The Washington State Supreme Court ruled Thursday that warehousing mentally ill patients in hospital emergency rooms because there isn't space at certified psychiatric treatment facilities is unlawful -- leaving mental-health officials and hospitals scrambling to respond.
The controversial practice, known as "psychiatric boarding," has become more prevalent the past few years as hospitals have struggled with a shortage of resources. In extreme cases, patients are strapped to gurneys and forcibly medicated for days without further psychiatric care.
"It's always been inhumane not to provide treatment; now it's clearly illegal," said Ross Hunter, D-Medina, chair of the State House Appropriations Committee. Hunter said the state will have to respond sooner than the Legislature can act.
Health officials spent Thursday trying to grasp what the ruling means. The practice is widely opposed by mental-health experts, but it's unclear what will happen to patients when no long-term beds are available.
The practice of boarding quintupled from 2009 to 2012 in King County -- and the problem has continued to get worse. In February, more than nine of every 10 patients who were involuntarily admitted for psychiatric care experienced the practice, according to data compiled by the county's mental-health division. Harborview alone boarded more than 1,100 patients in 2013, hospital data show.
Given how common the practice is, many wonder what will become of the patients after Thursday's ruling.
"We can't just let people that are not safe out into the streets," said Darcy Jaffe, chief nurse officer at Harborview Medical Center. "As a hospital we have federal requirements for safe discharges. So we're still trying to figure out what it all means. I don't think that anybody knows what to do."
A lawyer representing mentally ill clients was among those celebrating Thursday's ruling.
"The decision is the court recognizing that when our clients are involuntarily committed, they need to be placed in a setting where they can get proper psychiatric treatment," said Mike De Felice, who supervises public defenders who represent involuntarily committed patients in King County.
The ruling already was cited in a civil-commitment case Thursday, said De Felice, and the judge ruled that the patient must be sent to a certified psychiatric-care facility, instead of back to the boarding hospital. He said public defenders will continue to use this ruling to try to get their clients into proper treatment more quickly.
But it's still unclear where the patients will go.
Jim Vollendroff, King County's top mental-health official, is working on solving that problem.
When Vollendroff came into his position earlier this year, one of his priorities was to end boarding in King County. But Vollendroff said he was surprised by the immediacy of the Supreme Court ruling.
"I think it's a challenge for the entire system when we learn one morning that something we've been practicing for many, many years is deemed unconstitutional," he said.
Vollendroff said he's working to identify all the people now being boarded in King County and trying to find alternative treatment options, which could include transferring them to a crisis center.
He's also found a facility he believes could be quickly converted into an inpatient psychiatric hospital, and is requesting funding from the governor.
Hunter said the state must open new beds at Western and Eastern State hospitals, but should also try to add less-expensive beds at community treatment facilities, which allow patients to remain closer to home with more continuity of care. Hunter said beds at state psychiatric hospitals can cost $600 a day, while the care in a community clinic might cost half as much and be eligible for Medicaid reimbursement.
He noted that the task force made up of representatives from the Department of Social and Health Services (DSHS), King County, the Governor's Office and the King County Executive's Office is working on the issue.
He said it could cost tens of millions of dollars to solve the problem.
Victoria Roberts, deputy director for DSHS, expressed concerns about what will happen to patients in need of treatment when no beds are available. As an unintended consequence of this ruling, mentally ill patients in need of care could end up on the streets, she said.
"DSHS, as always, respects the authority of the courts, but we are very concerned for the people in need and for the community," she said.
Thursday's ruling arose from a 2013 Pierce County case. Ten patients retained under the involuntary treatment act were placed in emergency rooms or acute-care facilities and did not receive psychiatric care. They sued to dismiss the county's involuntary treatment petitions, and the trial judge found the practice, known as psychiatric boarding, illegal.
Pierce County and DSHS appealed the cases.
The Supreme Court said in its ruling that patients may not be warehoused without treatment because of a lack of funds, nor can it justify the state's failure to provide the treatment necessary for recovery.
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