Why King County mental health facilities decline 27% of referrals

Jul. 7—A wheelchair, using a CPAP machine for sleeping, pregnancy — these are among the reasons why hundreds of people are turned away from mental health crisis facilities in the King County area every year.

Known as evaluation and treatment centers (E&Ts), their goal is to stabilize patients in a psychiatric emergency with medication and therapy. But people with mental illness, their families and their advocates point out that despite this mission, some of the most vulnerable people often are denied treatment.

For people with substance-use disorders, intellectual and developmental disabilities or criminal records, it can be a maze to decipher which facility will offer the proper staff, training and bed availability to take them. And if no facility accepts them, some people languish in emergency rooms or are released without treatment into the community and sometimes into homelessness.

Staff at these facilities say declining some people is necessary to keep themselves and patients safe: It's a delicate balance managing the needs of patients with the care that underfunded and understaffed facilities can realistically offer in a siloed mental health system that pinballs patients through it all.

E&Ts turned down about one in every three referrals for treatment in 2015, according to an Evaluation and Treatment Decline Report, the first of its kind to document why patients were turned away from King County centers. The report examined data from 2015 through 2019.

"It became apparent that some places were declining people for reasons that were frankly upsetting," said psychiatrist Maria Yang, the former medical director for King County'sBehavioral Health and Recovery Division, who authored the report.

Decline rates lessened over the next few years and centers admitted more patients, but the COVID-19 pandemic stifled improvements. According to the newest data from county officials from December 2021, the decline rate across all facilities was at 27% — with 1,227 declines last year alone in King County.

County officials point out that while an individual may be declined from one facility, they may be accepted on the next referral or several days later when a bed opens — it's a complicated lottery draw.

The most declines last year occurred at Fairfax Behavioral Health in Kirkland, with 314 declines total. Recovery Place in Kent, however, had the highest rate of declines, turning down 41% of referrals, followed by Cascade Behavioral Health in Tukwila, which declined 36% of referrals. Cascade chose not to comment and Fairfax didn't respond to multiple requests for comment. Staff at Recovery Place cited staffing issues, among other reasons.

Though some providers cite an overall bed shortage, King County data finds that's not the main reason people are turned away. Instead, facilities cite patients' medical and behavioral issues, as well as administrative reasons. Even under the coronavirus threat, only 41 individuals were turned away in 2021 for COVID-19-related reasons.

"This data over time started telling a story," Yang said. "Certain hospitals seemed much more likely than other hospitals to not take individuals."

Finding care

Donald Bremnor found himself on Zoom in February 2021 testifying in front of Washington state legislators.

He was speaking in favor of a bill that would mandate E&Ts to accept all patients, presuming they have room and can provide care; no more cherry-picking.

Senate Bill 5397 would have meant a different future for Bremnor and his adult son who has schizophrenia. His son, a military veteran whom The Seattle Times is not naming for privacy reasons, was seeking care for a mental health crisis in 2018.

Bremnor said his son was denied care at two E&T facilities, though he never understood why. Instead they waited over 100 days at two hospitals — one in Gig Harbor, another in Lakewood — on a single bed certification, a temporary license that allows emergency rooms to hold patients involuntarily. Critics of the license say it hardly qualifies as treatment.

Bremnor's son was eventually accepted to a facility, but, due to high blood pressure and a fall, bounced between an acute care hospital and an E&T facility in Lakewood, though the hospital medically cleared him each time.

For Bremnor and his family it was devastating.

"Seeing all of this happen, I wondered how — in the procedure where the promise of treatment justifies legal detention — a provider of that treatment had the discretion to refuse him," he shared.

In the King County area, E&Ts turned away about half of all referrals over the past two years due to medical reasons. Examples include dementia, CPAP machines, substance use, autism or a developmental disability, pregnancy, or a person with COVID-19. Staff say it's hard to care for these patients with their limited resources, and in some cases canes or oxygen tanks can pose a safety risk for patients and workers.

Administrative issues contribute to declines a quarter of the time. That can include short-staffing or "acuity on the unit," meaning that staff are already focusing on people requiring higher levels of care and can't take on additional people with high needs.

Reasons for decline also include people who are transgender and may need an individual room (most facilities house two or three people to a room), though some advocates have critiqued the policy as discriminatory. If an incoming patient has a history of violence or is a registered sex offender, they can also be administratively declined by a facility.

Behavioral declines can include someone coming into the facility in restraints, people who are currently violent, and anyone considered too acute or sick.

Finally, not having enough beds resulted in 7% of declines in 2021, and 1% of declines occurred for unknown reasons. In their latest report, county officials note that criteria for declines vary across facilities, and the facilities may not always apply their criteria consistently.

A separate report by the Washington State Hospital Association also found high rates of decline across the state, with 7,600 declines in a four-month period in 2021. Half of the providers cited "No beds available" as their reason. Another 17% of declines were due to "complex behaviors," while 12% were for medical reasons.

Altogether the data paints a grim picture for people in crisis with dozens of barriers that stack up along the way, sometimes disenfranchising the very individuals who would most benefit from care.

"This system is so broken and impossible to navigate. It's so ineffective and people aren't getting help," said Caitlin Sellhorn, a former Seattle-area psychiatric nurse of six years. Sellhorn recently moved to Portland, Maine, but spent time working in both inpatient and outpatient centers in the region, including Navos, UW and Harborview.

One challenge she saw during her time is that for-profit hospitals run lean businesses — and even the nonprofit models have to balance their services in order to stay afloat.

"The hospitals don't want to keep them [patients] if they're gonna have to eat the bill," she said.

According to the Washington State Health Care Authority, fully funding treatment is tricky at freestanding E&Ts (those not connected to a traditional medical hospital), and few private insurances cover the care, though recently passed legislation addresses that.

To complicate matters, hospitals also have to think through liability issues — that's why people in crisis are initially medically cleared in emergency rooms, despite everyone agreeing ERs are costly and sometimes the worst place for a person who's already stressed and overwhelmed. Staff and beds are also limited after years of underfunding mental and behavioral health services. And even when freestanding E&Ts take patients with higher needs, it's sometimes harder to discharge them to appropriate housing, creating a cascading backlog.

"We can only admit and care for as many patients as we can staff for," said Richard Geiger, the chief of inpatient and residential services at Valley Cities, which oversees Recovery Place, a facility that serves people with mental health crises and substance-use disorders.

Geiger said the facility does its best to accept people with some medical conditions, like pregnant patients or those who use CPAP machines, but people with more complex backgrounds are accepted on a "case-by-case basis." He adds that while some facilities can handle medical needs or more acute patients, Recovery Place doesn't have that capacity.

Dr. Mark Snowden, chief of psychiatry at Harborview, explains that hospital-based E&Ts have physicians, nurse practitioners and physician's assistants who are trained in both behavioral health and medical services and can respond rapidly to either need, leading to better acceptance rates at hospitals like Harborview and Swedish.

"I can't say that there is no cherry-picking. But I think it's more complicated than that," he said.

Snowden shared that more and more patients coming in with psychiatric needs also have untreated chronic medical conditions like diabetes, heart disease and lung disease. Those medical needs don't disappear when a patient is experiencing a mental health crisis, but Snowden urged other hospitals to take a broad view on what kinds of patients they can manage in order to help freestanding E&Ts that don't have that option.

"You don't have to avoid the patients that you might fear [have] all these potentially horrible outcomes," Snowden said.

Attempting change

To address the high rates of declines, King County has a patient placement committee that meets monthly. Staff from various hospitals come together to find beds for hard-to-place individuals.

"We can work with each hospital individually, but as you can see from the data, it's really going to take the entire system to agree this is a priority," said Kelly Nomura, director of the King County Behavioral Health and Recovery Division.

Washington State Senator Emily Randall (D-Bremerton) tried to tackle this problem at the state level by sponsoring a bill mandating evaluation and treatment centers and detox facilities to take all patients and provide adequate treatment. Bremnor, whose son struggled to find a bed, was part of the reason Randall took up the cause.

That bill, however, never made it out of committee. The Washington State Hospital Association and medical staff pushed back, stating they were too understaffed and could not keep patients or themselves safe. The bill was well-intentioned but the wrong approach, they said.

Randall, who is running for reelection, said she plans to make a similar attempt in the next legislative session, though she's not sure yet how it will look.

"No one is moving fast enough," she said.

And while she understands hospitals' concerns, she responds with a story about a ride-along she took with the Kitsap County Sheriff last month. One officer was from Arizona, one of the states with the best crisis mental health services in the country.

"One of the things that he said was that when he was in Arizona, there was always a crisis facility to take someone to," said Randall. "Here, his options are an ER or jail."

Seattle Times engagement reporter Michelle Baruchman contributed to this report.

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