The story of the Central Washington Comprehensive Mental Health Triage Center
Background
In 1990 Yakima County faced a crisis. Since the beginning of the Involuntary Treatment Act (ITA) in the mid 1970’s, many of the persons needing evaluation for involuntary treatment evaluation were routinely transported to the emergency room of Yakima Valley Memorial Hospital (YVMH) where County Designated Mental Health Professionals (CDMHPs) employed by Central Washington Comprehensive Mental Health (CWCMH) would evaluate them. YVMH operated a psychiatric inpatient unit as a part of its general hospital. This unit was facing increasing challenges as a result of under funding, it also faced significant problems maintaining psychiatric coverage since the three psychiatrists taking call were older and in private practice. The hospital began moving strategically away from accepting involuntary treatment admissions and pursuing private pay patients.
This produced increasing numbers of complaints from the emergency room because ITA patients, who could not be admitted to the hospital, were spending long periods in the ER while the CDMHP attempted to arrange admission and transportation elsewhere. As a result of these complaints the hospital ultimately refused to have persons brought to the ER for ITA evaluation. Yakima County was forced to find a new location to hold individuals for evaluation and began utilizing the County jail for that purpose.
Of course that was unacceptable. The Mental Health Division quickly threatened the county with removal of its E&T certification and required a corrective action plan. The County, working with CWCMH and other community stakeholders, convened a broad community planning effort to find other options. So began the story of the Crisis Triage Center.
The Data
Here are some important facts to note about Yakima County in 1990 and 1991. The average daily census of Yakima County residents at Eastern State Hospital (ESH) was 65 individuals. Yakima County had the highest number of detentions per capita of any county in the State. A high number of persons who were intoxicated and suicidal were being detained and transported via ambulance to ESH. Frequently these individuals were sober upon arrival at ESH and were quickly returned to Yakima. ESH referred to this process as “mobile detox”.
Planning
The first step in the process was for Yakima County to hire a planner to help facilitate the process. Yakima hired a part-time, contract staff person who assisted in bringing parties to the table, pushed on organizations and individuals to make change and challenge entrenched thinking. A community planning process was begun. Included were family members, consumers, providers, the hospital, law enforcement, community physicians, and just about anyone else who wanted to be there. A well-respected community physician, unassociated with any interest group was recruited to chair the process with the facilitator doing the staff work.
We didn’t know what we needed. We didn’t know what we wanted. We didn’t even know what the possibilities were. We just gathered ideas and input. The discussion began turning toward the development of “something like a psychiatric emergency room only not at the hospital”. As the group continued to share ideas concepts took shape. We began hearing from experts from other states who had done or were thinking about doing similar things.
Finally a decision to implement a variety of different activities was formulated and submitted to the County Commissioners by the large community forum. All this took place over approximately 2 months and 4 meetings. It was important to submit these recommendations to the Commissioners because their adoption and implementation of them provided a community sanction to them and further pushed the process forward.
The major recommendations were to:
- Develop a formal written working agreement between CWCMH and YVMH. This agreement was to include hiring of psychiatrists by both YVMH and CWCMH to provide the on-call coverage
of both the psychiatric unit and the outpatient crisis/ITA system.
- Develop a sub-acute detox capacity that could hold, evaluate and refer persons with co-occurring disorder while the best course of intervention was put in place. This involved written working agreements between hospital ERs and the detox, CWCMH, the psychiatric unit at YVMH and the County.
- Yakima County established interlocking priorities for the spending of both its mental health and chemical dependency funding to insure that the most difficult to serve and high resource using population was served first.
- CWCMH was to establish a “psychiatric emergency room”-type facility in a new building it had purchased and which housed the sub-acute detox operated by another agency.
- Implement the protective custody (substance abuse detention) process allowed in RCW 70.96A using the CDMHPs in Yakima County and the sub-acute detox as the place of custody.
- An emergency services steering committee, appointed by the County Commissioners, would be established to guide the process to completion. Membership included the Vice President of CWCMH (Rick Weaver), Dr. Greg Sawyer of the YVMH Psych unit, a community psychiatrist (Dr. George Vlahakis), a consumer and the Director of Dependency Health Services (DHS), the agency operating the detox (David Mitchie). The county facilitator served as staff. Key rules for this committee were that it met regularly (every week) and that if you weren’t there the decisions would still be made and that you would be expected to implement them.
Through the work of this oversight committee the CTC was eventually born. We built this gradually with small incremental steps in programming. For example, we started with just trying one crisis bed placement on a trial basis. As staff comfort and expertise grew we added more. We also started the entire program with existing resources. We didn’t need a huge influx of new money. Instead agencies voluntarily re-directed resources to new activities. In those rare cases in which agencies could not or would not voluntarily re-direct funds, Yakima County revised contract to insure consistency of priorities with the CTC program. As time has gone on further improvements have been made to the CTC program. These changes have occurred by consciously re-directing the savings achieved by the program (e.g., reduced inpatient expenses) to the program.
The Program
It is simply not possible to describe the depth and nuances of the Triage Center in perfect detail. The most important thing to know is that the program is about a culture and attitude much more than it is about brick and mortar or policies and procedures. We could hand you our policy and procedure manual and our building and we would be pretty sure the program would not work without the leadership, community commitment, attitude and principles in place to support it. >/p>
That being said we’ll begin with the basic structure. The Triage Center, as it exists today, is entirely operated by CWCMH. After many years of a close working relationship, DHS chose to merge with CWCMH. CWCMH is dually licensed and funded by MHD (through Greater Columbia RSN) and DASA. After 14 years of operation in CWCMH’s main center building, a new triage center incorporating the learning from the original center was completed in October 2005. This facility is licensed by the Department of Health and by DASA as a sub-acute detox facility. The facility is licensed for 20 beds but only 16 beds are operated at this time. The beds in the facility are just that, beds. The beds are used flexibly for sub-acute detox, protective custody under RCW 70.96A, Becca placements for adolescents, and crisis bed placements for persons with co-occurring disorders or mental illness. The funding source for each of these bed uses varies by the utilization.
Short-stays to prevent developing bed availability backlogs; use of formalized medical screening, behavioral monitoring, and other checklists; formal written working agreements guiding behavior; forced interagency staff interaction (e.g., making CDMHPs work out of Detox at night or making psych unit staff have dinner with CDMHPs); and formal transfer agreements (e.g., between detox and ERs) are all part of the core program. Other critical pieces included common medical leadership over the CDMHP and Detox function, shared psychiatric call for both the hospital and the outpatient crisis system, and mandatory staffing between CDMHPs and on-call psychiatrists in defined situations. We made a formal effort to change the name and spirit of our crisis outreach staff. We no longer call them CDMHPs. They are now Crisis Outreach Professionals focused on crisis response and intervention. The CDMHP hat is now just a tool that can be employed rather than the whole package.
The real reason for the success of this program, however, is that CWCMH, DHS, YVMH and others laid the cornerstone of the Crisis Triage Center by agreeing to say YES to each other. As noted above, as other communities have coveted the effectiveness of our collaboration, their questions normally revolve around procedures and policies; however, the real source of our effectiveness is rooted in an intellectual decision to trust each other.
Other facts you might wish to know about the Crisis Triage Center include:
- The facility is not locked. The facility relies on the relationship between staff and clients to retain clients in the program.
- Our focus remains on responding to clients and referral sources in the community. We over 80% of our crisis interventions occur in the community and at the location where the call came from. Even those individuals who ultimately come to the CTC are most often first seen in the community.
- The facility does not operate in a drop-off or walk-up mode. Police, families, consumers, etc. come to the facility only at the request of the Crisis Outreach Professional.
- The program relies on highly skilled paraprofessional mental health aides to support the crisis outreach work of the Crisis Outreach professionals. These aides assist with language and cultural competence (they are bilingual/bicultural staff). In addition these aides provide support for arranging and linking services, coordination with families, and safety back-up.
- There is an active and mandatory interchange between the on-call psychiatrist and the Crisis Outreach Professional. This improves medical support, facilitates hospital admission when necessary, improves the linkage to the local psychiatric unit and provides opportunities to divert from the hospital.
- The Triage Center now serves the entire three county region served by CWCMH (Kittitas, Yakima and Klickitat Counties).
- Triage Center staff regularly provide tours, training and consultation to other communities working to improve their crisis systems. This training occurs both at the Triage Center and in other local communities.
- The Crisis Triage Center won the National Council for Community Behavioral Healthcare Award of Excellence for Crisis Services in 1998.
The Data Now
The average daily census at ESH for all three counties served by the Triage Center is 12. This represents a reduction of 84% in state hospital utilization.
For More Information
Rick Weaver
Central Washington Comprehensive Mental Health
PO Box 959
Yakima, WA 98907
509.575.4024 phone
509.575.4811 fax
