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.

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Summary of Amended Bill:

The Department of Social and Health Services (DSHS) 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, 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.

Amended Bill Compared to Second Substitute Bill:

The amended bill eliminates the task force comprised of legislators, executive branch representatives, and tribal representatives to conduct a comprehensive review of the adult behavioral health system.

The Health Care Authority is removed from developing the adult behavioral health system strategy, so that only the Department of Social and Health Services (DSHS) will develop the strategy. The requirement that the strategy include ways to incentivize medical care, behavioral health, and long-term care systems to collaborate is removed. A steering committee is established to assist the DSHS in developing the strategy.

When preparing the inventory of evidence-based practices, the Washington State Institute for Public Policy may consult other groups, including the University of Washington Evidence-Based Practice Institute, the University of Washington Alcohol and Drug Abuse Institute, and the Washington Institute for Mental Health Research and Training.

The DSHS must contract with a consultant for a review of the provision of forensic mental health services.

Applicants for registration as agency-affiliated counselors may work for 60 days while their applications are being processed by the Department of Health.

Staff Summary of Public Testimony:

(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.