SEATTLE — Four people sat at a table, coloring with crayons and singing along as rock music played from a TV behind them. First Lynyrd Skynyrd, then The Eagles.

The calm, soothing repetition of coloring and the upbeat music was meant to help them practice mindfulness, one of the therapy activities for residents at the Lacey-based mental health facility Supreme Living.

Everyone there had been recently discharged from mental health institutions — either the state psychiatric hospital or locked community treatment centers — where they’d received care under a state law known as the “Involuntary Treatment Act,” aimed at treating those so mentally ill that they’re deemed dangerous, or unable to meet their own basic needs.

The path for people once they’re released from involuntary treatment, or “civil commitment,” is far from simple. Patients who no longer meet legal requirements for detention must be released, but there’s no law that requires them to continue receiving support.

Many patients who’ve been released from civil commitment are not ready to live on their own — still struggling with mental or physical health challenges, and without steady employment or community support to keep them on track. And even those who are doing well often struggle to find housing afterward, which can threaten their recovery.

Several years ago, Washington began funding the development of local facilities aimed at helping these patients. Known as “Intensive Behavioral Health Treatment Facilities,” these services were meant to provide a place for patients to get further therapy, and develop skills to help them live on their own again. The facilities, which house up to 15 people, are owned and operated by private health care organizations, but are largely funded by the state. Three have opened, with six more scheduled across the state for the next two years.

Three years after the first facility opened its doors, the impact of those facilities still largely remains to be seen.

Angela Rinaldo, the CEO of Supreme Living, which operates two of the three intensive behavioral health facilities open now, said the model provides needed services at the back end of involuntary treatment.

“These are chronically mentally ill adults who, for the most part, make their way cycling through the systems,” Rinaldo said. “And that’s why we need to interrupt this, because if we don’t, they’ll just continue to cycle through the system.”

But the first few years have not been without challenges, she said, including navigating bureaucratic hurdles and finding enough patients to fill beds.

State officials say they’re optimistic about what they’ve seen so far, but it will be difficult to tell how successful the model is until they have more data and more facilities are open.

“We’re typically talking about folks who have some of the more complex, long-term needs,” said Jeff Landon, the adult services and involuntary treatment section manager for the Health Care Authority’s Division of Behavioral Health and Recovery. “They may no longer require involuntary inpatient treatment, but going to independent housing and living may be a big stretch. So this is filling that in-between space.”

Filling a gap

Five years ago, Washington began trying to revamp its mental health system. The plan included moving many of its patients out of the state’s psychiatric hospitals, and transitioning them to smaller community-based facilities closer to their own communities.

Shortly after that, the state entered into a settlement agreement with Disability Rights Washington, the state’s largest advocacy organization, over its failure to quickly discharge patients from long-term care due to a lack of places for them in the community. The state said it would better coordinate discharge for those leaving involuntary treatment by beginning to plan for patients’ discharge well before they are released.

The state began opening the intensive behavioral health treatment facilities shortly after these developments. The buildings were funded by the Department of Commerce for construction and the Health Care Authority for operation, and are run by private organizations.

Supreme Living, the Lacey facility, was the first. Aristo Behavioral Health opened in Renton soon after, and Supreme Living just opened a third in Tacoma last month. Six more are planned for the next two years, including two more in Tacoma and others in Bremerton, Kennewick, Mount Vernon and Spokane.

The Health Care Authority said the Lacey building has had 66 patients so far, and Aristo has treated 45. Supreme Living’s Tacoma campus has admitted two since it opened in November.

The state has an annual operating budget of about $6 million, between state and federal dollars, for these small “stepdown” clinics.

Unlike assisted living or long-term care facilities, such as the “enhanced services facilities” that serve some mental health patients, intensive behavioral health facilities don’t offer day-to-day assistance with activities like bathing or feeding. Nurses are on site to help patients manage medications and coordinate with medical providers, but instead of caregivers, the building is staffed by peer mentors, who have experience with mental health challenges and who now have mental health counseling credentials.

There’s no prescribed amount of time for treatment, although the typical stay is between six months and a year. While residents can leave the facility, each door in the building has a 15- or 30-second delay for “limited egress,” where an alarm will sound and the facility’s staff will arrive, try to find out why the person is leaving, and try to convince them to stay and continue treatment.

Rinaldo said that even though treatment is voluntary and patients can leave if they choose, it typically benefits them to stay and maintain a consistent schedule. Coming and going frequently can mean they miss out on important treatment.

Daily activities include regimented therapy and rehabilitation services like anger management, job skill development, substance use disorder treatment, and individual and group counseling. Peer mentors help residents develop routines for things like meals, sleep and taking medications, as well as helping them integrate back into the community — offering guidance on reconnecting with friends, family and jobs.

“They’re providing a lot of the same types of services (as involuntary treatment), but again, on a voluntary basis, and supporting people not only to continue in the recovery journey, but to apply those skills,” Landon said. “They’re going to have to be in the community and continue on that journey of readiness toward more independence once they’re discharged.””

Rinaldo said it’s too early to say how successful the facilities have been. About 15% of those who’ve come through the door since the facility opened have not made it through the duration of their planned stay. For others, she said, success looks like getting people to recognize where they need help.

“If we do our jobs right, and we walk them through that cycle of change and help them see what’s caused the upsets in their lives, maybe they’ll make different decisions next time,” Rinaldo said.

Bureaucratic inconsistencies

Even as the need for “stepdown” behavioral health treatment remains high, Rinaldo said it’s been difficult to fill beds at the new centers.

“I don’t know where the clog is,” Rinaldo said. “When I talk to institutions like Western State Hospital, they’re saying there’s a lot of people.”

Since opening the Tacoma facility in November, Rinaldo said they’ve only had two patients referred.

She said part of the issue could be that those leaving state hospital treatment may take a while to be ready, given their significant mental health histories.

But one of the biggest challenges, she said, has been managing incongruencies between different state agencies involved with this model of care.

The Department of Health, which licenses the facility, requires staff to check on patients and account for them every 15 minutes. But the Health Care Authority, which developed the model and funds it, says people can come and go at will.

Patients are referred to the facility through Washington’s managed care organizations, which coordinate Medicaid, the federally funded health insurance program for low-income residents, in different regions of the state. And while those organizations require patients to be assessed regularly to see if they’re making progress in treatment, the Health Care Authority says patients can’t be required to do any treatment.

“We’ve waddled this tightrope, if you will, for a couple of years now, and it can be extremely difficult,” Rinaldo said.

Health Care Authority staff said it’s difficult to say what exactly is causing delays in referring patients, but attributed many of the challenges to opening a new model of care, and having only a few active programs.

“When you only have two facilities serving the entire state, opening up the valve as wide as possible can be a little confusing. You may have a ton of referrals and then a lot of denials,” Landon said.

He said he anticipates more usage as new facilities are built across Washington.

“We’re really trying to get people home, closer to their community,” he said. “We’re not looking to get people discharged from all over the state, so that also narrows down the potential referral streams.”

While those working with patients say the facilities are filling a needed gap, some mental health advocates say they’re concerned the model is still highly restrictive, and emphasizes institutionalization, instead of badly needed community programs.

Kim Mosolf, an attorney with Disability Rights Washington, said it’s good to have more places for people to go after discharge. But she said these types of facilities are still very expensive for the state to run, and are limited in who they serve.

“There’s lots of other ways you can discharge someone successfully where we’d prefer to use resources,” she said.

Mosolf said she’d like to see more of an emphasis on permanent supportive housing and community navigator programs that help people stay on track after they’re released.

Mosolf also said that while the facilities are voluntary, it raises concerns when patients are told such facilities are their only option once they leave institutional care.

Rinaldo said that while they’re still navigating other challenges, like finding longer-term housing for patients once they leave, and handling the fragmented mental health system, it’s still vital to provide in-between care for patients who’ve left involuntary commitment.

“This back-end piece is essential,” Rinaldo said. “To be able to structure for people so when they go back out in the streets, where they go from here, whether adult family homes, another group care setting, their own apartment, wherever it is from here, that they have the supports in place. If they don’t, they won’t make it.”

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