In the month after a court decision took effect that is shaking up Washington’s troubled mental-health system, patients were detained 290 times outside of facilities where their treatment is intended to take place.
Two situations that the state Supreme Court specifically noted as allowable accounted for 110 of those instances, according to state records.
But many of the other 180 detentions took place because the proper facilities were overcrowded. The high court ruled that detentions driven by overcrowding — known as “boarding” — are illegal.
“People are still being boarded,” said Sandi Ando, an advocate with the Washington chapter of the National Alliance on Mental Illness.
The state Department of Social and Health Services has spent millions adding more space and has adopted a rule to ensure patients receive some treatment while waiting.
The rule sets minimum standards, including at least daily contact with a psychiatric doctor or nurse or a social worker.
“Somebody might still be in a hospital, but the difference is now they’re actually getting mental-health treatment,” DSHS assistant secretary Jane Beyer said.
The rule also gives hospitals a say in who they accept. Only if a hospital is “willing and able” to treat the patient will the state give approval for that to happen, a restriction that state lawmakers are moving toward placing into law.
Dozens of hospitals, especially in more urban areas, have been willing and able, which has provided a setting for the state-approved detentions to continue.
About 65 patients are affected on any given day, Beyer said.
“If we had enough capacity in the system, we wouldn’t be seeing those,” said Chelene Whiteaker, policy director with the Washington State Hospital Association.
The lack of room leaves medical providers with a choice: detention in a setting that might be inappropriate, such as a hospital emergency room, or no detention at all.
“I don’t want to release people to the street,” said Ian Harrel, past president of the Washington Association of Designated Mental Health Professionals.
So boarding continues, Harrel said.
Boarding is the illegal version of the practice known as “single bed certification.”
The state Involuntary Treatment Act allows a court to detain someone for treatment of a dangerous or disabling mental illness. That detention is supposed to take place at a facility certified as an evaluation and treatment center, or for longer-term detentions, at a state psychiatric hospital.
If it happens anywhere else, it’s a single bed certification.
There are reasons a patient might need a different setting — to treat a physical medical problem, for example, or to stay closer to home in preparation for discharge. The court recognized those kinds of single bed certifications are not boarding, and are legal.
“We find that the (Involuntary Treatment Act) authorizes single bed certifications for statutorily recognized reasons individual to the patient,” Justice Steven Gonzales wrote for the unanimous Supreme Court last August, “but not merely because there is a generalized lack of room at certified facilities.”
In response to the ruling, which took effect Dec. 26 after a court-ordered delay, DSHS added about 145 beds to the system. The Legislature agreed last month to pay for that space at least through June.
DSHS wants lawmakers to fund the construction of evaluation and treatment centers to bring 80 more beds into operation.
The space added so far has helped.
The number of monthly single bed certifications, which Beyer said was about 600 at one point last year, dropped from 430 in August to 300 in October and then stabilized.
There were 290 in January, the most recent month of available state figures.
Medical needs accounted for 46 of January’s certifications and trying to keep patients in community facilities close to their discharge accounted for another 64, according to reasons cited in state records.
The other 180 presumably were needed because of the space crunch. At least 146 of those took place in a hospital that wasn’t a psychiatric facility, records show.
Eighty of those 146 were at hospitals with psychiatric units and 66 at hospitals without such units — but either way, Whiteaker said single bed certifications with rare exceptions take place outside psychiatric units.
“There’s easily more than 100 single bed certifications in January where a patient is not in a certified psychiatric unit,” Whiteaker said.
“They could be on a (medical surgical) floor. They could be on the ER floor. It’s where the patient care team and the hospital feels they can keep the patient safest.”
Patients who need specialized care shouldn’t be stuck in emergency rooms, Ando said.
“That’s not giving people the kind of therapeutic environment they need,” Ando said, “to be moving into recovery and becoming stable.”