In August 2014, the Washington State Supreme Court unanimously banned psychiatric boarding, the involuntary detention of a mentally ill individual in a hospital ED setting while waiting for proper psychiatric treatment.1 This ruling refers to the state’s Involuntary Treatment Act (RCW 71.05), making it unlawful to board these individuals without treatment, regardless of the state’s lack of funds or resources.2 The ruling became effective in December of that year.3
Recognizing that Washington did not have the support or appropriate resources to adhere to this ruling, Alex Rosenau, the president of the American College of Emergency Physicians, made the following recommendations to Washington in response to the ruling:4
- Increase hospital inpatient staffing and capacity, with additional psychiatric inpatient beds helping to alleviate boarding for patients who might require hospital-level care
- Improve case management of patients to decrease psychiatric emergencies
- Increase outpatient capacity community alternatives, specifically crisis residential services and mobile crisis teams
- Implement telemedicine, specifically telepsychiatry
Many mental health advocates and experts hoped the Supreme Court ruling would bring positive change to the state’s behavioral health care system. Within just three months of the ruling, more than 160 psychiatric beds were added to psychiatric facilities, with Washington Governor Jay Inslee allotting $30 million to fund additional beds.5
However, despite the promising ruling, other experts questioned if the court’s decision only created a “Band-Aid” mental health care solution, as lawmakers, doctors and mental health experts became forced to turn away potentially dangerous psychiatric patients due to Washington’s limited mental health services and psychiatric beds.6 Washington Department of Social and Health Services (DSHS), which oversees the state’s largest psychiatric hospital, Western State Hospital in Lakewood, reported 170 fewer mental-health workers and 120 fewer beds in 2015 than there were in 2008, prior to the recession. Money initially budgeted in 2014 for the new beds will not restore the hospital’s 2008 capacity.7 As of October 2015, the hospital had 800 beds.8
In January 2015, some members of the Washington Senate drafted Senate Bill 5644 out of concern for the “inflexible ban” psychiatric boarding resulting in patients “ending up on the streets.”9,10
However, others felt that this bill, appearing to override the Supreme Court’s initial ruling, was drafted to fix budgets and capacity issues, changing the ruling without drafting solutions.11 This bill was introduced around the same time federal regulators began to cut funding from Western State Hospital. The hospital requires more funding and staff to be considered a safe option by the Center of Medicaid and Medicare Services (CMS). This threat of federal budget cuts came after inspectors found the hospital fail to supervise violent patients as well as facility issues, such as broken fire alarms.12
2016 has seen Washington continue to address issues surrounding psychiatric care in the state. In February, the CMS approved the DSHS’s plan to correct these issues. Additionally, in his 2016 supplemental budget, Gov. Inslee has proposed spending $6.8 million to hire 51 more nurses, $9.5 million for bonuses and pay raises to help recruit and retain psychiatric staff and $5.2 million to open four 16-bed crisis-triage facilities to treat individuals before it would be necessary for them to go to Western State.13
As individuals are turned away from services due to inadequate funding and resources, solutions such as telepsychiatry, as recommended by ACEP, are a necessary step in addressing behavioral health needs and ultimately reducing the overall need for psychiatric boarding.
Telepsychiatry providers can be used in a variety of settings, including hospital emergency departments, psychiatric hospitals and community-based facilities. Benefits of telepsychiatry include shorter ED wait times, a reduction of inappropriate commitments and an increase in hospital revenue.14
“Telepsychiatry is an advantageous way to bring psychiatric care where it is not readily available,” says Dr. Jim Varrell, Medical Director of InSight Telepsychiatry. “Telepsychiatry can reduce the time patients spend awaiting evaluation and treatment that ultimately has a significant impact on patient care, the patient experience, and the general healthcare system.”15
1Thompson, L. (2014, August 4). State Supreme Court rules psychiatric boarding unlawful. Retrieved March 27, 2016, from http://blogs.seattletimes.com/today/2014/08/state-supreme-court-rules-psychiatric-boarding-unlawful/.
2Chapter 71.05 RCW: MENTAL ILLNESS. (n.d.). Retrieved March 27, 2016, from http://apps.leg.wa.gov/rcw/default.aspx?cite=71.05.
3Washington state Supreme Court grants stay on psychiatric boarding ban. (2014, September 6). Retrieved March 27, 2016, from http://www.modernhealthcare.com/article/20140906/INFO/309069937.
4Kramer, A. (2014, November 11). Washington State Scrambles to Address Psychiatric Boarding – InSight Bulletin. Retrieved March 27, 2016, from http://insightbulletin.com/washington-state-scrambles-to-address-psychiatric-boarding/.
5Aleccia, J. (2015, March 21). State’s psychiatric care changes still not enough, say some experts. Retrieved March 27, 2016, from http://www.seattletimes.com/seattle-news/health/psychiatric-boarding-dips-but-fix-just-a-band-aid-critics-say/.
7O’Sullivan, J. (2016, February 20). Can Inslee, lawmakers improve Western State and broader mental-health system? Retrieved March 27, 2016, from http://www.seattletimes.com/seattle-news/politics/governor-lawmakers-grapple-with-how-to-fix-western-state/.
8Zak, A. (2015, October 12). Federal regulators threaten to cut funding for Washington state’s largest psychiatric hospital. Retrieved March 27, 2016, from http://www.bizjournals.com/seattle/blog/health-care-inc/2015/10/federal-regulators-threaten-to-cut-funding-for.html.
9SB 5644. (n.d.). Retrieved March 27, 2016, from http://app.leg.wa.gov/billinfo/summary.aspx?bill=5644&year=2015.
10Zak, A. (2015, February 3). State hospital association: New bill would ‘override’ court’s ban on psychiatric boarding. Retrieved March 27, 2016, from http://www.bizjournals.com/seattle/blog/health-care-inc/2015/02/state-hospital-association-new-bill-would-override.html.
12Zak, A. (2015, October 12). Federal regulators threaten to cut funding for Washington state’s largest psychiatric hospital. Retrieved March 27, 2016, from http://www.bizjournals.com/seattle/blog/health-care-inc/2015/10/federal-regulators-threaten-to-cut-funding-for.html.
13O’Sullivan, J. (2016, February 20). Can Inslee, lawmakers improve Western State and broader mental-health system? Retrieved March 27, 2016, from http://www.seattletimes.com/seattle-news/politics/governor-lawmakers-grapple-with-how-to-fix-western-state/.
14Boyce, O., & Adams, C. (2015, August 19). The Value of Telepsychiatry in the ED. Retrieved March 27, 2016, from http://insightbulletin.com/the-value-of-telepsychiatry-in-the-ed/.
15Varrell, J., MD. (2014, January 09). Alleviate Psychiatric Boarding in Washington with Telepsychiatry – InSight Bulletin. Retrieved March 27, 2016, from http://insightbulletin.com/alleviate-psychiatric-boarding-in-washington-with-telepsychiatry/.
About the Author
Blythe Riggan has written for The InSight Bulletin since 2015. She has a background in behavioral health, journalism, political science and anthropology.