Department of Human Services A G E N D A

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1 Department of Human Services Doug Washburn Director Aging & Long Term Care / Senior Information & Assistance (Sr. I&A) Givens Community Center 1026 Sidney Avenue, Suite Division Street, MS-5 Port Orchard, WA Fax: (Sr. I&A) Stacey Smith, Administrator Phone: Community Development Block Grant Norm Dicks Government Center th Street, Suite 400 Bremerton, WA Bonnie Tufts, Manager Phone: Developmental Disabilities 614 Division Street, MS-23 Port Orchard, WA Fax: Kelly Oneal, Coordinator Phone: Kitsap Recovery Center 1975 NE Fuson Road Bremerton, WA Fax: Bergen Starke, Clinical Manager Phone: Mental Health 614 Division Street, MS-23 Port Orchard, WA Fax: Anders Edgerton, Administrator Phone: Mental Health/Chemical Dependency/Therapeutic Court 614 Division Street, MS-23 Port Orchard, WA Fax: Gay Neal, Coordinator Phone: Substance Abuse Prevention and Treatment 614 Division Street, MS-23 Port Orchard, WA Fax: Laura Hyde, Treatment Coordinator Phone: Vacant, Prevention Specialist Phone: Veterans Assistance 1300 Sylvan Way Bremerton, WA Fax: Tom Vialpando, Coordinator Phone: Workforce Development 1300 Sylvan Way Bremerton, WA Fax: Bob Potter, Director, OWDA Phone: Youth Services 614 Division Street, MS-23 Port Orchard, WA Fax: Laura Hyde, Coordinator Phone: Citizens Advisory Committee Meeting Tuesday, January 20, :30 p.m. 6:30 p.m. Kitsap WorkSource Center, Kitsap Room 1300 Sylvan Way, Bremerton A G E N D A 1. Call to Order - Introductions 4:30 4:35 Russell Hartman 2. Review and Approval of December 16, :35 4:40 Minutes* Full Committee (Attachment 1) 3. Review 2015 Meeting Calendar 4:40 4:50 Full Committee (Attachment 2) Request for Proposal* 4:50 5:20 RFP Committee 5. Crisis Triage Report 5:20 5:40 Staff (Attachment 3) 6. Recommendation for Strategic Planning Team 5:40 6:00 Full Committee (Attachment 4) 7. Contractors Meeting 6:00 6:10 Staff 8. Committee Member Check-in 6:10 6:20 Russell Hartman 9. Community Input 6:20 6: Adjourn * Action Item 507 Austin Street 614 Division Street, MS-23 Port Orchard, Washington Main Line FAX From: Olalla Bainbridge Island

2 Attachment 1 MENTAL HEALTH, CHEMICAL DEPENDENCY AND THERAPEUTIC COURT CITIZENS ADVISORY COMMITTEE (CAC) MINUTES DECEMBER 16, 2014 Russell Hartman, Chair, called the meeting to order at 4:35 p.m. APPROVAL OF MINUTES After review of the November 18, 2014 Minutes, the following action was taken: ACTION: Lois Hoell moved to approve the November 18, 2014 meeting minutes as presented. Jeannie Screws seconded the motion. Motion carried unanimously. COLLECTIVE IMPACT PROCESS DISCUSSION After a review on the Collective Impact Process, Russell Hartman asked members if there is interest in using the Collective Impact Process to conduct the strategic planning process. The following are comments that came from that discussion: The Collective Impact Process has been used during the initial strategic planning process (without it being called Collective Impact). The Collective Impact Process is a process which urges the group to move in the same direction. It could help the group choose which gaps to fill and focus funding on those gaps. How do we show we are making an impact in the community? Will need to narrow the focus to measure this. Collective Impact would bring a common set of metrics. With Continuum of Care, there could be multiple Collective Impact Processes going at the same time. Collective Impact appears to be a better process than traditional planning methods; why wouldn t we want to try it? Implementing the Collective Impact Process will take a lot of work. Need to come up with a common agenda. The key element would be to move the CAC and stakeholders in the same direction. Need to define success. REQUEST FOR PROPOSAL DISCUSSION After an update on the status of the 2015 Request for Proposal, Russell Hartman asked members for comments. The following comments came from that discussion: 1

3 It was suggested that the budget forms be consistent with the Consolidated Block Grant Application. It was noted that sustainability was weighted higher in the Continuation Grant Scoring than the Initial Grant Scoring. There is an internal struggle with having the grant applications either be seed funding for new or expanded programs verses operational funding for long-term commitments of the 1/10 th of 1% tax funds. Maintaining flexibility in decision making is important. If tax dollars are set aside for seed money, it needs to be made clear in the application process. Funds from the Affordable Care Act are a resource the CAC wants to tap into as much as possible. Funding from the 1/10 th of 1% Tax has been designed to fill gaps in the mental health/chemical dependency/therapeutic court systems. These are gaps because there isn t any other funding that will cover the services. There is not enough money to fill all the gaps, therefore, it is important to develop priorities. It is important to have a matrix of gaps in services. This is part of the original needs assessment. May need to do a funding gap analysis. The Resolution as written does not conceptualize the funding as seed funding. Gaps will shift over time as the available state and federal funding shifts. The 2015 RFP will be on the January 20, 2015 CAC meeting agenda for approval and then will be released to the public. STRATEGIC PLANNING TEAM (STP) MEMBER CHECK-IN The following comments were made after the discussions as stated above: Jail services are improving with New Start however, misdemeanors are excluded who also need services. Housing issues need to be addressed. Local competency process is still a missing link. Need to provide local competency evaluation process. The CAC has done a commendable job in the first year of the process. Funding stability is important for programs and service providers. The gap analysis and needs assessment should be studied and updated regularly so we know what the local needs are year to year. Multi-year funding for projects that are providing a need in filling in an identified gap. Need to keep some focus on prevention. Look at programs that have made a difference. Multi-year grants are important to measure long-term success. Impressed with the RFP Review process. 2

4 OPEN TO PUBLIC Opportunity for public attendees to address the Committee. NEXT MEETING The next Citizens Advisory Committee meeting will be held on Tuesday, January 20, 2015 at the Kitsap WorkSource Center (Kitsap Room), starting at 4:30 p.m. and ending at 6:30 p.m. ADJOURN There being no further business to come before the Committee, the meeting was adjourned at 6:30 p.m. CITIZENS ADVISORY COMMITTEE ATTENDANCE MEMBERS Richard Daniels Aimee DeVaughn Russell Hartman Lois Hoell Bill Mosiman Carl Olson Robert Parker Jim Pond Jeannie Screws Dave Shurick (Excused) Connie Wurm (Excused) GUESTS Kathleen Cronin, NAMI Kaydon DeClerk Trevor DeClerk Collin DeClerk STRATEGIC PLANNING TEAM Patricia Bronson Judge James Docter Larry Eyer Robin O Grady Joe Roszak Kristin Schutte Susan Turner Che Che Murphy Gay Neal Doug Washburn STAFF 3

5 Attachment 2 Mental Health, Chemical Dependency and Therapeutic Drug Court Citizens Advisory Committee 2015 CALENDAR All meetings will be held on the third Tuesday of each month at the Kitsap WorkSource Center, Kitsap Room, 1300 Sylvan Way, Bremerton, from 4:30 p.m. to 6:30 p.m. Tuesday, January 20 Tuesday, February 17 Tuesday, March 17 Tuesday, April 21 Tuesday, May 19 Tuesday, June 16 Tuesday, July 21 Tuesday, August 18 Tuesday, September 15 Tuesday, October 20 Tuesday, November 17 Tuesday, December 15

6 Report to the Kitsap County Board of Commissioners Crisis Triage Center Recommendations December 2014

7 Report to the Kitsap County Board of Commissioners Crisis Triage Center Recommendations December 2014 TABLE OF CONTENTS I. Background. 3 II. Strategic Plan Recommendations for Crisis Intervention and Triage 5 III. Current Delivery System for Persons in Crisis.. 8 IV. Crisis Facilities Licensing Options V. Overview of the Funding and Service Delivery Models 12 VI. Kitsap Mental Health Services Proposal for Crisis Triage Services.. 16 VII. Recommendations for Alternative Building Site VIII. Potential Alternative Operational Funding Options and Challenges 19 IX. ATTACHMENTS: ATTACHMENT A Community Survey Results ATTACHMENT B Crisis Triage Facility Licensing Options 23 ATTACHMENT C Survey of Washington State Crisis Stabilization and Triage Facilities ATTACHMENT D Crisis Triage Annual Budget (in development) 27 ATTACHMENT E Department of Health Plan Review 29 Report Prepared by Kitsap County Department of Human Services Contact: Gay Neal, M.S.W, phone or gneal@co.kitsap.wa.us

8 I. Background In 2005, Washington State approved legislation allowing counties to raise their local sales tax by one-tenth of one percent to augment state funding of mental health and chemical dependency programs and services (including but not limited to, treatment services, case management, and housing that are a component of a coordinated chemical dependency or mental health treatment program or service) and for the operation or delivery of therapeutic court programs or services - one penny for every $10 of purchases or $10 for every $10,000 of purchases. Programs are required to be new or expanded. In September 2013, the Kitsap County Board of Commissioners passed a resolution authoring a sales and use tax for Mental Health, Chemical Dependency and Therapeutic Court Programs. The goal of this tax is to prevent and reduce the impacts of disabling chemical dependency and mental illness by creating and investing in effective, data driven programs for a continuum of recovery-oriented systems of care. Measurable outcomes will: Improve the health status and wellbeing of Kitsap County residents. Reduce the incident and severity of chemical dependency and/or mental health disorders in adults and youth. Reduce the number of chemically dependent and mentally ill youth and adults from initial or further criminal justice system involvement. Reduce the number of people in Kitsap County who recycle through our criminal justice systems, including jails and prisons. Reduce the number of people in Kitsap County who use costly interventions including hospitals, emergency rooms, and crisis services. Increase the number of stable housing options for chemically dependent and mentally ill residents of Kitsap County. In February 2013, the Kitsap County Human Services Department requested proposals for mental health and chemical dependency programs and services and for the operation or delivery of therapeutic court programs or services. Approximately $3 million was awarded for services along a continuum of care including prevention, intervention, treatment and recovery support services and addressed the recommendations for funding improvements to the County wide infrastructure for behavioral health treatment programs and services identified in the Kitsap County Behavioral Health Strategic Plan. Kitsap Mental Health Services submitted a proposal for the development of a Crisis Triage Center. In their proposal, services are designed for adults in crisis in the community who might otherwise be arrested for minor crimes and might be at risk for incarceration, are in crisis but do not meet involuntary commitment criteria, or are more appropriately treated in a short term 24/7 crisis triage facility rather than the Emergency Department. The proposal included three phases in development process. Phase I: Planning and Operations Development: The planning and development of a 24/7 facility for a voluntary triage center that can assess medical, chemical dependency and mental health status and provide stabilization for persons meeting services criteria. Phase I s initial focus is to work with the Department of Health (DOH) to secure Residential Treatment Center licensing, including 1) certificate for crisis triage service provision - a lengthy, extensive process; 2) physical design of facility,

9 facilitating bid process, securing construction project manager and contractor/s, participating in and monitoring construction process, and 3) simultaneously developing a clinical program operating a recovery-oriented BH milieu for assessment, treatment, and rapid referral for needed services. Phase II: Developing Facility for Services: Facility Specifications: 16 bed capacity, 7,000 square feet ideal; locking doors & security measures; meets DOH RTF license requirements, ADA Compliant; welcome area for assessment/ triage, intake/interview capacity; 2 interview rooms with security features; 3 offices (1 large); 2 calming rooms; medical exam room, locking medical supply closet, dispensary; secure records room. Male/female sleeping rooms with single privacy cubicles/beds; Cameras for line of site monitoring; Men/women's bathroom with showers, ADA bath; staff bathroom, keyed staff entry; Living Room; Food storage, preparation area, eating area; large secure storage for client belongings, storage for extra clothing; storage for earthquake supplies; laundry area; stocked clothes closet. TOTAL COST YEAR 1 for Phase I and II: Develop Project/Facility Site 1: Kitsap County Work Release, 701 Tyler, Port Orchard - $693,059 or Site 2: 2625 Wheaton Way, Bremerton - $910,608 Phase Ill: Triage & Stabilization Services: Service delivery is designed and Crisis Triage Center oversight provided by Program Director; assigned staff perform functions as described in the staffing model by professional capacity, using a multi-disciplinary team model. TOTAL COST YEAR 2: Operational Funding Site 1: Kitsap County Work Release, 701 Tyler, Port Orchard - $2,651,332 with requested funding of $2,410,302 or Site 2: 2625 Wheaton Way, Bremerton - $2,813,031 with requested funding of $2,557,301 After reviewing Kitsap Mental Health Services Proposal, the Citizens Advisory Committee requested Human Services Department Staff to work with the Proposing Agency, Stakeholders, State and Local Partners to identify and develop alternative funding opportunities for the on-going support of this facility. In addition, the Citizens Advisory Committee recommended that Year 1 request for $693,059 should be held in reserve pending the identification of viable and sustainable alternative funding sources by December 31, In this report, the Human Services Department shares their findings and make recommendations back to the Citizens Advisory Committee and Board of County Commissioners and includes: 1. An overview of the funding and service delivery models of other Crisis Triage facilities in King, Snohomish, Benton/Franklin and Yakima Counties. 2. Alternative funding sources for the on-going support of the facility. 3. A budget that details the sustainability of funding sources to support the facility. 4. Recommendations for alternative service models that are sustainable and costs/funding sources associated with each of the alternatives.

10 II. Strategic Plan Recommendations for Crisis Intervention and Triage The Behavioral Health Strategic Planning Team was established and approved by the Kitsap County Board of Commissioners in August Made up of subject matter experts, this team was responsible to research existing local data for behavioral health service needs, existing capacities, gaps in service, and community readiness to address the needs and gaps. Kitsap County established the following continuum of care to address the behavioral health needs of the County. Behavioral Health Prevention, Early Intervention and Training Crisis Intervention/Triage Services Outpatient Care Psychiatry, Medical and Medication Management, Counseling Services Medical and Sub-Acute Detoxification Services Acute Inpatient Care Services Recovery Support Services Crisis Intervention and Triage Services are defined as services provided on a very short term basis to intoxicated or incapacitated individuals on the streets or in other public places and may include general assessment of the patient's condition, an interview for diagnostic or therapeutic purposes, and transportation home or to an approved treatment facility. Mobile or other outreach staff at a variety of community sites to identify hard to reach individuals who are abusing alcohol and other drugs, or have a mental illness for the purpose of facilitating their enrollment into treatment, to include motivational counseling, behavioral health information and education, referral to assessment, referral to treatment, and linkage with support services. Key informant interviews were conducted with members of the Strategic Planning Team and subject matter experts in the community to identify gaps in service along the above defined continuum of care. A system map was completed with the assistance of the Strategic Planning Team and catalogs an extensive range of services along the continuum that are currently in place. It also identifies local gaps in service. This information, along with a review of local data has been used to establish the following recommendations for Crisis Intervention and Triage Services within Kitsap County. Develop County wide protocols for first responders responding to a call where mental illness or substance use may be a factor. Conduct crisis intervention training for all first responders Countywide to respond to calls where mental illness or substance use may be a factor. Establish a Mobile Crisis Team and infrastructure to handle attempts by law enforcement or mental health outreach teams to preempt entry into legal system, jail or the hospital. Develop, enhance or expand an adult diversion programs for low level offenders with mental illness or substance abuse disorders. Establish specialized homeless outreach services, including specialized outreach to Veterans with mental health or substance abuse issues.

11 Establish specialized geriatric outreach team to assist providers working with the aging population. Provide behavioral health screening, brief intervention, and referral for treatment for youth, adults and older adults in primary care. Provide crisis triage/respite and/or drop-off center alternative for individuals with behavioral health needs not eligible for acute hospital or evaluation and treatment services but are in need of short term 24 hour services, including assessment and referral. Expand capacity for 24 hour crisis response for youth through law enforcement training, mobile crisis team, emergency housing and crisis triage. Expand youth Involuntary Treatment Act/Crisis Response services, including crisis residential center. Provide advance beds for dementia patients who are not currently accepted by Western State Hospital, Kitsap Mental Health Services or other providers. Between 2003 and 2014, Kitsap County providers have three times commissioned experts to assess need for a crisis triage 24/7 short stay stabilization facility for adults with acute Behavioral Health illnesses. Each assessment revealed pressing need for at least a 12 bed crisis triage facility, but inadequate funding for facility and operations. While the community partners are unanimous as to the need for Crisis Triage services in Kitsap County, at this time the partners simply do not have the resources to fully implement the needed program. The need is so acute, however, that the partners have nonetheless proceeded with an interim, truncated Crisis Triage program. This interim model is far from optimal, and because of its limited size it will not obviate the adverse impacts on the quality of life in Kitsap County. Because the Partners have demonstrated that Crisis Triage services provide an alternative to incarceration and emergency room use for residents, and reduce overall public costs, they remain committed to continuing to identify innovative options for funding the service and for ensuring that the program operate for a timeframe sufficient for analysis of the quantifiable, societal benefits. Kitsap County Interim, Truncated Mental Health and Substance Abuse Crisis Triage Program: Opened in March, 2003 Funding partnership between Kitsap Recovery Center, Kitsap Mental Health Services and Harrison Medical Center 3 beds plus a quiet room Not a self-contained program, but housed within existing Kitsap Recovery Center space Expected average patient stay will be 24 hours Only one dedicated staff person (evening shift). Will share staff during other shifts. Receive all non-medical crisis cases, if client is willing Clients will have alcohol/drug intoxication and/or be in crisis resulting from mental illness Provides a new first point of referral for law enforcement Need for a county-wide 24/7 crisis triage alternative is again identified in the 2013 Needs Assessments and a recent review of local law enforcement, hospital, and mental health data is consistent with past recommendations. Kitsap Mental Health Services proposal represents

12 a major collaborative, cross-system commitment to effectively address and meet four policy goals as set forth in the 2014 Kitsap Behavioral Health Strategic Plan: 1. Reduce the incidence and severity of chemical dependency and/or mental health disorders in adults. 2. Reduce the number of chemically dependent and mentally ill adults from initial or further criminal justice system involvement. 3. Reduce the number of people in Kitsap County who recycle through our criminal justice systems, including jails and prisons. 4. Reduce the number of people in Kitsap County who use costly interventions including hospitals, emergency rooms, and crisis services. The proposal also addresses Key Recommendations & Local Gaps in Services identified by community "survey monkey" results as a top priority to fund: 1. For Adults with Mental Illness, Gap #2, Crisis Intervention/Triage Services "Provide Crisis Triage/Respite and/or Drop Off Center alternative for individuals with Behavioral Health (MH/SA) needs not eligible for acute hospital or Evaluation and Treatment Services (inpatient psychiatric hospitalization) but are in need of short term 24 hour services, including assessment and referral. 2. For Individuals with Mental Illness and Substance Use Disorders in the Adult Criminal Justice System: Gap #2 Crisis Intervention/Triage Services After review of fifteen (15) proposals for mental health and chemical dependency programs and services and for the operation or delivery of therapeutic court programs or services, Kitsap Mental Health Services proposal for a Crisis Triage Center received the highest score and was assessed to meet the highest community need identified in the Strategic Plan.

13 III. Current Delivery System for Persons in Crisis Currently, persons in need of behavioral health crisis services in Kitsap County access the system in one of three ways: via contact with law enforcement, through the emergency department of Harrison Memorial Hospital, the sole non-military hospital in the County or through the existing Kitsap Mental Health Services or Kitsap Recovery Center s Detoxification program. Individually, none of these existing providers has the capability, resources or expertise to fully address the need. Harrison Medical Center is the region's busiest medical center. The not-for-profit organization cares for patients from Kitsap, North Mason, Clallam, and Jefferson counties with locations in Bremerton, Silverdale, Port Orchard, Belfair, Poulsbo, and Forks. Harrison Bremerton serves as the medical center's acute-care center and home to cardiovascular services, including open-heart surgery; oncology; critical care; inpatient and outpatient surgery, orthopedics, rehabilitation, a sleep center, and 24/7 emergency care. Programs in place to provide crisis services for adults with chemical dependency and mental illness include: 1. Harrison's Emergency Department - Bremerton's Emergency Department is a Level III trauma center staffed with physicians and registered nurses certified in emergency medicine and advanced cardiac life support. Emergency Department utilizers requiring mental health or chemical dependency intervention require mental health evaluations and or detox patients requiring medical evaluation and monitoring. In 2013 about 3,000 people with mental health issues ended up in Harrison s Emergency Room, for lack of other options. Kitsap Mental Health Services is a private, not-for-profit community mental health center that provides both mental health and behavioral health care services to children, families, adults and seniors in Kitsap County. Through comprehensive inpatient and outpatient programs, individualized and tailored care is provided to individuals affected by mental illness. Services are designed to help consumers function as independently as possible. This includes linking consumers with natural supports in the community. Programs in place to provide crisis services for adults with mental illness include: 1. Adult Inpatient Unit (AIU) The Adult Inpatient Unit provides 15 residential evaluation and treatment beds for services to involuntarily detained adults suffering acute psychiatric symptoms. Individuals 18 years of age or older who have been involuntarily detained within the Peninsula Regional Support Network receive evaluation and treatment designed to resolve acute psychiatric episodes and return them to the community and individualized outpatient services. Voluntary inpatient treatment is offered on a space-available basis. 2. Residential Services (RS) Residential Services located at Keller House is a 16-bed unit. Along with providing 5 long-term residential beds, RS provides short-term transitional and stabilization services to individuals who suffer from severe impairment in psychosocial functioning and in need of 24-hour support and supervision. Strategic interventions will be designed and implemented for skill building in areas of identified deficits, (e.g. daily living skills, medication management, decision-making, etc.) which are barriers to independent living.

14 Kitsap Recovery Center (KRC), located in East Bremerton next door to the Kitsap Mental Health campus, provides both inpatient and outpatient substance abuse treatment services. They are state-approved and utilize the American Society of Addiction Medicine (ASAM) treatment criteria. The facility houses 42 inpatient treatment beds, 8 sub acute detoxification beds, and 4 triage beds. Programs in place to provide crisis services for adults with chemical dependency include: 1. Sub Acute Detoxification KRC provides 8 detoxification beds. Services are provided to individuals to assist in the process of withdrawal from psychoactive substance in a safe and effective manner. Sub-Acute is nonmedical detoxification or patient selfadministration of withdrawal medications ordered by a physician, provided in a homelike environment. Kitsap Recovery Center programs in place to provide crisis services for adults with chemical dependency and mental illness include: 1. Crisis Triage Program KRC provides 4 crisis triage beds and contracts with Kitsap Mental Health to provide a full-time co-occurring disorder specialist to work side by side with the chemical dependency professionals to provide multi-discipline care. This specialist provides mental health services to KRC patients, as well as consultation to staff regarding mental health issues of referred patients. Services include face to face contact with patients, screening, evaluations and care plans.

15 IV. Crisis Facilities Licensing Options The Crisis Triage Facility will need to be licensed by the Department of Health as a Residential Treatment Facility. The Division of Behavioral Health and Recovery certifies treatment programs, and regulates treatment agencies providing services for chemical dependency, community mental health (voluntary and involuntary commitment services), and problem and pathological gambling. There are three licensing options for programs providing short term crisis stabilization services for individuals experiencing an acute crisis without the use of long-term hospitalization including: Crisis stabilization unit; Triage voluntary placement facility; and Triage involuntary placement facility. "Crisis Stabilization Unit" means a short-term facility or a portion of a facility licensed by the department of health and certified by the department of social and health services under RCW , such as an evaluation and treatment facility or a hospital, which has been designed to assess, diagnose, and treat individuals experiencing an acute crisis without the use of long-term hospitalization. The standards for certification or licensure of crisis stabilization units shall include standards that: Permit location of the units at a jail facility if the unit is physically separate from the general population of the jail; Require administration of the unit by mental health professionals who direct the stabilization and rehabilitation efforts; and Provide an environment affording security appropriate with the alleged criminal behavior and necessary to protect the public safety. "Triage facility" means a short-term facility or a portion of a facility licensed by the department of health and certified by the department of social and health services under RCW , which is designed as a facility to assess and stabilize an individual or determine the need for involuntary commitment of an individual, and must meet department of health residential treatment facility standards. A triage facility may be structured as a voluntary or involuntary placement facility; "Triage voluntary placement facility" is a triage facility wherein the individual may elect to leave the facility of their own accord, at anytime. A triage voluntary placement facility may only accept voluntary admissions. "Triage involuntary placement facility" is a triage facility that has elected to operate as an involuntary facility and may, at the direction of a peace officer, hold an individual for up to twelve hours. A peace officer or designated mental health professional may take or cause the person to be taken into custody and immediately delivered to the triage facility. The facility may ask for an involuntarily admitted individual to be assessed by a mental health professional for potential for voluntary admission. The individual has to agree in writing to the conditions of the voluntary admission. Only involuntary triage facilities may accept clients who are brought to the facility by police involuntarily.

16 An involuntary triage facility: Is licensed by DOH and DSHS Can take individuals brought in by law enforcement involuntarily Serves people age 18 and older Can be located in another facility if physically separate (locked doors, not foot traffic between, etc.) Must have a memorandum of understanding with local law enforcement regarding what types of individuals it will accept Is secure, including all doors and windows are locked and ongoing visual and/or video monitoring An individual taken to an involuntary triage facility will be: Assessed by a mental health professional within 3 hours Given a medical screening by a qualified health care provider Seen by a DMHP within 12 hours if involuntary Individuals at involuntary triage facilities: Can be subjected to seclusion (locked room) or restraint with a doctor s order Can be forced to take anti-psychotic medication with orders from two doctors.

17 V. Overview of the Funding and Service Delivery Models Kitsap County Human Service and Kitsap Mental Health Staff together toured the following Crisis facilities and developed a summary grid of service delivery models. See Attachment C. King County Downtown Emergency Service Center (DEC) (1600 South Lane Street, Seattle WA ) Department of Health Licensure: Residential Treatment Facility Division of Behavioral Health and Recovery Certification: Crisis Stabilization Unit Number of Beds: 16 Voluntary or Involuntary: Voluntary Average Length of Stay: 2 Days Attached Support Services: 32 Crisis Stabilization/Residential Treatment Center Funding Source: Mental Health, Chemical Dependency and Therapeutic Court Tax The Crisis Solutions Center (CSC) provides King County first responders with alternative options to jail and hospital settings when engaging with individuals, age 18 and older, in behavioral health crisis. The CSC has three program components; Mobile Crisis Team, Crisis Diversion Facility, and Crisis Diversion Interim Services; intended to stabilize and support an individual in the least restrictive setting possible, while identifying and directly linking that individual to ongoing services in the community. These services were developed as a pre-booking or pre-hospitalization diversion program. The goal of these programs is to reduce the cycling of individuals with mental health or substance use disorders through the criminal and crisis systems. Individuals in behavioral health crisis are not always best served in jail and hospital settings. This facility allows for individuals to receive services to both stabilize crises in the moment and to address the situations that cause or exacerbate crises. By focusing on an individual s immediate needs, and through facilitating engagement in services and supports in the community the CDF may be able to reduce need for law enforcement involvement. A team of mental health and chemical dependency professionals help stabilize the current crisis in a voluntary inpatient setting. They also immediately work to refer participants to long-term assistance and housing, tailored to each person s needs. Clients will stay in this program for up to 72 hours, and receive stabilization, evaluation and psychiatric services, mental health and chemical dependency assessments and intensive case management. 1. The Crisis Diversion Interim Services (CDIS) is a 30-bed "step down" program which admits clients referred directly from the CDF who are homeless, or at risk for homelessness. Clients may stay up to 14 days and will have access to psychiatric services, mental health and chemical dependency assessments and intensive case management. 2. The Mobile Crisis Team (MCT) is a 15-member team of Mental Health Professionals and Chemical Dependency Professionals. The MCT accepts referrals from police and medics for any individual who are experiencing crisis.

18 Snohomish County Crisis Triage and Stabilization (3322 Broadway, Everett, WA ) Department of Health Licensure: Residential Treatment Facility Division of Behavioral Health and Recovery Certification: Currently working on Crisis Triage Certification Number of Beds: 16 Voluntary or Involuntary: Voluntary Average Length of Stay: 3 Days Attached Support Services: Comprehensive Mental Health Center and Evaluation and Treatment Center Funding Source: Mental Health, Chemical Dependency and Therapeutic Court Tax; ESSB 5480 funding from their Regional Support Network for the development of intensive community programs that allow individuals to be diverted or transitioned from the state hospitals. Compass Health provides two Crisis Triage facilities ~ one located at the Bailey Center in Everett, WA and one in Bellingham. Compass Health is a private, non-profit, state licensed organization providing mental health and chemical dependency services. The program utilizes a recovery model to assist those in behavioral health crisis to access services and supports and resume typical levels of functioning. They have a multi-disciplinary team to address their needs, including Peer Counselors, Mental Health Technicians, Clinicians and Nursing staff. At the Everett facility they can accommodate 16 individuals and the Bellingham facility can accommodates 5 individuals that are recovering from a mental health crisis or who need nonmedical sobering support. This program is capable of receiving referrals directly from law enforcement in an attempt to divert those in behavioral health crisis from local Emergency Departments and Jails. Lengths of stay can vary dramatically from hours to several days and is dependent on the details of any given crisis episode. Contact Lourdes Counseling Center Transitions (1175 Carondelet Drive, Richland, WA Department of Health Licensure: Residential Treatment Facility Division of Behavioral Health and Recovery Certification: Crisis Triage Number of Beds: 16 Voluntary or Involuntary: Voluntary and Involuntary Average Length of Stay: 3 days Attached Support Services: Lourdes Health Network (Medical Center) and Evaluation and Treatment Center Funding Source: ESSB 5480 funding from their Regional Support Network for the development of intensive community programs that allow individuals to be diverted or transitioned from the state hospitals; Regional Support Network per diem of $550 per day after ESSB 5480 funds exhausted. Lourdes Health Network consists of several facilities throughout the Mid-Columbia area. With Lourdes Medical Center serving acute hospital needs, Lourdes Counseling Center cares for those with mental health needs. Lourdes Counseling Center, the mental health division of

19 Lourdes Health Network, offers a full continuum of mental health services. Counseling services are available for adults, adolescents, and children. Chemical dependency services are available for adults dealing with mental illness. Family and group counseling is provided in addition to individual counseling. As well as counseling, other outpatient services are available such as medication management and community support. The 20-bed inpatient hospital at Lourdes Counseling Center serves adults aged 18 and over in times of need. On the same campus as Lourdes Health Network, Lourdes Counseling Center's Transitions provides a crisis triage program that utilizes a recovery and evidence-based model to assist those in behavioral health crisis to access services and supports and resume typical levels of functioning. They have a multi-disciplinary team to address their needs, including Peer Counselors, Mental Health Technicians, Clinicians and Nursing staff. The program can accommodate 16 individuals that are recovering from a mental health crisis or who need nonmedical sobering support. Transitions does allow referrals directly from law enforcement in an attempt to divert those in behavioral health crisis from local Emergency Departments and Jails. Lengths of stay can vary dramatically from hours to several days and is dependent on the details of any given crisis episode. Yakima Comprehensive Mental Health - Crisis Triage Center (505 S 4th Avenue, Yakima, WA ) Department of Health Licensure: Grandfathered Residential Treatment Facility Division of Behavioral Health and Recovery Certification: Crisis Triage Number of Beds: 16 Voluntary or Involuntary: Voluntary Average Length of Stay: 3 days Detox and 5 7 days stabilization Attached Support Services: Comprehensive Mental Health Center and Evaluation and Treatment Center Funding Source: Regional Support Network Crisis State only, Regional Support Network Medicaid and County funded Detox through Division of Behavioral Health and Recovery The Triage Center entirely operated by Central Washington Comprehensive Mental Health (CWCMH). CWCMH is dually licensed and funded by through Greater Columbia Regional Support Network and the Division of Behavioral Health and Recovery (DBHR) through Yakima Human Services Department. This facility is licensed by the Department of Health and by DBHR 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 Designated Mental Health Professionals (DMHPs) work out of Detox at night or making psych unit staff have dinner with DMHPs); 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 DMHP and Detox function, shared psychiatric call for both the hospital and the outpatient crisis system,

20 and mandatory staffing between DMHPs and on-call psychiatrists in defined situations. They have made a formal effort to change the name and spirit of our crisis outreach staff. They no longer call them DMHPs. They are now Crisis Outreach Professionals focused on crisis response and intervention. The DMHP hat is now just a tool that can be employed rather than the whole package. The facility is not locked. The facility relies on the relationship between staff and clients to retain clients in the program. Their focus remains on responding to clients and referral sources in the community. Over 80% of the 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. Recommendations from Local Law Enforcement Agencies regarding the above Crisis Triage Centers: We requested that Kitsap County s local Law Enforcement agencies reach out to their Law Enforcement colleagues from agencies in the above jurisdictions and make recommendations on moving forward with a Crisis Triage Center. Here are the recommendations we received: Form a steering committee, and include law enforcement (particularly the Local Enforcement agency where the Triage Center will be located). Keep line officer informed as plan develops to establish local buy-in. The center is designed to benefit people experiencing a mental health crisis in Kitsap County and as one of the first points of contact for individuals in crisis, law enforcement admits must be given priority. Identify a law enforcement liaison early and have that liaison work closely with facility staff and line officers. Provide frequent presentations to officers via video or in-person training. Agency heads need to buy-in and support concept and encourage his/her officers to use the Triage Center. Involve head of County Emergency Management Services. Have Director allow private ambulance to transport to Triage Center instead of law enforcement transports only. This is still a problem for some Counties.

21 VI. Kitsap Mental Health Services Proposal for Crisis Triage Services Development and implementation of a Kitsap Crisis Triage and Stabilization facility will provide 16 individuals with 24/7 care, for up to 5 days. Based on research at other such facilities, past Kitsap needs assessments and local data, this proposal assumes that at an 80% occupancy rate, with 20% repeat visits, and an average stay of 48 hours, the Crisis Triage Center will serve 2,336 persons annually. Services are designed for adults in crisis in the community who might otherwise be arrested for minor crimes and might be at risk for incarceration, are in crisis but do not meet involuntary commitment criteria, or are more appropriately treated in a short term 24/7 crisis triage facility rather than the Emergency Department. Services are provided on a space available basis, and accepted referrals are prioritized in the following order: 1) police and other law enforcement agency, 2) hospital emergency department, 3) designated mental health professionals (DMHPs), 4) emergency medical services, 5) jail services, 6) Kitsap Mental Health Services and Kitsap Recovery Center. Services provided: Psychiatric assessment and treatment, Substance abuse assessment, brief treatment and rapid referral/linkage to follow-up services, Social assessment and stabilization, including housing referrals, Brief Mental Health counseling, stabilization, and rapid referral/linkage to outpatient follow-up services, Physical health assessment, monitoring, stabilization, referral to primary care providers, Socialization opportunities and interpersonal skill building, Transition to 24/7 services or Law Enforcement, as indicated. Upon arrival persons will be fully assessed within 3 hours by Psychiatrist, Advanced Registered Nurse Practitioner or Registered Nurse; and a Mental Health Professional. Engagement begins with warm welcome, clear explanation of rules and resources, introduction to all shift staff. Immediate needs and wants are identified and addressed. Bathing facilities, nutritious food, basic medical care, communication with family or friends, laundry facilities, and a bed are offered. Crisis is viewed as a temporary relapse in progress toward recovery; the approach is to promote hope, connections & supports. Staff use engagement strategies, a trauma informed approach, a welcoming and relaxed environment while assessing and providing crisis stabilization services. Disposition planning begins on entry; releases for information sharing are sought for collaborative care, and a practical Goal Plan established. Electronic records are maintained, describing diagnosis, recent Mental Health/Substance Abuse status, relevant criminal history, current medication treatment, physical health status, and current conditions requiring monitoring/treatment. Staff are trained to make speedy, effective referrals for next step services, accompany client to initial appointments as possible and desired. Protocols for clients transitioning back to Law Enforcement for disposition are in place, with collaborative agreements to address transportation functions where needed (i.e. Emergency Medical Services). Tight care coordination is made between psychiatric, chemical dependency, medical institutions for transitions between care facilities and providers. The client's Discharge Plan includes

22 transportation options to return home or to shelter/housing, inpatient/outpatient treatment, or jail. Much like wrap-around services models, should staff transport client home, stops for groceries and medications, and observations regarding living conditions can be made that lend additional support for successful re-entry. Follow-up contact is made or attempted post discharge at 24 hours, 7 and 30 days. Review of Proposed Facility Options: Eight sites visited, with best two options below: Site 1: Kitsap County Work Release, 701 Tyler, Port Orchard. 1980's construction, fire code/suppression system upgrades 2003, 8,500 SF, requires minimal modifications only. Building constructed for purpose of 24/7 residential services and population. No interior wall changes; needs interior facelift with floor coverings and paint. Facility is equipped with emergency generator, bathroom, shower, laundry facilities in place. Needs addressable fire alarm; modifications to computer and security system. Advantages: Minimal remodel. County owned; near court services, jail. Emergency Medical Services vehicle access good; parking adequate. Some history on janitorial, maintenance, utility costs available. Disadvantages: Located in South Kitsap County. Harrison Medical Center Emergency Department, Kitsap Mental Health Services Inpatient and Residential Services Center, Kitsap Recovery Center Chemical Dependency Inpatient/ Detox services are in Bremerton, Law Enforcement access requires up to 30+ miles travel North to South County. Other: Remodel costs are estimated at $253,550, construction timeline is dependent on timely Department of Health licensure. The County is asked to partner in nominal lease cost ($1+). Site 2: 2625 Wheaton Way Bremerton.1970's construction, small at 4,500 SF, requires extensive renovation work. At minimum, improvements involve interior wall reconstruction for sleeping areas, intake, kitchen expansion, creation of shower, restroom, laundry facilities with extensive plumbing upgrades; fire alarm system modification, security system installation, addition of generator for 24/7 services. Advantages: Offers centralized county location for Law Enforcement drop-off; 2 mile radius of Harrison Medical Center Emergency Department, Kitsap Mental Health Services Inpatient and Residential Services Center, Kitsap Recovery Center Chemical Dependency Inpatient/ Detox services. Many support services in Bremerton area, nearby bus route. Disadvantages: Harrison Medical Center has since announced a new Silverdale campus location, smaller facility, is slow, difficult remodel, and ceiling has hard drywall lids creating difficulty for electrical, communication and plumbing lines thus increasing costs. Lease Year 2 calculated for 7,000 SF at $21 per SF, for a total of $147,000; this calculation estimated at 7,000 SF should we find other more suitable site. Total Operational Funding: Site 1: $2,651,332 with requested funding of $2,410,302 Site 2: $2,813,031 with requested funding of $2,557,301

23 VII. Recommendations for Alternative Building Site The service delivery model designed by Kitsap Mental Health Services for the Crisis Triage Center is sound and has a blend of the best features seen in the four Crisis Triage Centers toured as part of this report. The two options for site selection are not the most advantages. Both sites are stand alone facilities and do not have easy access to the wide range of community mental services located at Kitsap Mental Health Services main campus on Almira Drive in east Bremerton. They also lack access to detoxification services which the Crisis Triage Centers around the State said included up to 50% of the clients presenting for services. The Wheaton Way site is located near Harrison Emergency Department but that facility will be moving to Silverdale in the next few years. After touring the four facilities, Kitsap County Human Service and Kitsap Mental Health came to consensus that Kitsap Recovery Center would be an ideal location to site the Crisis Triage Center. It is physically near Kitsap Mental Health Services main campus and it would be in the same building as sub acute detox services. After reaching consensus, Kitsap County Human Services invited Clynn Wilkinson, an architect with the Department of Health, whose role is to inspect facilities and provide technical assistance on siting chemical dependency and mental health facilities. The Crisis Triage Center would be required to be licensed by the Department of Health as a Residential Treatment Facility. Clynn works closely with the Division of Behavioral Health and Recovery whose role would be to certify the Crisis Triage Center either as a Crisis Stabilization Unit or a Crisis Triage Facility. After touring the Kitsap Recovery Center, Clynn offered two options for siting the Crisis Triage Center at this facility: 1. Remodel the Center to house 16 Crisis Triage beds in one half of the facility and 16 sub acute detox beds in the other half. This would then require the inpatient chemical dependency treatment beds to be relocated. Currently there are 36 inpatient beds in the facility. Potentially the Kitsap County Work Release at 701 Tyler in Port Orchard could be remodeled to accommodate up to 36 inpatient chemical dependency treatment beds. 2. Construct an addition on to the Center to add up to 16 Crisis Triage Beds. With modifications to the existing structure, the facility could accommodate the inpatient chemical dependency beds, the sub acute detox beds and Crisis Triage beds. The total number of beds for each service to be determined. $693,059 of Mental Health, Chemical Dependency and Therapeutic Court Services funding has been set aside for Capitol improvements and start-up costs for the Crisis Triage Center. After meeting with the Division of Behavioral Health and Recovery about potential funding for the Crisis Triage Center they have agreed to provide $400,000 of ESSB 5480 funding. Capitol funds for relocation of inpatient chemical dependency beds would need to be provided through the Kitsap County Human Services Department.

24 VIII. Potential Alternative Operational Funding Options and Challenges Sources For purposes of budgeting operational expenses for the Crisis Triage Center will run an average of $2.5 Million per year. The following State and Local funding sources have been explored. State Funding Options Kitsap County Human Service staff met with the Division of Behavioral Health and Recovery (DBHR) and the Peninsula Regional Support Network (PRSN) on Friday, November 21, 2014 to explore ongoing operational funding for the Crisis Triage Center. At this meeting DBHR expressed support with moving forward with a Crisis Triage Center. They have been collecting data from Lourdes Counseling Center Transitions Crisis Triage Center in Richland, WA which opened in August 2014 and shows a steady decline in Boarding since the facility opened. DBHR agreed to recalculate the Peninsula Regional Support Network s Medicaid per member per month rate taking into account the new Crisis Triage facility expenditures in the formula. This would increase the overall PRSN budget and allocate State Medicaid funding to support the Crisis Triage Center. We believe this could amount to approximately $1.5 million per year. Local Tax Dollar Options Several local tax dollars have been identified that could be allocated to the Crisis Triage Center s annual operational budget: $100,000 - $200,000 - Local Millage Funds $100,000 - Harrison Medical Center contract for Crisis Triage beds at KRC $65,000 - County Substance Abuse funds Balance to be paid for by the Mental Health, Chemical Dependency and Therapeutic Court Tax Funding Challenges In August 2014, the Washington State Supreme Court ruled that boarding psychiatric patients temporarily in hospital emergency rooms and acute care centers because there isn t space at certified psychiatric treatment facilities is unlawful. The court ruled unanimously that patients held temporarily in settings that don t provide individualized psychiatric treatment violates the state s Involuntary Treatment Act. Since this ruling, DBHR has been working with agencies around the State to provide more options for individuals experiencing a mental health crisis. The 2014 State Legislature passed Senate Bill 6312, directing Department of Social and Health Services (DSHS) to change how it purchases mental health and chemical dependency services. Currently, the state purchases mental health and chemical dependency services from two separate systems: Regional Support Networks and counties. Beginning in 2016, these services will be purchased by regionally operated Behavioral Health Organizations (BHOs) through a managed-care structure. Some key recommendations relevant to the purchasing of behavioral health services include achieving greater integration of mental health, substance abuse, and primary care services by phased reductions in administrative and funding silos; restructuring Medicaid procurement into regional service areas; and requiring all health providers to collect and report common performance measures. By January 1, 2020, the community behavioral health program must be fully integrated into a

25 managed health care system that provides mental health services, chemical dependency services, and medical care services to Medicaid clients. This change in funding structure makes it very difficult, if not impossible for the Division of Behavioral Health and Recovery to provide any specifics about future Peninsula Regional Support Network (PRSN) mental health funding or County chemical dependency funding. An actuarial study is in progress to develop the formula for a Medicaid per person per month rate for chemical dependency treatment services in the new Behavioral Health Region. Beginning in 2016 DBHR mental health and chemical dependency contracts will be integrated with new Medicaid per member per month. In July 2015 detailed plan requirements for Behavioral Health Organizations (BHO) will be released. Regional responses are due to the State in October In January BHO plans will be reviewed, with contracts for integrated care finalized April 1, If the Crisis Triage Center moves forward with construction and opened in July 2015 operational funding support from both the PRSN and the County for mental health and chemical dependency would only be in place nine months before the new funding structure is in place. Restructuring could provide new opportunity in January 2016 for blended funding for both mental health and chemical dependency crisis services. This could provide new, potentially richer State resources for crisis response in the region.

26 1

27 Crisis Triage Center Law Enforcement Training GeroPsych Success 2

28 Crisis Triage Facility Options Attachment 3 Crisis Stabilization Crisis Triage (Involuntary) Crisis Triage (Voluntary) Licensed by DOH and DSHS Can take individuals brought in by law enforcement involuntarily Yes Yes/12 hours Yes (Residential Treatment Facility) No Age No stated limits. 18+ Located in another facility Yes if physically separate with no foot traffic and doors are locked. Medical Requirements Health screening by licensed health care provider upon admit and provider available for consultation 24/7. MHP requirements On site 24/7, provide an assessment with 3 hours of admit. DMHP requirements When involuntary, seen by DMHP within 12 hours. N/A Seclusion or Restraint Require physician s orders, assessed hourly, seen by a physician within 24 hours. N/A Involuntary Medication Requires orders from 2 physicians for ongoing involuntary medication. N/A MOU with Law Enforcement Secure Status N/A Must address what types of clients facility can accept based on behavioral, medical, etc. Doors and windows locked at all times, visual monitoring, space to segregate potentially violent individuals. N/A ATTACHMENT B

29 Survey of Washington State Crisis Stabilization and Triage Facilities King, Snohomish, Benton/Franklin and Yakima Counties Attachment Attachment C 3 King County Snohomish County Benton/Franklin Counties Yakima County Recommendations for Kitsap County DESC Crisis Solutions Center Compass Snohomish County Triage Lourdes Transition Facility Comprehensive MH Triage Center How many Beds in the Facility? 16 Crisis Triage & Stabilization 16 Crisis Triage Licensure? 6 Respite/Observation Recliners 16 Crisis Triage 16 (Flexes Triage, Stabilization and Detox) DOH Residential Treatment Facility Residential Treatment Facility Residential Treatment Facility Grandfathered RTF Residential Treatment Facility What DBHR Certifications do you hold? Crisis Triage Crisis Stabilization Unit Residential Treatment Facility Other Licensing Voluntary or Involuntary? Deferred Charge Option? Is it a stand-alone unit or connected to E&T or hospital? What are the criteria for admission? Who can directly refer? DMHP evaluation required prior to admission? Who does medical evaluation prior to admit? Do you take twelve hour holds from law enforcement? Yes Yes Voluntary Yes 32 Crisis Stabilization/Residential Treatment Center Adult 18 + with emotional or behavioral disturbance, including substance use/abuse. Would benefit from crisis services Agrees to participate (voluntary) Law Enforcement Emergency Rooms Mobile Crisis Teams EMS/Fire DMHPs Working on this Certification Yes Voluntary Yes Comprehensive Mental Health Center Evaluation and Treatment Center Adult 18 + with emotional or behavioral disturbance, including substance use/abuse. Would benefit from crisis services Agrees to participate (voluntary) Law Enforcement Emergency Rooms DMHPs EMS/Fire Yes Yes JCAHO Voluntary & Involuntary 12 hour hold. Lourdes Hospital Yes Evaluation and Treatment Center Adult 18 + with emotional or behavioral disturbance, including substance use/abuse. Would benefit from crisis services Agrees to participate (voluntary) Is involuntary Committed Law Enforcement Emergency Rooms DMHPs EMS Self Referrals Yes Yes JCAHO Voluntary Yes Comprehensive Mental Health Center Evaluation and Treatment Center Adult 18 + with emotional or behavioral disturbance, including substance use/abuse. Would benefit from crisis services Agrees to participate (voluntary) Law Enforcement Emergency Rooms Mobile Crisis Teams EMS Mental Health Court Detox Self-Referral Only 16 Would apply for CSU Would apply for RTF Voluntary Yes TBD ideal is within range of MH E & T and CD detox, inpatient (ie KRC) Other option remains Work Release site. Adult 18 + with emotional or behavioral disturbance, including substance use/abuse. Would benefit from crisis services Agrees to participate (voluntary) Law Enforcement Emergency Rooms EMS DMHPs Mobile Crisis Teams, if in place No No Yes Yes No Pre-admit phone screening Onsite RN/ARNP does evaluation Pre-admit phone screening Onsite RN/ARNP does evaluation Pre-admit phone screening Onsite RN/ARNP does evaluation Not required Transport to ER if necessary Pre-admit phone screening Onsite RN/ARNP does evaluation No No Yes No No Do you take persons on alcohol or drugs? Yes-BAL.20 Yes -.25 Yes -.25 Yes -.30 Yes BAL 2.5, other substances including some opiate within scope of practice Do you provide Detox? No No Medical Detox Sub-acute/Social Detox Medication Assisted Detox Yes (CIWA) Yes Yes To be explored within scope of practice

30 What are your procedures for: Persons who are detained for transfer to an E&T or ER? King County DESC Crisis Solutions Center Snohomish County Compass Snohomish County Triage Benton/Franklin Counties Lourdes Transition Facility Yakima County Comprehensive MH Triage Center Attachment Attachment C 3 Recommendations for Kitsap County Ambulance Transport Police Transport Ambulance Transport Police or Ambulance Transport Ambulance Transport Do you use seclusion & restraint? No No Yes No No What is your maximum length of stay? 3 Days (+ 14 day Stabilization Facility) 5 Days 14 Days 14 Days 5 days What is the average length of stay? 2 Days 3 Days 3 Days 3 Days for Detox What are the goals for patient treatment? Crisis Stabilization Secure Housing or Residential Treatment Reengagement/engagement with outpatient treatment Actively connect to essential services/needs Medication stabilization Diversion from the Hospital/Jail What partnerships are in place to provide Harborview Medical Center coordination into and out of the facility? DESC Crisis Mobil Team King County DMHPs NAVOS (E&T beds) Outpatient chemical dependency provider network Outpatient mental health provider network EMS and Fire Law enforcement agencies King County Jail Housing and shelter providers DSHS DDD Essential service providers What is your funding source? 1 10 th of 1% Tax 1 10 th of 1% Crisis Stabilization Diversion from hospital/jail Refer to other services Hospital DMHPs Compass E&T Outpatient mental health provider network EMS Law enforcement Special State Grant - 2 years through 06/30/16 Crisis Stabilization No Medication changes Skill Building Refer to other services Lourdes Hospital Outpatient chemical dependency provider network Inpatient chemical dependency provider network Outpatient mental health provider network Jail diversion Law enforcement EMS Special State Grant 2 years through 06/30/16 RSN Per Diem Rate - $ Days Stabilization Crisis Stabilization Refer to services No Medication changes Care Coordination with mental health and chemical dependency providers Yakima Valley Hospital E&T Law enforcement Jail diversion Outpatient chemical dependency provider network Inpatient chemical dependency provider network Outpatient mental health provider network Crisis State Only Medicaid roll up to RSN Detox County funded through DBHR (Note: Kitsap has 30 day step down via Keller House MH 16 bed RTF & KRC Inpatient CD Services as available & if meet services criteria) 3 days Crisis Stabilization Secure Housing or Residential Treatment Reengagement/engagement with outpatient treatment Actively connect to essential services/needs Medication stabilization Diversion from the Hospital/Jail Harrison Medical Center/Hospital Kitsap DMHP s All LE jurisdictions, including Suquamish tribal LE EMS/Cencom KMHS (E & T inpatient, 30 day residential treatment unit) KMHS Outpatient MH providers KRC Inpatient, detox services West Sound Treatment Center & other CD providers Peninsula Community Health Services Kitsap Community Resources Housing Solutions Center (housing & shelter provider connections) DSHS DDD Prosecutor s Office Others TBA including essential services Do you bill Medicaid? No No No Yes No - MH is capitated under PRSN What is you staffing ratio? 4 clients 1 staff 4 clients 1 staff 4 clients 1 staff 4 clients 1 staff 4 clients 1 staff TBD Other TBD?

31 King County Snohomish County Benton/Franklin Counties Yakima County Attachment Attachment C 3 Recommendations for Kitsap County DESC Crisis Solutions Center Compass Snohomish County Triage Lourdes Transition Facility Comprehensive MH Triage Center What is your staffing positions? Psychiatrist/Medical Director RN Psychiatrist/Medical Director MHP Team Leader Psychiatrist/Medical Director (.1 In-kind) Psychiatric ARNP MHP Shift Supervisor Psychiatric ARNP Mental Health Assistant Psychiatric ARNP RN MHP Case Manager RN CDP Case Manager RN MHP Shift Supervisor Case Manager MHP Shift Supervisor BA Case Manager MHP Shift Supervisor MHP Case Manager Peer Counselor MHP Case Manager MHP Case Manager CD Case Manager Program Assistant Case Manager CD Case Manager Case Manager Program Assistant Case Manager Peer Counselor Peer Counselor Psychiatric Aides Psychiatric Aides Program Assistant Program Assistant What outcomes are you measuring? Quantitative Program Utilization Qualitative to include: % reduction Jail Utilization % linked to mental health treatment % linked to substance abuse treatment % reduction hospital emergency department utilization % reduction utilization psychiatric hospitals % enrolled in housing or shelter % engaged in CTU % of admits stabilized at discharge % of admits connected to needed services % of admits with follow-up contact at discharge Quantitative Program Utilization Quantitative Program Utilization Quantitative Program Utilization Quantitative Program Utilization Qualitative to include: % reduction Jail Utilization % linked to mental health treatment % linked to substance abuse treatment % reduction hospital emergency department utilization % reduction utilization psychiatric hospitals % enrolled in housing or shelter % engaged in CTU % of admits stabilized at discharge % of admits connected to needed services % of admits with follow-up contact at discharge

32 CRISIS TRIAGE CENTER: ANNUAL OPERATING BUDGET Based on FY 2015 Projection to operate 24/7 Residential Services at Kitsap County owned facility Agency: Kitsap Mental Health Services Estimated Project Costs Total Requested Funds Other Funds Personnel* Managers & Staff 1,643,676 Fringe Benefits 477,688 SUBTOTAL $2,121,364 $2,121,364 $ Supplies & Equipment Equipment 3,000 Office Supplies 2,500 Office Equipment Lease 3,036 SUBTOTAL $8,536 $8,536 $ Administration Advertising/Marketing 0 Professional Services - Evaluator 3,680 Communication 12,000 Fees & Taxes 4,200 Indirect Administrative Expenses (10%)** 241,030 Insurance/Bonds 20,824 Training/Travel 2,500 Transportation 25,000 SUBTOTAL $309,234 $68,204 $241,030 Ongoing Operations & Maintenance Janitorial Service 18,642 Laundry Services 22,880 Maintenance Contracts 5,000 Meals 44,000 Repair of Equipment & Property 5,000 Utilities 26,675 Building Lease (KITSAP COUNTY $1) 1 25,000 Pharmacy & Medical Supplies 50,000 SUBTOTAL $197,198 $197,198 Other Client Security Deposit Assistance (30) 15,000 SUBTOTAL 15,000 $15,000 TOTAL CTC ANNUAL OPERATING BUDGET $2,651,332 $2,410,302 $241,030 *Staffing Budget Detail Attached ** Note: Other funds are RSN funds to cover the cost of indirect administrative expenses

33 Crisis Triage Annual Operating Cost: Salary Summary for FY 2015 Description Number of Professional FTEs 25.5 Number of Clerical FTEs 1 Number of All Other FTEs (on call fte's) 3.43 Total Number of FTEs Salary Information Salary of Program Director $77, Salaries of Professional Staff $1,266, Salaries of Clerical Staff $33, Other Salaries (Describe Below) Description: on call professional staff $216, Description: differential pay $49, Total Salaries $1,643, Total Payroll Taxes $156, Total Cost of Benefits $272, Total Cost of Retirement $48, Total Payroll Costs $2,121,364.00

34 Letter of Transmittal December 12, 2014 Construction Review Services 111 Israel Rd. SE Tumwater, WA PO Box Olympia, Washington tel fax Project Info: CRS# Kitsap Recovery Center Chapter WAC RTF TA - 16 Bed Crisis Triage/16 Bed Sub-Acute Detox Key People: Assigned DOH Clynn J Wilkinson Jr RA Reviewer: clynn.wilkinson@doh.wa.gov Facility Administrator: Architect / Engineer: Consultant: Kitsap Recovery Center Doug Washburn 1975 NE Fuson Rd Bremerton, WA (360) x. dwashbur@co.kitsap.wa.us N/A N/A x. Project location: Local Permit #: Facility Contact: Local AHJ: Consultant: 1975 NE Fuson Rd Bremerton, WA Kitsap Recovery Center Bergen Starke 1975 NE Fuson Rd Bremerton, WA (360) x. bstarke@co.kitsap.wa.us Kitsap County Jeffrey L Rowe 614 Division St MS-36 Port Orchard WA (360) x. jhornbak@co.kitsap.wa.us N/A x. x. Contact: N/A Contact: N/A x. x. Copies To: Local AHJ: Kitsap County Architect / Engineer: N/A Consultant: N/A Consultant: N/A Contact: N/A Contact: N/A CRS File DOH Child Birth Center Licensing DOH Office of Investigations & Inspections DSHS,, Div. Of Alcohol & Substance Abuse DSHS,, Aging & Adult Services Admin. L&I, Bill Eckroth, Electrical Section L&I,, Factory Assembled Structures Page 1 of 8 Plan Review Comments for Project #