eligible individuals out of community support services, residential services, and inpatient evaluation and treatment services. When a patient has received community mental health services and state mental hospital services, the RSN and the state mental hospital must establish a mutually agreed upon discharge plan to transition the patient into the community.

Agency-Affiliated Counselors.

The Department of Health regulates several types of mental health professionals, including agency-affiliated counselors. Agency-affiliated counselors are counselors that are employed by a county, or an agency or facility operated, licensed or certified by the State of Washington. Agency-affiliated counselors must register with the Department of Health by demonstrating that they are employed by an agency or have an offer of employment by an agency, and by passing a background check.

Summary of Amended Bill:

The Department of Social and Health Services (DSHS) and the Health Care Authority must implement a strategy for the improvement of the adult behavioral health system. To develop the strategy, the DSHS must establish a steering committee consisting of a broad group of stakeholders including recipients of behavioral health services, local governments, Regional Support Networks (RSNs), law enforcement, city and county jails, tribes, behavioral health service providers, housing providers, hospitals, Medicaid managed care plans, and long-term care service providers. The strategy must:

• assess the capacity of the current publicly funded behavioral health services system to provide evidence-based practices, research-based practices, and promising practices;

• identify, develop, and increase the use of evidence-based practices, research-based practices, and promising practices;

• design and implement a transparent quality management system;

• identify behavioral health services delivery and financing mechanisms to improve the behavioral health system; and

• identify effective methods for promoting workforce capacity, efficiency, stability, diversity, and safety.

The Washington State Institute for Public Policy must prepare an inventory of evidence-based, research-based, and promising practices for prevention and intervention services for the DSHS to use when preparing the strategy. The DSHS must seek private and federal funding to support the strategy. By August 1, 2014, the DSHS must report to the Governor and Legislature on the status of implementing the strategy.

The Health Care Authority and the DSHS must develop a plan by November 30, 2013, for a tribal-centric behavioral health system that includes both mental health and chemical dependency services. The plan must: include implementation dates and financial estimates; emphasize culturally appropriate, evidence-based, and promising practices; address equitable access to services; identify statutory changes; and include consultation with tribal representatives in developing the plan.

The DSHS must contract with an independent consultant to review the provision of forensic mental health services. The consultant must provide recommendations regarding whether or not the forensic mental health system should be modified to provide an appropriate treatment environment for people with mental disorders who have been charged with a crime while enhancing the safety and security of the public, other patients, and staff at forensic treatment facilities.

To the extent that funds are specifically appropriated, the DSHS must issue a request for a proposal for enhanced services facility services by June 1, 2014. The procurement must be completed by January 1, 2015.

An RSN must develop an individualized discharge plan and arrange for the transition to the community within 21 days of a determination that inpatient, active psychiatric treatment is no longer needed for an individual who was involuntarily committed for 90 or 180 days.

Applicants for registration as agency-affiliated counselors may work in that capacity for up to 60 days while their applications are being processed by the Department of Health. The applicant, however, may not provide unsupervised counseling until either the employer or the Department of Health has completed a background check.

The definition of the term "evidence-based" is expanded to include one large multiple site randomized or statistically controlled evaluation where the evidence demonstrates sustained improvements in an outcome. The term "research-based" is specified to mean a practice that has been tested with a single randomized or statistically controlled evaluation demonstrating sustained desirable outcomes or where the evidence from a systematic review supports sustained outcomes but does not meet the standard of "evidence-based." The definition of "promising practices" is clarified to refer to practices that may become evidence-based or research-based based on statistical analysis or a well-established theory rather than preliminary information.

Appropriation: None.

Fiscal Note: Available.

Effective Date of Amended Bill: The bill takes effect 90 days after the adjournment of the session in which the bill is passed, except for section 3 relating to discharge plans and community transitions for individuals receiving inpatient active psychiatric treatment, which takes effect July 1, 2018.

Staff Summary of Public Testimony (Health Care & Wellness):

(In support) This bill builds from the successful strategy used with children's mental health with the same goals of increasing the use of evidence-based practices and measuring system-based performance based on outcomes that are meaningful to clients. This bill takes an important step to evaluate and improve the mental health delivery system and care for clients.

There has been a decline in the ability of the mental health system to respond to clients in crisis due to recent budget declines. The emphasis on incentives for cross-system collaboration across medical care, long-term care, and behavioral health is good. There is strong support for public reporting of performance measures. The focus on prevention services addresses an issue that has been missing for too long in community mental health financing. Enhanced services facilities are long overdue. There needs to be an examination of the best practices related to boarding psychiatric patients when inpatient beds are not available.

The broad list of community stakeholders is appreciated. The Washington State Medical Association, a psychiatric advanced registered nurse practitioner, a mental health provider, state mental hospital workers, and a chemical dependency provider should be included on the participant list. In order for evidence-based programs to succeed there needs to be buy-in from the workforce. The bill should also address workforce capacity issues.

(Opposed) This bill will not improve the behavioral health system. The bill does not address the fact that the behavioral health system is designed to create psychiatric disability, not health. This bill does not have the direction necessary to make broad-based solutions. This bill has broad appeal to those in the current system and against practitioners who will be interested in creating health outcomes.

Staff Summary of Public Testimony (Appropriations):

(In support) Many Medicaid clients have complex needs including medical, mental health, chemical dependency, and long-term care. Restoring two pieces of language from the original Senate version will help improve the bill. The first is language requiring the Health Care Authority and the Department of Social and Health Services to partner in developing the behavioral health improvement strategy. The other is language creating incentives for collaboration among the medical, mental health, chemical dependency, and long-term care systems.

This is a good bill and it is important to do an assessment of the mental health system. The composition of the steering committee should be expanded to include representatives of the employee unions that are critical to making the work successful. In addition, the words "stability" and "diversity" should be added in the section regarding workforce.

(Opposed) The question is whether this bill will help improve the over $800 million per year behavioral health system. Recent revisions do not change the major issue which is that it addresses symptoms and not causes. For example, it is a symptom to say that there are not enough resources, while the cause is treatment that fails to improve the health of those that receive it. This bill will fail if it does not address this fundamental issue. The fundamental failure that drives public mental health costs, risks to public safety, and people being warehoused in the community is the inability of the system to create health. The system appears to be designed to create an ever-growing population of psychiatric and pharmaceutically dependent customers rather than achieving healthy, well citizens. With a public mental health system already costing over $800 million per year and a $1.2 billion budget shortfall, this bill could be very expensive.

Persons Testifying (Health Care & Wellness): (In support) Jane Beyer, Department of Social and Health Services; Preston Cody, Health Care Authority; Melissa Johnson, Association of Alcoholism and Addictions Programs; Ellie Menzies, Service Employees International Union 1199NW; Katie Kolan, Washington State Medical Association; Eleanor Owen, National Alliance on Mental Illness; Leslie Emerick, Association of Advanced Practice Psychiatric Nurses; Gregory Robinson, Washington Community Mental Health Council; Matt Zuvich, Washington State Federation of State Employees; and Lisa Thatcher, Washington State Hospital Association.

(Opposed) Ruth Martin, Citizens Commission on Human Rights.

Persons Testifying (Appropriations): (In support) Jane Beyer, Department of Social and Health Services; and Ellie Menzies, Service Employees International Union Healthcare 1199NW.

(Opposed) Sandy Finn, Citizens Commission on Human Rights.

Persons Signed In To Testify But Not Testifying (Health Care & Wellness): None.

Persons Signed In To Testify But Not Testifying (Appropriations): None.