New behavioral health sites in the works in Pierce County. Why has it taken so long?
Washington state’s plans to move more patients out of the state’s large psychiatric hospitals into smaller facilities are taking shape statewide and in Pierce County, after initially being introduced via the Legislature years ago.
Enhanced service facilities and intensive behavioral health treatment facilities are just two such examples, with plans now on file with the City of Tacoma.
Both offer alternatives for those needing continuing behavioral health care, but in a smaller, more targeted setting, alleviating crowding and extended stays at Western State Hospital in Lakewood and Eastern State Hospital, southwest of Spokane.
So far, just one enhanced service facility is in operation in the county, in Lakewood.
The new Tacoma facilities would be licensed to offer 16 beds each and have received funding from Department of Commerce grants created to spearhead development statewide.
The latest round of Commerce grants, issued in October, were provided as part of Gov. Jay Inslee’s plan “to modernize and transform Washington’s mental health system, with the goal of ending civil patient placements at the state’s two large hospitals by 2023 in favor of smaller community-based facilities,” according to Commerce’s October news release.
Development has been slow and in some cases met with pushback from residents, but those supporting the projects maintain that they offer a much more targeted approach to behavioral health care in the state.
Claudia Johnson is founder and administrator of Emerald City Enhanced Services. ECES operates the county’s only enhanced service facility, located in Lakewood.
Her background includes working as a critical care nurse for the Portland VA Hospital and briefly at Western State Hospital in 2021. She now lives in Lakewood.
She said her previous work made her want to take on these types of development.
“I’m a critical care nurse, and I worked for the VA. My heart went out to all the people who couldn’t get behavioral health care within the system. So I wanted to do something about it, and be able to provide that kind of care.”
ESF SITE DEVELOPMENT
Enhanced service facilities were introduced “as a new provider when Engrossed Substitute Senate Bill 5763 passed in 2005,” according to DSHS media relations manager Jessica Nelson, in an emailed response to questions.
“There was a clause regarding not implementing the bill if not funded, and when the law initially passed, no funding was attached,” she wrote. “Funding was finally provided through the budget bill for 2014.”
She added that the first statewide rules went into effect in October 2014, and in June 2016, Upriver Place in Spokane became the first licensed/operational enhanced service facility in the state.
ESF sites are licensed through DSHS, processed by the state’s Aging & Long-Term Support Administration.
ALTSA, in its FAQ, says the sites in general are designed to serve as a transition from state or local psychiatric hospitals, with each client “assigned case managers with the Home and Community Services Division.”
The state describes ESF clients as those whose “complicated personal care and behavioral challenges do not rise to a level that requires an institutional setting.”
It adds, “Individuals are referred to an ESF if they are coming out of state and community psychiatric hospitals or have no other placement option due to their complex behavior, medical, chemical dependency and/or mental health needs.”
ESF care per resident costs $455 per day, according to Nelson, with most residents on Medicaid.
Washington state currently has nine anticipated enhanced service facilities, according to Nelson, “with eight of those nine being implemented by 2024, which we project will meet the demand.”
Amy Abbott is director of residential care services at DSHS and discussed enhanced service facilities development recently with The News Tribune.
“Typically, these are folks who are coming from Eastern State, or Western State. But now that we have more treatment centers opening up in the community, we do have some that are coming from some of our involuntary programs that are in local communities as well.”
She further explained how placement is determined.
“We have people who work at Home and Community Services who work directly with those hospitals. And if we have a person in those hospitals that are meeting some of the criteria for ESF, the discharge planners at the hospital, we’re working with Home and Community Services and say, ‘I think this person might meet ESF level of criteria. Maybe we want to talk to them about an ESF as an option.’ And that discussion starts with the patient in the hospital.”
Length of stay depends on the individual.
“Some of these folks, they go into these programs, and they just plan on staying there,” Abbott said. In other cases, “we have a lot of younger clients who go into these facilities. They have some extra care needs, medication management, maybe they have some ADL needs, or they may have burned a lot of bridges in the community in other programs. So they’re working on showing they can make it and do OK, and they’re working on transitioning to even a lesser level of care after ESF or just transitioning back into the community in general.”
Pierce County Council adopted an ordinance in the fall of 2020 updating the county code introducing ESF development in the county’s urban growth area, establishing permitting rules focused on mixed use districts, high density residential districts and community centers zones.
The approval came after the council’s six-month moratorium on siting enhanced service facilities, which started Sept. 24, 2019 and extended for another six months starting April 3, 2020. The moratorium was to allow time to “identify appropriate zoning and development standards for siting,” according to information from the County Council’s agenda packet for its Sept. 22, 2020 vote.
IBHTF DEVELOPMENT
According to the fact sheet, “During a systematic review of the state hospital discharges, a group of people were identified that no longer benefited from treatment but were unable to discharge due to the need for further treatment and no facility able to provide it.”
The sites, staffed 24/7, “bridge the gap between hospitalization and full discharge,” using a clinical team “to work with the individual all hours of the day, if needed,” according to HCA.
“The facilities are designed to be residences for the individuals that live there. Individuals will only be discharged from the facility if they complete their treatment plan objectives and can be safely served within the community in a less-structured setting. The facility will allow for limited egress from the facility by monitoring individuals leaving the facility, providing staff the ability to assess if the individual presents as a risk to themselves or others,” the HCA fact sheet noted.
A Senate Behavioral Health Subcommittee meeting in December 2022 received details from an HCA representative on site development in the state.
Teesha Kirschbaum of HCA told members of the Senate panel that their addition to behavioral health treatment in Washington was the result of the facilities bill passed in 2019.
“It increased the capacity for long-term civil commitments to be treated in the community instead of state hospitals, and developed alternative placement options for persons with co-occurring developmental disability and behavioral health needs,” she said.
The facilities are created through a partnership with the Department of Commerce and the Health Care Authority, she added.
The sites “focus on the needs of the person and will offer onsite behavioral health interventions, psychosocial rehabilitation, and the development of skills to integrate back into the community,” she said.
She added that “We expect that individuals will stay at intensive behavioral health treatment facilities for a year, but this could be longer. It’s really based on what the individual needs to be successful.”
Melissa Thoemke, behavioral health communications manager for the state, told The News Tribune in response to questions that managed care organizations and administrative services only benefit plans “will develop contract rates based on region needs and their overall contracting structures. The rate for services is negotiated between the Managed Care Organizations and the provider.”
She added that “The actual payment amount per individual is negotiated between the facility and the payor ... based on their particular contracts. The Health Care Authority has projected an average cost per client per day of about $700.”
One intensive behavioral health treatment site is operational so far (in Olympia), according to Thoemke, and there are 9 other facilities “which have been awarded funds by Department of Commerce and are in various stages of development.”
IN TACOMA
Plans filed in February with the city of Tacoma outline plans for a new IBHTF facility at 8217 S. Hosmer St. The property was the former site of Great Wall Buffet, destroyed by fire in November 2019 and later demolished. It is next to the Hampton Inn & Suites and is being developed by Emerald City Enhanced Services.
Johnson of ECES spoke in March with The News Tribune about her plans.
The Lakewood ESF site, 11421 Pacific Highway SW, is next to WoodSpring Suites Tacoma-Lakewood.
While the city permit files online list the Hosmer project as an ESF, Johnson says her plans, and funding, are tied to offering a higher degree of care.
“I wanted to place mine not too far away from (the Lakewood) ESF, which is an enhanced service facility, and the one on Hosmer is going to be an intensive behavioral service treatment center,” she said.
“So, (the Hosmer site) is where they first go, and then they get sent to the Lakewood facility and then from the Lakewood facility they get placed in the community or sent home.”
She further explained: “Intensive behavioral health treatment facilities are a setting where residents receive treatment and care at a higher level than the ESFs. The goal for both is to eventually help clients move on and go home to their own communities.”
Johnson told The News Tribune she intends to purchase the Hosmer site.
While the street has made headlines for its levels of crime, “the pickings are very slim as far as where you are going to put the facility,” she noted.
“It’s really hard to find locations or lots to build on,” Johnson said in a recent interview. “And these kind of facilities or commercial facilities that have a lot of requirements are built special. So it’s hard to … remodel a building into a building that you want, just because of the requirements.”
She also said she wanted to keep the Hosmer and Lakewood sites relatively close for transfers. “It just makes sense to keep them together.”
In 2020, Emerald City Enhanced Services was one of 22 projects awarded grants from the state Department of Commerce. The grants were in support of 395 new beds and outpatient services to assist with local community placements for people leaving Eastern and Western State hospitals.
ECES received $1.96 million in October 2020 to develop its 16-bed Lakewood site, which opened in January.
Two years later, it received $2.5 million from Commerce for an intensive behavioral health project in Gig Harbor that was later switched to the Hosmer location. That grant bundle totaled $17.9 million for eight new behavioral health facility projects across Benton, King, Pierce, Skagit and Snohomish counties for further services and community-based treatment options.
“Gig Harbor was a perfect site, but someone outbid me on the site, so I am moving that IBHTF grant to the Hosmer site,” she told The News Tribune.
She added that state officials were fine with the switch “as long as it is within Pierce County.”
Permit filings show another ESF site in Tacoma planned for 3711 Pacific Ave., an office building that sold in November to Reliance Senior Housing Fund LLC, affiliated with Destry Witt of Vancouver, Washington. That site is in the site revision land use process with the city.
The 2022 grant bundle awarded Reliance $2.2 million for an ESF project in Puyallup and $2.5 million for a Tacoma project.
NEED FOR COMPLEX CARE
Kim Zacher is CEO of Comprehensive Life Resources, a nonprofit organization that provides behavioral health care among other medical resources in Pierce County.
While Comprehensive Life Resources isn’t tied to any ESFs, it does run Park Place Residence on South Yakima Avenue near Wright Park. In operation since 2000, the site serves as an adult residential treatment and recovery center, offering therapy, psychiatric services, counseling groups, community skill building, case management and more. It is surrounded by the neighborhood’s apartments, homes and offices.
“That’s a 5-story, 70-plus bed facility for people with serious mental illness,” she said. “And so there’s some symmetry (with ESFs) and we certainly understand a little bit about how to be successful and what it takes to work with the neighborhood community, but also people just have concerns.”
Big facilities such as Western State, Zacher noted, are limited in a capacity to adequately accommodate everyone.
“It’s just really hard to do programming if you have these big facilities,” she said. “They are these complex cases that are there and we also have a lot of various health conditions that cause behavioral health issues.”
One example, she noted, would be patients struggling with depression along with heart disease/congestive heart failure.
She added, “I bet almost everybody has a story, if anybody’s had an older relative that had dementia, or something, they can relate to the nursing home saying, ‘Whoa, this might be a little too much for us.’ Or if you’ve had a relative that had pretty serious behavioral health issues, and they become frail, or can’t move around as well. Your average nursing home or adult or average adult family home can’t handle that.
“They need a different kind of facility,” she said.
That’s where the new sites can help in a specialized manner, she said. “With the smaller 16 bed-facilities, you can run a special population because it really works, the way you would want to offer recreation and therapy.”
Such site development has not been without controversy from neighbors in some areas. In February, protesters outside a Supreme Living housing facility near Lacey were upset about plans to house sex offenders at a different Supreme Living facility near Tenino, and drew parallels to the Lacey area facility, according to coverage earlier this year in The Olympian.
The sites, though, are different, with the site near Tenino considered Less Restrictive Alternative community home, and the site near Lacey an enhanced service facility.
Johnson explained the types of clients for her facilities, making clear she would not admit sex offenders.
“Our patients are coming from the Western State Hospital or diverting from the Western State Hospital, and they are patients with behavioral health needs. And we only take residents who are nonviolent and don’t have any kind of sex crimes.”
She noted that her sites “are more of a transition back to real life. The kind of residents that I can work with and help them eventually move into their old communities where they came from, and maybe apply for housing, stabilize them on medication, teach them life skills, and teach them how to go get a job and how to take care of their own personal stuff.”
As far as life skills, she said the aim for her center’s clients is to know how to do their own paperwork, how to apply for a job, and take transit for transportation before departure.
Johnson said she is selective about who is accepted.
“The state can’t force me to accept all the clients they send me,” she told The News Tribune in a separate email in response to questions. “I did turn down a lot of clients because I feel I’d be taking on too much risk, and I want to keep my other residents, all employees and the community safe.”
While the different types of sites are operating at different degrees of intensity and serving specific types of clients, Johnson said they all face the same challenge.
“My point of view is, we’re trying to help them, and teach them to integrate in the community,” she said.
Zacher underscored the need for all the new options in the area.
“We desperately need all kinds of facilities to meet really specialized care needs,” she said. “If we don’t have facilities like this, we will have more people who are homeless or chronically homeless.
“The option isn’t somewhere else, the option is they get discharged to the streets.”
