Stephanie Hepburn is a writer in New Orleans. She is the editor in chief of #CrisisTalk. You can reach her at editor@crisisnow.com.
Senator O’Ban entered the Senate in 2013, inheriting committee roles from his predecessor, Senator Mike Carrell, who passed away unexpectedly. This included the chair position of the Human Services committee, which focuses on mental health. Although he’s now the ranking member on the Senate Health and Long Term Care Committee and serves on the Behavioral Health Subcommittee, when O’Ban started, the learning curve was steep. “In 2013, I knew little about mental health policy but was thrust into these roles and needed to quickly get up to speed. I decided to learn all I could about mental health policy.” Since then, he has sponsored several vital bills enacted by the legislature to improve the delivery of mental health. By 2017, he had become a leading policymaker on mental health in the Senate, and when Bruce Dammeier became the Pierce County Executive in 2017, O’Ban joined his executive team as Senior Counsel for Behavioral Health. In that role, he has gained more and more practical knowledge and has headed up many key behavioral health initiatives for the county, including establishing a new crisis triage facility (think of it as an emergency room for mental health crises), expanding an innovative mobile mental health care team, launching a new regional system of care planning task force, spearheading an innovative “assisted outpatient treatment” program being piloted in Pierce County, and helping to oversee integrated healthcare for Pierce County, Washington. While performing his new role for the county, he continues to serve in the Senate.
Historically, people with Medicaid coverage in Washington have had to navigate convoluted, fragmented, and siloed systems to get their physical, mental, and behavioral healthcare. Providers often don’t communicate, resulting in treatment that’s neither comprehensive nor coordinated. Just like in many other states, the consequences of separate systems have wreaked havoc on and overburdened local emergency rooms, resulting in people in mental health crises sometimes being held for days awaiting treatment. The Washington State Hospital Association did a snapshot of psychiatric boarding during a single month, finding 155 patients held in emergency or acute care departments in October 2018. O’Ban says integrated health will foster communication between formerly segregated areas of health, improving early identification and allowing people to be matched to the right level of care instead of defaulting to the emergency room. “Change won’t happen overnight as the state is still in the throws of bringing together long-separated healthcare disciplines, both financially and clinically.”
The senator says integrated health is person-centered and cost-saving, and by financing mental health, substance use disorders, and physical health together, it promises to result in collaboration and bidirectional communication and an individualized health plan. He gives the example of a patient who is diabetic and has been diagnosed with bipolar disorder and isn’t taking his insulin medication. Traditionally, there’s minimal or no communication between the general practitioner and the person’s mental health provider. Under the integrated model, says O’Ban, the two clinicians communicate with one another and, along with the patient, come up with a plan to address his physical and mental health needs. “Connecting the financing for healthcare is going to force those conversations. We are pushing providers to look at people holistically instead of compartmentalizing them, and finding a way to have those parts speak to one another.”
The idea of integrated health isn’t a new concept, but, generally, the focus on whole-person care—and the resulting savings and improvement—has been on physical wellbeing. Mental health is a critical part of comprehensive care, says O’Ban, and integration promotes better care because the walls between silos are broken, and each field has a better understanding of the part of the person they haven’t been looking at. “General practitioners can communicate with mental health providers and vice-versa so that the patient doesn’t experience deteriorating physical or mental health that makes healthcare so expensive. It’s documented that it saves money and provides better care.”
The benefits, both for patients and the health system, are well-accepted, but that doesn’t mean the senator hasn’t faced opposition. He says resistance to change is what has delayed integration for years. The biggest challenge in Pierce County has been getting smaller mental health and substance use disorder healthcare systems to adapt to working with Managed Care Organizations like Beacon Health Solutions, Molina Healthcare, and UnitedHealth Group. “They are unaccustomed to working with these larger groups and have to learn each MCO. You can’t just learn United and think you will understand Molina.” Initially, there were cultural differences and logistical challenges, like adapting to varying ways of doing preauthorizations. Collaboration wasn’t just about preparing the substance use and mental health providers to work with the MCOs but also getting the MCOs ready to deal with the nuances of the providers in the community. “There were some cultural oddities, and these big systems had to adapt to the way we were delivering care here in Pierce County.”
Senator O’Ban says collaboration is happening, but it has taken time, patience, and a bit of gently applied, and sometimes less so, pressure. At times, the process was incredibly uncomfortable for everyone involved. “Anytime you are shifting culture—even if for the greater good and even if they agree with you—you’re going to get pushback.” The problem is that these groups had to figure out how to work together and do so quickly. He says not all providers, particularly the smaller ones, can weather a delay in getting their bills paid on time. Pierce County, like many other parts of the United States, is experiencing an opioid crisis. It was, and is, imperative that the county not lose any of the Substance Use Disorder (SUD) providers. “We have to get through integration and end up with not fewer but more SUD providers; we can’t have this change bring them to financial ruin.”
Integrating healthcare makes common sense, but equally logical, says Senator O’Ban, is to divert people experiencing mental illness or an SUD from entering the criminal justice system and create a more robust crisis care continuum. Pierce County, which has around 891,299 residents, making it the second-largest county in the state, has a crisis facility in Fife in the northeast part of the county. It works well, says Senator O’Ban, but is mostly inaccessible from the southern part of the county. Early in the process of coordinating healthcare systems, Dammeier quickly realized the county needed a second crisis facility. The senator took over the leadership to get the new facility financed, sited, and built. The operational financing will be paid from Medicaid and state-only funding and flow through the MCOs, Beacon Health Options, to the new facility, which had its ground-breaking on Wednesday, November 6th. (Image: Crisis Recovery Center. See highlights from the Pierce County Parkland ground-breaking on YouTube).
Looking holistically at what happens to a person shouldn’t drop off simply because their experience doesn’t take place in the healthcare system. Senator O’Ban says people in crisis are often charged with a crime, commonly a misdemeanor, and enter the criminal justice system. “We were and are having a huge problem with people getting charged with a crime and then held in jail waiting for a competency evaluation. If it looks like they can be restored to stand trial, then the restoration process also takes forever.” In many cases, people are held, waiting for their competency assessment and restoration, for even longer than the maximum sentence they would have faced if they’d stood trial and been found guilty. “It’s a serious civil liberties problem.” The long-waits were propelled into the spotlight in the lawsuit Trueblood et al. v. Washington State DSHS, where plaintiffs challenged the delays. The judge agreed, finding that the Department of Social and Health Services (DSHS) was taking too long and ordered the state to provide court-ordered competency evaluations within 14 days and competency restoration services within 7 days. Senator O’Ban says the decision pushed the conversation to the forefront, forcing an overall examination of the mental illness and SUD to criminal justice pipeline. “One of the decisions wisely made out of that lawsuit is to invest more in crisis and diversion services. Many of these folks aren’t criminals. What they are is mentally ill and not getting good healthcare.”
In the 2019 legislative session, Pierce County expanded programs that help police and mental health services work together, including behavioral health crisis training for various stakeholders such as police, dispatchers, and jail personnel. Senator O’Ban says while healthcare integration will help people get better care—so they don’t enter the criminal justice system in the first place—there are also five intercept points for diversion, including before arrest, after arrest, before trial, after trial, and at sentencing. Continuity and communication within the healthcare system and between it and the criminal justice system will improve people’s lives. “We want to provide better care on the front end as opposed to after a person has been charged but also need to ensure that there are other touchpoints in the course of the criminal justice matter where we have the right people asking the right questions.
“Across the United States, we’ve got to have a better working, collaborative healthcare system, or else we’re going to be dealing with the symptoms and plugging holes rather than addressing the underlying problems that are forcing people into homelessness and the criminal justice system in the first place.”
