PROBLEM—

Snohomish County League of Women Voters’ position on mental health care services was last considered in 1989 when the following program policy was adopted:
Provision for housing of the mentally ill, including homeless mentally ill.
Distribution of services to meet county-wide needs.
Increased community education.
Vocational training.
Evaluation and treatment services at the county jail.
Support of the five-county mental health plan.

In the ensuing fifteen years, many changes have taken place. Some elements of our program are still very much alive and well; others are no longer so urgent or even relevant. The Five-County Mental Health Plan has evolved into the North Sound Regional Services Network which channels money from state funds to community mental health providers. It has no further need for our support (except perhaps as the first step in the distribution of state funds). There is no indication that the state intends to change this regionalized system.

There are now only three community mental health providers in the region – Compass Health in Snohomish, Skagit, Island and San Juan Counties, and Whatcom Psychiatric and a residential program in Whatcom County. In Snohomish County, outpatient services are now quite well distributed geographically, extending from Edmonds to Monroe and Darrington, and readily accessible to most clients. In addition, Snohomish County clients can now access needed services in Skagit County through the same provider.

Inpatient services are another matter as will be apparent later. Vocational training is now being provided by Compass Health so the need is not so urgent. Housing, including some housing for homeless mentally ill, is now available, though the need probably exceeds the supply. Availability of all publicly funded mental health services continues to be limited and controlled by funding and by eligibility limits.

Thus, it is time to revise and update our policy and program elements, and the following study is intended as a basis for this update.

METHOD—

Mary Hovander and Margery Krieger have conducted interviews and gathered materials from the two primary mental health providers in Snohomish County – Stevens Hospital and Compass Health, Inc. We have focused on: (1) identification and location of services presently offered, and nature of clients served, (2) funding sources, (3) problems and needs. We also contacted Dr. Lucy Homans, Director of Professional Affairs of the Washington State Psychological Association, on the present status of Medicare and other public funding for psychological services as well as the progress of the mental health parity bill and the community mental health budget in the current legislative session.

The report that follows first describes existing services and providers in both the public and private sectors, with emphasis on accessibility and availability of needed services. It then discusses funding, and, since they are closely linked, the problems and needs identified by our sources. Finally, it proposes a revised position statement for the League of Women Voters of Snohomish County.


PROVIDERS AND SERVICES—

Three agencies provide mental health services in Snohomish County: Compass Health, the community mental health center, which is based in Everett but serves clients in many locations throughout the county, Stevens Hospital in Edmonds, and Valley General Hospital in Monroe. All are licensed by the state of Washington.


Inpatient programs: There are only three inpatient facilities for mentally ill persons in Snohomish County, and these are quite limited as to size and type of patient served. Stevens Hospital in Edmonds operates a 25 bed psychiatric unit for acutely disturbed adults, both voluntary and involuntary; 7 of these beds are for geriatric patients. Valley General Hospital in Monroe has a 14 bed geriatric inpatient unit. The Snohomish County Evaluation and Treatment Center in Mukilteo is a 15 bed facility operated by Compass Health which admits acutely disturbed adults on a short term basis who are being evaluated for involuntary treatment. Compass Health also operates a similar 15 bed evaluation and treatment program at Sedro Woolley in Skagit County.

Other than the small geriatric unit in Monroe, there are no facilities in Snohomish County for inpatient treatment of chronically mentally ill persons. In the distant past, there was Northern State Hospital in Sedro Woolley – now closed for more than two decades. More recently, there was Western State Hospital in Steilacoom, but because of downsizing, beds are no longer available there. While it is certainly more desirable to treat chronic patients in their own communities when possible, the State of Washington has never adequately funded such programs. Even worse, there are no inpatient facilities for children in the entire 5- county area of northwest Washington. In fact, in all of western Washington, only Children’s Hospital and Fairfax Hospital, both in King County, and with a total of only 27 beds, admit children. Fairfax has recently reduced the number of its children’s beds. At Sacred Heart Hospital in Spokane, there are 8 children’s beds. When these 35 beds are filled, children must be hospitalized out of state.

Though accurate figures are not available, given the total population of Snohomish County, it is likely that many seriously mentally ill persons needing 24-hour care are being held in jails where there are no treatment facilities.

Outpatient programs: Stevens Hospital conducts a partial hospitalization (day treatment) program for acutely disturbed persons who do not need 24-hour care. Patients are seen on weekdays for a total of 6 hours per day in a variety of treatment modalities. While day treatment services are usually long-term programs, the average length of stay in the Stevens program is only 5 to 10 days. Patients are then referred to follow-up in community services or to inpatient care if needed.

Compass Health offers a broad, comprehensive range of outpatient services providing both acute and extended care for individuals and families in eight locations throughout the county, as well as in-school and in-home programs. Services include individual, group, family, and older adult counseling, psychiatric services, play therapy, parenting and life skills classes, chemical dependency services for adolescents, a variety of treatment services for infants, toddlers and preschool children and their families, a special juvenile firesetter intervention program. A child advocacy program, operated together with the Snohomish County Prosecutor’s Office and Providence Hospital’s Sexual Assault Center, offers counseling services to sexually abused children and their non-offending parents. Culturally sensitive and relevant services are provided to individuals and families of diverse ethnic backgrounds throughout the county, including individual, group and family counseling and case management. Languages include: American sign language, Vietnamese, Chinese, Korean, Cambodian, Farsi, Spanish, German, Czech, Russian, Bosnian, Serbian, Croatian, and Arabic.

Special programs are available for infants, children, adults and older adults needing extended care (longer-term) services. These include counseling and group activities, as well as a variety of case and medication management services, family support and education, job training and employment, peer counseling for older adults, and support services for mentally ill homeless persons.


Crisis services: Compass Health provides 24-hour, 7-day crisis outreach and intervention services throughout the county to individuals and families of all ages. These counselors attempt to stabilize crisis situations and refer into other services as needed. A new program recently established at Compass’ main campus in Everett is a 6-bed residential unit for children in crisis (ages 7-12). The program is staffed 24 hours per day and includes schooling. It serves all 5 counties of northwest Washington and should have a larger capacity but there is no funding for additional beds.

Stevens Hospital has a psychiatric social worker on staff in its ER from 8:00 A.M. until midnight who can triage crisis needs and hospitalize or refer to outpatient service. During other hours, a social worker is on call.


Residential services: Compass Health operates a number of residential programs. Aurora House in Edmonds and the Greenhouse in Everett are each 20-bed supervised facilities serving adults and older adults with severe and persistent mental illness. Haven House in Everett is a 12-bed supervised transitional living program for young adults (ages 18-24). Cocoon Complex in Everett is a residential program for homeless and at-risk teens (ages 13-17) and Cocoon House is a temporary shelter for such teens. All facilities provide therapeutic and rehabilitation services. In addition, Compass Health coordinates housing units (beds) in other facilities in the county (e.g., Housing Hope) for adults who are receiving mental health services.


Outpatient services in the private sector: There are four groups of mental health providers in the private sector – psychiatrists who hold a medical doctorate and post-graduate training in psychiatry and are licensed by the state to practice medicine; psychologists who hold a doctorate in psychology and post-graduate training and are licensed by the state; social workers who hold a masters degree and are certified by the state; and counselors who hold a masters degree and are certified by the state. All are required to obtain continuing education in order to maintain credentials. Both good and poor mental health services may be provided by members of all groups. Only psychiatrists can prescribe medication and these days some psychiatrists limit their practice to medication prescription and management. Many responsible members of other disciplines work closely with a psychiatrist or other physician when medication is needed.

The services of a psychiatrist or a psychologist can be funded by Medicare or by private insurance. Only psychiatrists can be reimbursed by Medicaid. The services of social workers are reimbursed by some insurance companies, but not by all. Relatively few counselors are reimbursed by insurance so that persons seeing these providers must usually pay out of pocket.

Only nine psychiatrists and two psychiatric clinics are listed in the Snohomish County yellow pages. The office of one is in Shoreline. Only one identifies herself as specializing in work with children. A physician listed under “Counselors” with offices in Marysville may be a psychiatrist. All others are located in Everett or Edmonds. Given the rapidly growing population of Snohomish County, and its size, this reflects a significant shortage of these practitioners, especially since they are the only mental health providers who can see Medicaid patients. This means that private psychiatric services are essentially unavailable to the poor and to many others living in more remote areas.

Twenty-eight psychologists or psychological services groups are listed in the yellow pages. One group, located in Marysville and consisting primarily of five psychologists, is listed under “Counselors.” One group is located in Woodinville in King County, and one (“Ergometrics and Applied Research, Inc.”) does not appear to be a mental health provider. Again, most of these practitioners are located in Edmonds, Everett and Lynnwood, so that, while psychologists are more plentiful than psychiatrists, they are still not easily accessible to persons living outside urban areas.

Only one social worker and possibly a few social services organizations are listed that may provide mental health services. Counselor listings cover two pages, indicating that these practitioners are significantly more available. However, it must be remembered that, for the most part, they are not eligible for public funding or for insurance coverage so are essentially available only to persons who can afford private pay.


FUNDING AND NEED—

As is apparent in the above, mental health services are available to the residents of Snohomish County only to the extent that money is available to pay for them. This is true in both the public and private sectors, though the two differ somewhat as to the source of funds.

In general, public sector providers rely heavily on tax monies from state or federal governments and on health insurance; to a lesser extent on private pay. For persons who lack insurance or are not eligible for public funds, the services of Compass Health are available on a sliding scale based on ability to pay. Donations help to pay for services to a limited number of persons who cannot pay any amount. Stevens Hospital, as a community hospital, cannot refuse services to anyone. At Stevens, funding comes about equally from health insurance, Medicare and Medicaid, though state Medicaid funds are not available for their partial hospitalization program.

What funding is available is inadequate. State appropriations for community mental health services, administered through the Department of Social and Health Services, are always among the first items cut in biennial budgets, and are significantly reduced by administrative expenses at state and regional levels. Most insurance companies do not cover mental health services to the same extent as physical health services, and do not meet the needs of patients. Nor do other public funds cover the full cost of such services. The funding formulas for reimbursement under Medicaid and Medicare have always been inadequate, and cuts are continually being made in Medicaid reimbursement and in other state programs serving the poor – programs on which community mental health services are heavily dependent. As a consequence, providers find themselves falling farther and farther behind, a fact which has resulted in recent years in the closure of many programs, especially the more costly inpatient services.

The services of private sector providers are no better funded, and persons seeking these services often have significant out-of-pocket expenses. Health insurance companies reimburse only licensed providers and severely limit the amount of service that can be provided (for instance, by limiting the number of psychotherapy sessions). Medicare funding is available only to older adults and to some disabled persons, and the elderly typically do not seek mental health treatment because of the stigma attached. Medicaid reimbursement, available only for psychiatric services, is so inadequate that most psychiatrists in private practice do not accept Medicaid patients. The state of Washington provides limited amounts of funding for special needs through the Departments of Vocational Rehabilitation (disabled persons) and Labor and Industries (injured workers and crime victims).


Needs: It is apparent that the primary, overarching need in securing availability and accessibility of necessary mental health services for the residents of Snohomish County is the financial wherewithal to provide them.

Working from League’s existing position, the president and CEO of Compass Health, Dr. Jess Jamieson, has identified and prioritized the following major needs:

1. Services to children and families continue to be the most severely under-funded in all parts of the county.
   
2. Housing for the mentally ill, including the homeless mentally ill, many of whom are in rural areas.
   
3. Continue to fight the stigma of mental illness through increased community education.
   
4. Mental health evaluation and treatment services at the county jail.
   

1. Increase reimbursement formulas. Reimbursement from public funds continues to decrease as length of hospital stay and costs increase.
   
2. Medicaid coverage for partial hospitalization.
   
3. Lack of longer-term inpatient care facilities. Western State Hospital has reduced the number of its beds and Valley Hospital in Renton has closed its psychiatric unit.
   
4. Lack of available outpatient resources for follow-up.
   
5. Prevention/early intervention programs.
   

1. Demonstrates a continuing and urgent need for inpatient care – both acute and extended care - for seriously disturbed children;
   
2. Suggests an insufficiency of services for both adult and juvenile substance abuse and of psychiatric services, especially for children; and
   
3. Indicates that many people fall through the spaces of mental health care because they do not meet eligibility requirements for public funding and have no or inadequate insurance, or because they are unaware of services.

1. Crisis and treatment services for children and families, including inpatient care for seriously mentally ill children.
   
2. Housing for mentally ill, including homeless mentally ill, especially those in rural areas.
   
3. Increased community education to fight the stigma of mental illness and inform the public of available services.
   
4. Extended inpatient care for severely and persistently mentally ill.
   
5. Mental health evaluation and treatment services at the county jail and the juvenile facility.
   
6. Public funding for both acute and extended partial hospitalization (day treatment).
   
7. Increased prevention and early intervention mental health programs.
   
8. Increased prevention and treatment services for adult and adolescent substance abuse.
   
9. Revision of eligibility requirements for publicly funded services so that more people qualify.