Inside Olympia
Inside Olympia---Amber Leaders, Co-Chair of the Joint Legislative Executive Committee on Behavioral Health.
On this week's Inside Olympia ... What will it take to create a robust and comprehensive behavioral health system in Washington? Why is it taking so long to get there? And what are the barriers to success? On the program for the full hour this week, Amber Leaders, Co-Chair of the Joint Legislative Executive Committee on Behavioral Health.
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- 19 Sep 2024
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This week on Inside Olympia, what will it take to create a robust and comprehensive behavioral health system in Washington? Why is it taking so long to get there? And what are the barriers to success? On the program for the full hour this week, Amber Leaders, co-chair of the Joint Legislative Executive Committee on Behavioral Health. From the TBW Studio, it's Inside Olympia with host Austin Jenkins. And welcome to Inside Olympia. From de-institutionalization in the 1970s to present-day efforts to better serve psychiatric patients in the community, the journey to build a behavioral health system in Washington State that respects the rights and dignity of individuals while also getting them the help they need has been a challenge. Now, a Joint Legislative and Executive Committee on Behavioral Health is working to bring a more strategic approach to mental health care in the state. Why now? What are the committee's responsibilities and goals? What will the end product be? And what hope should patients, families, and Washington State citizens have that a better system is coming after so many decades of falling short? Joining me now and for the full hour this week is Amber Leaders, a senior policy advisor in the office of the governor and co-chair of the Joint Committee. Welcome to the program. Nice to see you. Nice to see you. Thank you for having me. And thanks for talking about this important issue. And it's nice that we have the full hour to do so because it is complex. There is a long history here and it's not as if there's an easy point in time to begin the conversation. But let's just step way back to the 30,000-foot view and ask the question, what is the purpose of this joint effort by the Legislative Branch and the Executive Branch? What is this Joint Committee supposed to do? What's your charge? Yeah, I think the primary charge of the committee is to do exactly what you just described, which is to come up with a strategic plan and a strategic vision for behavioral health. As you know, we've done, there's been a lot of work in the state of Washington over the least the last decade, probably longer, to really address the behavioral health needs of Washington citizens. And one of the things that continually comes up is how do we do that in a more cohesive cross-system kind of way? And there's been a continuing call for, well, what is our vision? If we want to design a behavioral health system for Washington state that really works for people and their families, what does that look like and how do we get there? And I think the primary charge of the JLAC is to bring legislative and state agency experts together to really think about what is that strategic vision? I know you were serving as the co-chair, it wasn't necessarily your brain child to come up with this and you don't hold the responsibility of decades of perhaps shortcomings in this arena on your shoulders alone, but one might wonder, why just now are we doing this? When there have been so many, there were so many opportunities earlier on to try to get those silos to break down their walls and start to create something cohesive. Any insight into why it's happening now, it didn't happen five, 10, 15, 20 years ago? Yeah, one of the things I would say is that I think it has happened some before. We've had a number of committees in place. For example, earlier in the 2000s, there was the select committee on state hospitals, which really took a more focused look on what are we doing with our state hospitals and how are we moving to more community-based care? After that, there was a committee known as the burst, which was the behavioral health system transformation committee, which also took a look at this. And so I think there's been continuing efforts to do exactly this, to try to bring that sort of strategic vision. And one of the things, I've been with the governor's office since 2019 now, one of the things that I think is a big challenge is that the behavioral health system is so large that it's very hard to get your arms around a comprehensive vision. But you're starting to see a more concerted effort to do that. The Children and Youth Behavioral Health Work Group has also taken on a strategic plan specifically focused on children and youth. And this really comes in on the heels of that, seeing some of the success of the Children and Youth Behavioral Health Work Group to really build out a more comprehensive strategic plan. Well, if that's the key to some extent and a point of fact, part of the work that's been done early work with this committee is to document how many groups there have been and entities have been set up to look at this. And it's multiple pages. And there's the squish. There's another one. Yes, that's the select committee on state hospitals. That's the squish. That's the one you were. Okay, so yeah, there's these different acronyms. But what is different this time around? Or why do you think this particular joint legislative executive branch committee might be able to succeed where others did not and taking a more comprehensive, fulsome, holistic view and look? I think a couple of things are different from my knowledge of how these committees have worked before. One is that this is a really comprehensive committee. It's modeled after some of our other joint legislative executive committees where you're bringing really bringing those two branches of government together to work in partnership. The legislature also appropriated some dollars to help support in terms of not only staff, but as well as a contracted facilitator to really help us through the process of building a strategic plan and doing that work. And I think some of the hope of the committee is that this committee might do some additional work in terms of stakeholder outreach, subcommittees, work group, community buy-in on a plan, which is one of the things that I think, again, looking to the children and youth behavioral health work group that they have done very well. They really have built a coalition not only of state government individuals, but of people, families, people with lived experience, community providers to really put important, these important plans together. And I think that's one of the things that we hope to accomplish with some additional time with this group. I should note that this joint committee has members of the legislature on it. It has executive branch agency directors or their designees. And it also has a couple of individuals who are directly impacted. And living with behavioral health conditions to represent the perspective of patients and individuals. You also have a, you mentioned the facilitator. There's also a private group that is helping you on the data side of things. Athena, can you explain kind of their role and how that's going to augment the work? Sure. Yeah. Athena group is a contracted facilitator. They're doing the facilitation. Oh, so they're doing the facilitation? Okay. Yes. And they're also going to do the data work. And part of what they're going to do is that they are doing work with research and data analysis unit at the Department of Social and Health Services, as well as working part of their task is to work with entities like the caseload forecast council and other sort of data entities to try, if not bring the data together, tell us what the gaps are and how do we build a more complete data system so we can be more predictive, more nimble, better, adaptable to what we need to build for the behavioral health system. Yeah. And for the future. And for the future. So another kind of data point or point in time, I was on the grounds of western state hospital in 2018 when governor Inslee announced a five-year transformation of the behavioral health system, which contemplated building this forensic center of excellence on the grounds of the state hospital to treat people coming through the criminal justice system. And then a shift of civil patients, those who are brought in on civil commitment, but not through the criminal system, to serve them out in the community. We've now passed the five-year period, if my math is correct. And one might also say, well, wait a second. You know, in 2018, the governor was announcing this transformation, but now we've got this new joint committee trying to, again, it seems transformed. So help us understand the last five years under the governor's initiative and how that fits into what's going on now. Sure. So as you note, there's been this plan to do sort of a transformation of the behavioral health system. And that's been really a focus of moving away from some of our institutional care, moving away from some of our deep-end systems. You know, people often cycle through our emergency rooms through the criminal justice system, through being unhoused, and trying to move into more community-based care that there's been built out of a number of facilities, work to integrate behavioral health as part of our insurance systems, all kinds of things. There's been the advent of the 988 system to build up more crisis services, all kinds of things to really move us towards that community-based option of care. And I think part of what this group is doing, if you look at the language in the proviso, is talking about continuing on that vision of moving us further upstream as a state, getting more to things like prevention, early intervention and crisis services, trying to contact people before they get into those deep-end systems of care. And it's one of the things the proviso calls out specifically in terms of the strategic plan, which is building out a plan that does exactly that and puts an emphasis on how do we really continue building towards community-based behavioral health. Well, a cynic might say, gosh, we're just reinventing the wheel over and over again here. From your perspective, though, how does the work of this committee build upon the effort to kind of separate out forensic from civil, treat the forensic patients to the extent necessary in the hospital setting, get the civil patients out into the community? Like to the extent that that transformation has a lot of it has happened, where now do you think this committee can kind of help with the next few steps? Yeah, I think one of the big roles of this committee is continuing to move us on that path to some of the investments that we really need to make in those, the earlier parts of the system. So if that, to some extent, if the system was built around dealing with people as you kind of use the term the deep-end, now, and so now this sort of realignments happened, now there's an opportunity to come into the back end and start to say, well, could we catch people sooner and earlier? I think that's right. I think that's exactly right. I think the initial vision of the governor is is moving us away from the state institution model, which is state-operated beds, large state hospitals, you know, hundreds and hundreds of beds, and moving to the smaller community-based models and building out. But even that was sort of talking about long-term inpatient capacity, and that's just a small sliver of the behavioral health system. And many people don't need that level of care, long-term inpatient, some do, and we need to make sure that capacity is available. But a lot of individuals, what they really need are those earlier interventions. How are we providing behavioral health to our youth in our schools? How are we making sure young adults when they're 18 to 25 are getting access when they have that first episode of psychosis? How are we building out our substance use system? I think this is building on that vision into that more comprehensive look of how do you really build in those early interventions so people don't go to those very deep, long-term behavioral health services, and that's what they really need. The podcast, the lost patients that KUW produced earlier this year, there was an analogy in that. And that looked at the history of this broken system in many ways, sort of a fractured system. I suppose some would say broken, others might use a different term, but a system that hasn't necessarily served patients well and holistically, and I think the analogy was, it was like somebody built a house, but none of the floors or rooms actually connect. And so it doesn't make you walk in, and it doesn't make sense. Using that sort of image, if this is the house this committee has inherited, and maybe some things, maybe somebody got in there and connected some things, and it's not as as fractious as it was initially, where do you go from here in terms of trying to make that house make more sense and work better? Yeah, I remember hearing that analogy, and I loved it, because it really resonated with me, because in terms of thinking about where do we go next, part of the challenges that we face in Washington is we have people in that house right now who are accessing care and services in that house right now, but we also recognize that house needs to be significantly remodeled. And so how do you do those two things in concert? How do you provide services and care to people who need it today, yesterday, as well at the same time as building out a better house so that hopefully it functions in the in the future? And so again, I think the jail act is really designed to build on work that has been done before, and is being very purposeful at looking at what are the prior recommendations? What's in progress? What haven't we done? You know, there's plenty of recommendations out there that haven't been picked up. Why haven't they been picked up? Is there a policy reason, a fiscal reason? Is it not workable? And trying to move us along on that path on all the work that's been done over the last decade? I should also note that was a podcast that was done in conjunction and partnership with the Seattle Times. I know kind of in the scientific community and the medical sphere, there are, you know, that you can do original research where you're studying a problem and maybe you're doing a study, you know, a double blind placebo study, but there's also examples where somebody will step back and say, "I'm not going to do my own research or individual research. What I want to do is kind of step back and look at all the research that's been done in a particular area, co-illate it, and then try to come up with what are the takeaways, what would the best practices be, what does the research say? Is there, and I wish I had the term for what that is, but is there an analogy to that sort of approach to what this committee is trying to do? I think that's a great analogy because I think in many ways that's what this committee is trying to do. I don't think the committee is trying to reinvent the wheel or set us on a new path. I think the committee is trying to glean from what has been done before. Where are we and where do we still need to go? Because there have been a lot of recommendations that have been picked up. There's been a really significant investment from the legislature over the last several years in behavioral health. It's been one of the billions of dollars. It's been a bipartisan priority. A hundred percent it has. I think because everyone is touched by behavioral health in some way, either personally, family, friends, neighbors, it is a universal issue. I think that part of this is with all that investment and with all that work, we are still seeing that the system is not working as it should for everyone. How do we really get there? How do we build on the work that's been done? How do we build towards filling the gaps that we're not yet filling? Or what are the things that we've started to fund that either we haven't done it in the right way or we need to keep moving forward on? I think that's part of what this JLEC is really tasked with doing. Let me go back to the governor's announcement and transformation plan. The Seattle Times in April of 2023, so about a year and a half ago when the five years was coming up, wrote a story saying five years later, the state has not met its goals that the governor laid out and acknowledged that COVID interfered and that change happened slowly and that there had been hang-ups to building more capacity for civil patients in the community the governor had originally planned a number of 16 bed or envisioned a number of 16 bed facilities in communities around the state so that you wouldn't even have to leave your home community to get care. Can you sort of two thoughts on my mind. One is why does it take so long to sort of meet these goals and then maybe more importantly, what's happened in the intervening year and a half to get closer to reaching what the governor laid out in that five-year plan but let's just start with that piece of setting COVID aside. I think the frustration people feels like why does it take so long and these leaders say we're going to do this in five years and then it doesn't happen and it sort of feels like a setback. Yeah, I might take a little bit of a different perspective on that in that. I think a lot of things have happened. If you look at the amount of capacity that's been opened or funded in the last five years, it's a significant amount and I also think that there's some truth to the fact that you know as you build out this plan, the plan needs to be nimble and dynamic and we have expanded into a variety of different areas. So I remember the original plan having sort of these concepts of 16-bed models and I think part of what's happened is that there are some 16-bed models, there's a Clark County facility, there's a project with the Tulalip, they are some state-operated facilities but there's also been investment in community provider-operated capacity through the Department of Commerce. The Department of Commerce has had quite a bit of money put to them for community behavioral health capacity grants, capital dollars that allow communities to come in and apply for money and to build out bed capacity in a variety of forms crisis stabilization and triage facilities, intensive behavioral health facilities, peer respite facilities and I think part of what the recognition is over the last five to seven years is the need for that really broad continuum that it's not just about building state hospital beds and community long-term inpatient beds, it's about building out all these other types of services because the need for behavioral health is not a monolith, people have all kinds of needs and we have to have a diverse system that meets all those different kinds of things. So what's happened in the intervening year and a half since the five years came up and the Seattle Times wrote the story about what kind of had not been completed, can you sort of bring us and again I'm asking you to sort of wear two hats here, I know you're here in your capacity as the co-chair of this committee but you also do sit in the governor's policy shop, what does the last 18 months look like? Last 18 months is that we have had quite a bit of the state capacity that has either opened or is on track to open in very soon, you've had the opening of the new teaching hospital up at the University of Washington which is one of the first of its kind in the country that does not only behavioral health capacity but is designed to hopefully increase our behavioral health workforce in the state of Washington. So you get more beds but you're also then using that teaching hospital to train up the next generation of people to work in this field? Yes because as I'm sure you've heard before one of the biggest challenges in building out behavioral health capacity is our behavioral health workforce, if we can build as many buildings as we want but if we don't have the staff and the people to work there, the professionals to work there, you know, beds don't do a lot for us and so I think that's, there's also been really concerted efforts in that space around increasing the Medicaid rates over the last several years for behavioral health providers. That's been one of the biggest things we've heard from providers is that they need the rates to go up so that they can appropriately pay and provide good wages to their staff so that they can not only recruit people but retain them when they come into behavioral health and so I think there's been a lot of work in those kinds of spaces that don't necessarily look like physical beds but are so critical to the behavioral health system functioning in the way that it should. Can you also update us on the forensic the New Forensic Hospital at Western State Hospital? Yeah my understanding and DSHS would be the best source of information for this but my understanding is that they're scheduled to break ground on that New Forensic Hospital later this year. The legislature has provided funding to do that New 350 bed hospital and so you know they've done the demolition work and the pre-work that all that goes along with it and they're getting ready to break ground just to get started on construction. And one last question about this, so you said in some sense as I heard you what was realized over the last five years is that sort of the one size fits all isn't going to work, yeah 16 bed facilities might work in some places but you need to have kind of an array of options. What else has and is coming online for instance remind us of what's gone on at Maple Lane which I think is a former juvenile lock-up facility or juvenile facility. What else has been established for civil patients in this state? Yeah so there's some capacity that has already come online at on the Maple Lane campus. And that's in Lewis County I believe. It is yes yeah and there's a there's a civil cottage that's come online there I'm going to forget the name I think it's Oak Cottage. There's been some conversion of some of the old units there a lot of construction work and rehab work done by the Department of Social and Health Services to bring that online. There's been a there's a partnership between the state and the till layup to build a 16 bed facility up in that region that's a civil facility I think that's well underway I'm forgetting the opening date of that and that's all just state operating capacity which is different than you know that's not the full universe of community capacity. We've used the term behavioral health a lot it's actually defined in the charter for this committee but why don't you remind us of when we talk about behavioral health what that is as opposed to just mental health which is sort of or psychiatric care which you know I think oftentimes the terms a little bit muddled. They do and one of the things I'd say is that actually I think that definition is a work in progress and the children in youth behavioral health work group is also working on a definition of behavioral health in fact we just met last week to talk about how are we going to synthesize the to work that the two group is doing so that we don't create multiple definitions of behavioral health out of these committees. I mean in its simplest form it's really thinking about mental health substance use well-being in a more comprehensive way it's almost more more like an umbrella term whereas previously mental health or psychiatric care you're really focusing on that mental health side but I think behavioral health is more comprehensive than that. The two ends of the continuum are really interesting to me the deep end of the continuum that you often hear about is the people who cycle in and out and don't ever seem to really get better on a at least long-term basis so as based on the early and I know it's early days yet but based on what you've what you know what you're seeing in the conversations that are being had is there is anything coming to light about how you could help so we'll talk about getting to people earlier in a moment but for those people that are sort of part of that revolving door any best practices emerging any thoughts about how to serve them better. Yes I think I mean I think some of it's going to be what we're going to talk about later about getting intervening earlier and providing services but for those folks who are in sort of the deep end system of care it's about making it's back to that array of options and making sure that there are a lot of options in sort of the less restrictive environment where people can move to once they have gotten sort of that deep end level of care and that can be you know not only build out of more long-term in patient beds but it's also things like there's been a lot of work in building out our long-term care system our home and community-based services things like our adult family homes assisted living those kinds of programs we have a lot of folks who have developmental or intellectual disabilities making sure that we have specialized service for them they often sort of get swept up into the behavioral health system which is not well suited to provide the care that they really need and so how are we building out our intellectual and developmental disability system. Same is true for people with dementia traumatic brain injury some of those specialty services I think there's also a really important role for the kind of housing options we're providing in permanent supportive housing low barrier no barrier housing those kinds of options that allow people to live more independently with wraparound services such as assertive community treatment teams other kinds of teams that provide that support but allow people to live in more independent settings. I know that generally there is absolute support for deinstitutionalizing serving people in the community but I also know that there's pushback on the idea that the state hospitals would just serve forensic patients and not civil patients because there are some very complex people on the civil side and I've talked to community providers who say you know look we're not equipped to care for these people or the community care facilities will pick and choose who they want and they won't take the most complex cases and I just wonder if there's any thought that the state is over corrected in this sense or what is the solution for those most acute long-term civil patients. Yeah that's a great question and it is something we wrestle with all the time because we do see that that there is some portion of the population that their needs are so high that they really need very comprehensive care in terms of what they need and probably long-term care and as you know we have certainly seen that oftentimes that can be very challenging for our community providers to take on and so I think there is probably always a role for our state institutions the state has an obligation under under the our state constitution to provide care for individuals who have a mental illness and so there will always be a need for that for that state level of care but I think the important piece is figuring out how do we narrow the pipeline coming in to that that level of state care so that people can can receive care in the community when that is better suited to them and then how do we make sure that the pathways out of state care are there and available so that people don't just sort of stall in our state hospitals and you know our state department of social and health services does a lot of work on this in terms of transition planning and other things but they need to have the resources available in the community for people to go there they can't you know they can't plan in isolation. Okay well we're going to take a quick break when we come back I want to ask you about both some of the civil rights components to this and then also trying to do more early intervention to reduce the pipeline into this kind of acute care we've talked about so we're going to take a quick break when we return we continue our conversation with amber leaders co-chair of the joint legislative and executive branch committee on behavioral health back right after this stolen vehicles are a problem we need a solution pursuits are not the solution to that just hit another vehicle with the current pursuit law you can literally have so much steel a vehicle and drive through a school zone actively at a hundred miles an hour back and forth and no one will be able to do anything about that passing by school and welcome back to inside Olympia joining me once again is amber leaders co-chair of the state's joint legislative and executive committee on behavioral health and I want to pick up where we left off with a question about balancing the civil rights of these individuals and patients with sort of the community imperative to get them the care that they need I know that california has been looking at and actually I think is lowering the bar making it easier to involuntarily commit people um what what is washington learning from california what's under consideration here as you think about balancing those sort of dueling needs and desires yeah that's a real it's always a real challenge when you're trying to balance those two things um we have looked at what california's doing a little bit mostly in terms of the kinds of things that they're adding to their continuum of care building out earlier diversion services uh building out you know we're doing a lot of work here on the crisis system but they're doing work there as well building out more of pack teams you know sort of community treatment teams which are those wrap around community training teams and so we've looked at that I know there have been some very recent conversations among community stakeholders about whether or not our involuntary treatment act needs a revision and whether we need to rethink that um I think that's a worthwhile conversation to have about have we hit the mark in the right way um but I also want to say that I also really believe that so much of behavioral health care can be provided without being in an involuntary system and I think the involuntary system really should be reserved for a limited number of individuals that really really it rises to that level where because involuntary treatment is a pretty significant invasion on an individual's personal rights and personal liberties and I think that should be taken very seriously and that we should be using that tool only when it's most appropriate and so part of that is is making sure all the other array of services are available so that we don't fall back on that tool um as just sort of an easy fix to to getting people to care. I think we've all read these um agonizing stories about family members with loved ones often adult children who are you know in perpetual crisis and um can't get them the help that they need feel like the law creates all of these barriers and that they essentially need to become an imminent threat to themselves or others they need to commit a crime they need to jump off a bridge before something will actually the system will actually respond and you know those examples are all real life examples that I've heard personally of what it took to get someone help but then there is the civil rights component and the fact that these are adults that we're talking about in this context so just to put a finer point on it or to go a little bit deeper when you think about ways to serve those desperate families short of amending the ITA are there any specifics yet about what you know what could it what could exist tomorrow that doesn't today or what exists today that didn't exist for some of these families a couple years ago yeah and I I've heard many of those really really heartbreaking stories too um and what I see is that many times not always but many times part of what's going on in the system is a response to the scarcity of resources available so for example designated crisis responder goes out um responds to a call and oftentimes they will have to make decisions about is there a bit available do I have some place for this individual to go or do I not and so I think it part of it is not only rethinking how we do involuntary treatment which I do think is important in a conversation we should have but I also think it's about how are we building out our workforce how do we have enough designated crisis responders how do we have enough early services so that people can get in when when that phone call comes through how are we building out our 98 system our crisis system our crisis stabilization facilities you know that's such a critical part that we need to have those locations where people when people are in crisis we have some place to take them and that's what I hear a lot of times out of these stories is that people have called numerous times and because there's no place for them to go they go deeper and deeper and deeper into their their mental health until ultimately that's where they land up is in these involuntary systems and we should do a better job on that we should have we should have be able to catch people much sooner than that the other thing you hear is the story of people cycling in and out of the hospital or out of drug treatment because they stop taking whether it's medication assisted treatment for addiction or they're psychiatric medicines which are keeping them stable and then you're feeling okay so you think you don't need them anymore and you go off of them and you cycle again and once again you get to the situation of people's rights are we going for are we going to mandate that they take this medicine are we going to have somebody standing there supervising them especially if they're not in a hospital setting what are the conversations around trying to navigate somebody once they're stable so that they don't become unstable again yeah one of the tools that we have in Washington state that it seems to be underutilized is assisted outpatient treatment so on the books under the involuntary treatment act that was added a few years ago it was yep and amended and there's been some resources dedicated to it but we're continuing to find that for whatever reason we don't have providers sort of fully implementing what is there and part of the work that the health care authority is doing and I anticipate this will be a conversation coming up in the next legislative session is what's going on there is it a challenge with the way we've outlined the statute is it a challenge with resources is it a workforce issue but to me that's one of the tools that's available to us that we're not using nearly well enough because it's an outpatient order and it does what you're talking about which is it provides some level of oversight and direction to an individual to live in the community you're not an inpatient care but you do have some requirements to take medications and do some other things medications often being one of the big requirements for assisted outpatient treatment and so I think that's an area where we really could do some more explanation exploration and figure out what's going on and why do we have this law on the books that's not not being picked up and just because I don't want to lose sight of the fact that behavioral health is a big umbrella on the access so we've been talking a lot about access to psychiatric care access to drug treatment especially because so much of it is medication assisted so much of it does have to actually be supervised and doled out by an individual you can't just send somebody home with the prescription and we know it doesn't exist in a lot of counties in this state and we're in the midst of a fentanyl deadly fentanyl crisis and this is a deadly addiction and it's incredibly hard for people to get off of fentanyl and that's why the medication is so important what's it going to take to build out a robust drug treatment system in this state concurrent to trying to also build out sufficient mental health services I mean I think in many ways it's going to look similar as you have to build out that full continuum of care that we need and some of that is you know getting more opioid treatment providers providing dollars making sure their rates are high enough so that they can actually operate their programs we also quite honestly we need more providers meaning medical professionals to be willing to provide medication assisted treatment that's one of the things that we have seen sort of from the executive branch side is that for a variety of reasons there's oftentimes a reluctance to do that within their scope of practice and we really need because of the crisis you're talking about we really need providers to step up and be willing to provide that medication assisted treatment if they are able to do so and we need to provide them the resources so that they can get that out there we're also looking at all kinds of other interventions in terms of there's long acting injectables now that provide longer-term stabilization as people are going through recovery we need to build our recovery end of the system yeah because treatment is one thing but there's a post-treatment element to this that's right and making sure that people have access to things like recovery housing and other places for them to go once they've been through treatment they're supportive often they're peer run or peer led that's really critical there's been really some some great investments in things like street medicine the build out of the health hubs which are really centralized locations where people can get not only drug treatment but also health care and other things i think there's a recognition of much like behavioral health it's a holistic response that we have to have as we're thinking about people who are using substances you've just prompted for me also a thought that you know you said earlier it's been really hard for folks to get their arms around behavioral health because it's so big but even if you manage to do that and even if this committee could sort of create a road map for success for next let's say the next decade it seems like so much of the what would predicate success is interconnected to other things for which this committee has no control and are also big intractable issues like housing so i'm just wondering is this committee capable of also starting to take in to account these other legs of the stool that may not be directly behavioral health but need to work in order for a better system of delivering behavioral health to work well so without my coach here i definitely don't want to take on the issue of housing completely but i but it's so critical and that is that a representative representative send yeah yes representative senders and so you know but it's such a critical component exactly as you describe i mean it's on that continuum for both mental health and substance use is the need for housing either permanent supportive housing or affordable housing is really critical i don't think the committee will take that on in terms of like a comprehensive review of the housing needs of the state but i also think it would be hard for us to talk about our strategic plan without talking about housing and the role that it plays in in the behavioral health system okay so we've spent a lot of time in the deep end of the pool let's go to the shallow end and let's imagine somebody starts maybe it's a young person starts to show some signs of schizophrenia and you could imagine a system that ignores that person and five years down the road they are deep in crisis and are experiencing what we've sort of just laid out but what if you could catch them earlier get them the treatment they need keep the disease from getting too acute and get them on a trajectory to to to live and manage with that schizophrenia what does a system that does that look like oh there's just add just so many different things that go into that i think it's what kinds of behavioral health services are we providing in the schools how are we supporting our schools to make sure behavioral health care is accessible not only to students but so that the teaching professionals can identify and know you know how to operate within the system what are we doing for our young adults who are graduating from high school and moving on to college or other locations how are we supporting our our youth who are sort of our young adults who are 18 to 25 what are we doing for parents and for families to provide them with different kinds of education and resources and tools so that they can work within the system i mean there's just so many different ways in which we could expand that um i want to go back to start well and i want to go back also to workforce because something you'll often hear from people is it's so hard to get into see a mental health professional it's almost impossible to get into see a psychiatrist it's often hard to if your child is having maybe an initial break it's hard to see a psychiatrist who will treat that you know that whose scope of practice includes treating a young person in crisis so all of these barriers to entry and then oh by the way is your do you have health insurance is health insurance going to cover it so it seems like we throw up all these roadblocks for families even those families that are trying to get their loved one help and i know you mentioned the teaching hospital which is supposed to help address some of these workforce issues but i mean psychiatrists alone are in such short supply and they're the ones who can prescribe they are and everything i know is that i think i think you're seeing fewer and fewer medical students going in into the psychiatry profession it's just it's um it's an area that we really have got to boost in terms of workforce i think some of that can also be you know how are we having a diverse workforce of prescribers you know there's been an increase in our armp's advanced registered nurse practitioners who can be prescribers and so i think that's one of the ways in which we can think about that i also think the integration of behavioral health into primary care which is some work that's been in progress now for a number of years is really critical to that because ideally part of what's happening is that you know those youth they're getting their first touch point from their pediatrician from their primary care doctor and that we're trying to provide some of those interventions and services earlier so that you don't necessarily have to see a specialist and that if you do need to see a specialist then we need to make sure that those individuals are available is there uh you know i think in some respects i'm just seeing a bunch of dollar signs piling up here and as we've noted the legislature has already put you know it is i think billions at this point more into this system when all is said and done and there will be a final report from this committee i don't expect you to put a dollar amount on it right now but prep us for and if there's a legislator or two watching this or listening to this what's the reality and i know there are also legislators on this committee but like what's the reality check about how much more investment is going to be needed well i think it's significant but i also think that there's been so much investment over the last several years that it's i don't think it's a duplication of what of what we've already done um and i think that's part of what the j-lec is tasked with is how do we you know how do we strategize and best invest for the next steps into the system what do those look like where do we really need to fill those gaps but i don't think anyone should expect that it's going to be um inexpensive to do so i mean but it's important it's so important for our community as we talked about earlier it just it touches on everyone in washington state and so it it's just an area that i think the investment is really critical but i don't think it'll be inexpensive yeah and in many respects the state has been digging out from a whole we dug ourselves over decades by not adequately investing and trying to get ahead of things is taking time uh so progress has been made it's none of this is going to happen overnight um and we've got a big deficit that we're sort of digging out of yes i want to um hit a few more points uh and issues in the time we have left one is um to put a finer point on nine eight eight as a new resource for those in crisis why why do you think that's such a potential game changer so uh nine eight eight um washington state has taken a really ambitious approach to nine eight eight so nine eight eight um was the national suicide hotline the federal government sort of put out that we were going to transition to this nine eight eight three digit system and washington state has not only done that but is proposing pretty big reforms in terms of how we do crisis response uh as well as providing services to those individuals who call in to nine eight eight with next day appointments and other things and so one of the things that i think is really important is that it it it anticipate to build out of our crisis system not only having the line but having the place for those individuals to go um you know there's a really a fairly small percentage of people who call in to nine eight nine eight actually need a dispatch of some time a mobile crisis response um but for those individuals that do how do we make sure that when the responders go out that there is a place for that individual to go after the response has come out there and i think what nine eight eight is doing is building out building out exactly that that system so it's i mean the concern would be you'd create a lot a number of people can call but there's no real resources on the back end but what you're saying is you think washington state is getting doing a good job of building the the response and the services that are needed for the people who might avail themselves of this new telephone number yes i think washington state is doing a very good job on that um and i think it's a it's a it's a pivot in terms of how the system is work you talk about the deep end systems you know from for a long time we mean the way to do that is to call nine one one and have a law enforcement response come out now there's been a lot of work to have co-response team social workers clinicians ride with law enforcement but i think even if you talk to law enforcement most would say for a behavioral health call there's better ways to do that either with behavioral health clinicians with fire with EMS and so i think part of what we're also building out is bringing out the right teams when a call is needed and so that you are doing more of that diversion into the treatment system rather than into the emergency room or the criminal justice system i also want to ask you about the true blood case which uh was i think a class action lawsuit but brought on behalf of people who were languishing in jail because they could not get into state hospitals for competency evaluations and then if they were not found not fit to stand trial competency restoration something i reported on extensively these very tragic stories of people just waiting and waiting and waiting so there's a lawsuit and then the judge federal judge said to the state you know here the timelines you got to meet i think it was 14 days for the eval and seven days after that if they found that competent to get into the hospital to get a bed for years the state wasn't compliant accrued huge fines but just this month it was announced that for the first time the state was at a point in time at least with those two examples the timelines for getting people services compliant so i'll let you reflect a little bit on that milestone and again it could change because it was just a moment in time but what what is the significance of getting to this point well it's a huge it is a huge milestone for the state and there's been incredible work that's been done by um our state agencies um both department of social and health services as well as health care authority uh DSHS has built out a tremendous amount of capacity over the last several years and i've heard some of the staff there really talk about you know it's been a multi vitamin approach and it's been the work of years to try and get to that place building out not only bed capacity but there's been additional investments in things like diversion resources building out outpatient competency restoration things like forensic navigators which are individuals that help navigate uh the system for people who have those behavioral health needs who are caught up in competency and so there's been all these different pieces that have come together um and it's a great it is a great accomplishment it is as you said a point in time and we need to maintain that uh going forward and one of the things we've seen over time if you look at the data and true blood um you know when the case first started in 2014 or so DSHS was getting about 3500 referrals per year they now get about 8500 referrals per year and so some of this um you know the legislature has made incredible investments to be able to respond to what's been going on in true blood but we also need to continue our work to figure out how do we bend that curve downward we still have far too many people with behavioral health needs going through the criminal justice system and i'm really happy that we can respond to those who are there that is an accomplishment that so that people aren't waiting for services but we also need to keep working towards having fewer people go through in the first place and making sure they're getting their access to care out in the community rather than coming through criminal justice at all which goes back to the diversion point you were just making is there a reason that anybody has been pointed or identified why the numbers have spiked in that fashion what's going on no as you know there's been a number of looks the court has looked at this as well uh people have sort of tried to pinpoint and you see little spikes here and there so for example with the expansion of um the ACA when you had more uh single males going on to medicate there is a little bit of a spike and the theory there is that you have more um individuals who previously weren't accessing the system at all sort of starting to access the system because they have uh access to medicate you see you don't really see a change in the number of uh prosecutions happening because that's one of the first things we looked at is it will have prosecutions gone up because that would make sense but you that really has in many ways stayed flat um and so you see um a little bit of a fluctuation during the covid years where there's a dip and then a pretty big spike as we come out of covid because some of that due to the backlogs that courts and others experienced and so the short the long answer I guess is no there's no we don't know for sure what's led to those increases but we know they happen and we know not only do we have sort of a steady increase in the number of referrals we get these blips where there's really significant increases for a short period of time and those blips those ones where we get really big increases all at once um are the hardest for the state to weather and that's one of the things we have to figure out how to predict a little bit better right because I could set you back on your compliance it what is it going to take to be fully compliant with true blood blood what's what's outstanding at this point yeah so it's um you have a couple of things in true blood so you've got the original constitutional timeline that the federal court set and that you know that we'll need to comply with at a very high level for probably some period of time um unclear how long the federal court might want to keep an eye on that keep jurisdiction of yeah yeah keep jurisdiction but but I would anticipate for some period of time we've been out of compliance for a number of years you probably will want to watch for some period of time you also have the settlement agreement that's in place which is really a settlement of the contempt that was in the in the case and that has a build out of a number of different items that's all the things we talked about the forensic navigators outpatient competency restoration some diversion services and that also has some compliance factors in it as well um that the state has to continue meeting as as we go forward um and within that agreement I don't remember the time frames off the top of my head but it does talk about the number of months that the state needs to be in compliance with the constitutional timelines in order to move away from that settlement of contempt so it is we are doing great it is a really really huge milestone but we need to keep working on it I and the skeptical side of me I remember when the lawsuit and conversation was around emergency room boarding where psychiatric patients were sitting in the hall lying in the hallways with nowhere to go and and now 15 years later I'm guessing um we that still happens and you know in some respects it seems like we never fully solve these problems or they come in cycles so whether it's true blood and forensic patients languishing in jails or patients languishing in the ER's what what can you say to to the community to families about these kind of seemingly never-ending problems of the system yeah I think one of the things I would say is that is that there is work going on it may not always feel like it because I know on an individual level that there's a lot of family still experiencing this but there has been a really significant effort the governor has really prioritized behavioral health the legislature has provided as we've talked about a number of times now really significant funding and I think there's a recognition from all involved that there's more work to be done and so I don't want any anyone out there to think that everyone's you know sort of resting on their laurels and saying well we've solved it we're good we've invested all we need to because I don't think anyone who works in the system would say that and some of this is the work that the j-lec is doing is how do we with all the investment and all the work that's going on and seeing progress but not being where we want to be how do we really get there and how do we take those steps I mean I think that's that's what is really on deck is like is how do we how do we really get there to the outcome that everybody wants us to have I just want to note that this that's other group looking focusing especially on children and services to children which is a whole other issue and challenge in this state getting kids the services they need just in the less than a minute we have left what will success look like for this committee as you do your work and reporting back in 2025 right yes reporting back in 2025 I think for me success of this committee will look like two things one that we get through the work and that we provide a comprehensive report that has buy-in from the community that people support and then that we act on it so a road map that gets implemented that bit that's that's exactly right um too often we have reports and recommendations that go and sit on the shelf somewhere and so I think real success is we got to act on it we've got to make a move with whatever we come up with okay amber leaders co-chair of the joint legislative executive committee and behavioral health also a senior advisor in the office of governor Jay Inslee thank you so much appreciate the conversation very much yeah thank you and thank you for watching inside olympia we will see you again next week you (upbeat music)