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Kids are waiting months for psychiatric beds. Why it's such a struggle to expand care in WA
Seattle Times - 5/21/2022
May 21—On the website for Tamarack Center, big bold letters read "DOES IT WORK?"
"We answer that question with an enthusiastic 'Yes'," the center says of its offerings: a children's residential program in Spokane, where kids with serious mental health conditions live and receive intensive psychiatric treatment for months at a time.
For the children and teens at Tamarack, the promise of something that "works" means everything.
Tamarack is one of Washington's four intensive inpatient facilities that serve as a veritable last stop for youth with mental health diagnoses so significant that they're unsafe living at home. Some of the youth have cycled in and out of emergency departments following a mental health crisis; others have bounced between foster homes, lived in juvenile detention or experienced lengthy and unsuccessful trials with outpatient care. Many have a history of aggressive behavior, mood disorders, suicidal behavior and trauma.
At a moment when more children than ever are in need, Washington's pediatric inpatient psychiatric facilities are reeling from chronic underfunding, a patchwork of laws that make expansion difficult, and a mental health workforce crisis that's translated to high employee turnover and serious understaffing.
Washington currently funds 94 long-term inpatient beds to serve the state's 1.1 million children. Even though the state has injected more funding to add additional long-term beds, providers say they're struggling even to keep their existing beds online because they can't retain or hire enough staff. And while the state is trying to set up a new inpatient facility, not a single provider has applied to run it.
Pearl Youth Residence, a 27-bed pediatric facility in Tacoma, had a 50% staff turnover rate last year, said Chris Gleason, chief communications and community affairs officer at Comprehensive Life Resources, which oversees Pearl Youth. Because it didn't have enough staff, Pearl Youth made the difficult decision in December to stop admitting new patients. Its census has since dropped to 17.
"Just trying to get a therapist?" to work at Pearl Youth, said Kymm Dozal, who is the facility's director. "I'm calling them unicorns now."
As Washington faces a burgeoning youth mental health crisis, places like Pearl Youth and Tamarack have become a central focus of debate over how to expand care for children experiencing serious mental illnesses or behavioral problems. On one front sit families who are fighting — through lawsuits or sheer determination — to piece together intensive outpatient services so their children can stay at home. On another are families who have gone through a long odyssey of diagnoses and outpatient services and see no other option but housing their children in long-term, inpatient psychiatric care.
Many families begin seeking out long-term care as they watch their child's symptoms become progressively worse, even violent, at home. More and more, though, children are in such a serious crisis that they're taken to an emergency department — and end up stuck living there for weeks or months as they wait to secure a long-term stay at facilities like Tamarack and Pearl Youth.
Hundreds of Washington children end up in this holding pattern, called "boarding," each year, The Seattle Times recently reported.
Waits for a long-term bed are lengthier than at any time in recent memory: Of those on the state's waitlist during the first quarter of 2022, children ages 6-13 waited an average of 144 days, and those ages 14-18 waited 96 days. And the number of admissions is historically high, a reflection of both the crushing need for long-term care and faster turnover at care facilities, experts say. Tamarack, for instance, admitted 47 children in 2021, its highest admittance ever. But kids are staying for shorter periods: The average is now 4.5 months, down from a typical stay of about 6 months.
"Our phone rings all day," said Tim Davis, who has run Tamarack Center for 34 years.
"Out of 10 phone calls from parents or folks to put a kid here we say no to probably nine. The phone just rings constantly for people wanting to get their kids some help."
To serve children with serious mental illnesses, Washington state contracts with three nonprofit residential facilities: Tamarack, Pearl Youth, and a small facility in Yakima called Two Rivers Landing. The state runs a fourth facility, called the Child Study and Treatment Center, near Western State Hospital in Lakewood.
Washington began funding long-term pediatric psychiatric beds, now called the Children's Long-term Inpatient Program (CLIP), in the 1980s. Davis said the state envisioned small, homelike facilities staffed by highly qualified physicians, nurses and teachers.
Tamarack largely fits that model. Teens who live there have school for five hours most days and spend the rest of their time in group therapy, individual therapy, family therapy and a mix of recreational activities like basketball, pool or video games.
Jason Longshore, who oversees the nursing department at Tamarack and has worked there 26 years, said the biggest change he's noticed over the course of his career is the length of time residents live at the center. In his early years at Tamarack, kids would stay an average of 10-12 months, he said, and "by the time they left here they were in pretty good shape."
Now, "there's been so many kids waiting to get in, whether it's from home or hospital, that there's a push, like 'We have people in line here, let's get going,'" he said.
There's also a financial incentive to get kids out of hospitals and into long-term care: The daily cost of boarding in an ER can top $2,000, depending on the hospital. The rate the state pays for long-term care at Tamarack is less than half that, at $880 per day.
Some who manage CLIP facilities say that's not enough money to recruit and retain the highly trained staff needed for this work — especially when they have to compete for staffing with hospitals, which can often pay more, and jobs that offer work-from-home or more flexible working environments. And CLIP facility operators say the state's rate for long-term care doesn't cover the cost of caring for many high-needs youth.
Davis remembers only three meaningful increases to the state's rate over the past 30 years, and the current rate doesn't leave room for facilities to scale up, he said. As part of the decades-long shift away from institutionalization, cultural and legal forces have focused on improving access to outpatient care rather than extended inpatient stays.
Tamarack has stayed afloat because it accepts children with public or private insurance, Davis said. Private plans tend to pay a little more than the state.
"The state is not happy with us at all because we say no to some of the CLIP kids they refer. I certainly understand their position on that," Davis said, but, "It's kept us from hitting the iceberg."
But several other residential facilities have closed or consolidated.
Seattle Children's Home, which was founded in 1884 and served youth before Washington was formally a state, merged with a provider called Navos in 2012. Then, Navos shuttered some of its programs: Citing staffing shortages and costs of care that outpaced the state's rate of reimbursement, Navos' Sunstone program closed in summer 2021. Several therapeutic group homes such as Ryther in Seattle and Navos Ruth Dykeman Children's Center in Burien, which offered less intensive services than CLIP, have also closed or shrunk their residential rehabilitation programs.
Long-term care is just one part of a splintered system that makes it difficult for kids to get back to stable homes, or from one point in the mental health system to the next. From foster care to hospitals to therapeutic group homes, long waiting times have created bottlenecks at nearly every stop. For instance, CLIP operators say sometimes they struggle to discharge youths into less intensive mental health settings because these services are full, leaving kids in a CLIP bed that's needed by another youth waiting in a hospital or at home.
For instance, a 15-year-old at Pearl Youth who met all his treatment goals and had been stable for five months was supposed to leave the facility in early May. But his guardians said they weren't prepared to pick him up, Dozal said. So Pearl Youth kept him for two additional weeks — and asked the state's Department of Children, Youth and Families to look for other options, like foster care or a group home. But by last Monday — the teen's new discharge date — nothing had panned out.
Pearl Youth couldn't hold the teen, and the facility also wouldn't release him into homelessness, so Dozal made every call she could think of: DCYF, law enforcement, child protective services. On that Monday afternoon, she decided to drive the boy to DCYF's doorstep.
"We get stuck in this situation where all of this progress the kid has made is essentially wiped out," Dozal said. "It was really hard for staff to even wrap their head around that we are dropping a kid off and essentially walking away."
In early May, eight Washington children ages 11 and younger, and 28 ages 12 and up were waiting for a CLIP bed, state data shows.
To help speed more children and teenagers toward care, Washington State Health Care Authority, which oversees the CLIP program, recently landed funding for a new 12-bed facility and at least 35 additional beds, officials said.
But problems persist.
In January, the agency solicited bids for the new 12-bed residential facility, which is intended to serve youth with co-occuring mental health conditions and developmental or intellectual disabilities — a population with complex needs that's often denied placement at existing CLIP facilities.
The state put up the funding to pay staff salaries and other costs that go into caring for a child, but no capital dollars to construct or renovate a facility. No one bid on the project.
"We were really hopeful we would get a bite," said Diana Cockrell, a behavioral health administrator at the Health Care Authority.
Davis and Pearl Youth's Dozal weren't interested: Chronic staffing concerns at their facilities make it hard to imagine trying to staff new beds. And Washington is uniquely hard-pressed to attract new long-term inpatient providers, Davis added. This is because Washington youth 13 and up have the right to both initiate their own mental health treatment and withdraw from it without their parents' consent. The law offers youth important protections, but also makes long-term care a precarious business proposition.
"There are lots of places for kids with varying degrees of psychiatric illness and many of them are profitable," Davis said. "With that being said, they stay away from Washington as fast as they can because kids can sign themselves out," of care.
Teenagers can be held involuntarily if a judge gets involved: At Pearl Youth and Tamarack, anywhere from 30-45% of residents are there under a court order, the facility administrators said. However, youth often buy into their treatment as it progresses, Davis said, and end up staying voluntarily.
Davis said he stays the course because, like Tamarack advertises on its website, long-term treatment can work.
"It's kind of like a slot machine. You can sit there and play all night and lose, but every now and then if you hit the jackpot you feel like a million dollars," he said. "We'll help a kid and they'll do so well and get amazingly better here ... you look around and say, 'Well, OK, we've got to keep doing this.'"
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