Legislative Meeting - Regular Meeting

Good morning, everyone, and welcome to our quarterly Spokane County Regional Interlocal Leadership Structure Meeting. My name is Ashley McGee, and I am the Assistant Director for the Community Services Department here at Spokane County. And our chair, unfortunately, is unavailable to join us today. And Justin Johnson, the Director of Community Services Department, will be joining us a little bit late to this meeting. So in their absence, I will be facilitating today's meeting. So welcome everyone. Happy Friday. A little bit gloomy over here on the east side of the state, which is some hopefully good rain on our way. If you all could please put your name and organization in the chat, that will help us be able to take attendance. That'd be greatly appreciated. And we've got a pretty good agenda here today. So we can go ahead and jump right into that, starting with state updates. And I believe we have representatives on from HCA. Jason, are you on?

Yes. Good morning. Can you hear me okay?

Yes, we can hear you great.

All right. And let me just check to see if any other partners here at HCA. I'm particularly thinking maybe Tisha Kirschbaum is joining, but I don't see Tisha on as of yet. So Tisha may join us, or I know we have a few folks out as well. So maybe it's just me this morning. And I appreciate being with you and always a good chance for some updates and discussions. So thank you. And I see the topics on the agenda online. all considerable work underway right now, and I'll put some links in the chat for you, which actually probably is the best way to engage on a lot of this work. Various teams underway, as you can imagine, for the HR1 impacts, for example. Mostly at this stage, eligibility enrollment related items there, although many of you are probably working on the HR1 rural transformation impacts in some way or another or your colleagues may be and considerable work there with advisory committee grants out and and that, and I'll be happy to follow up with a link on some of the materials there if you need to engage more. Reentry is a program, Medicaid programs here at HCA. My team is leading in terms of our implementation, and it is a major effort underway right now, particularly because July 1, we will have our largest set of carceral facilities across the state join and implement and happy to provide some additional information there and a list of those facilities. And legislative updates, happy to really probably just take your questions. But the one that may be most relevant, at least for the period we're in here, July 1, we are implementing crisis service delegation, working with our behavioral health ASO across the state, delegating those services individually. and working intricately with our managed care plans. And that work is almost complete and ready for July 1 implementation. It has been a significant lift. So I – you know what? I'm going to stop right there and happy to take questions and dive into anything that of interest otherwise. Happy to provide those links and the data, and I've got a few ready to go here, but wanting to defer to you and give plenty of time here for questions and discussions as you may be interested.

Thank you, Jason. Greatly appreciate that. Are there any questions from the room, from the virtual room, not the physical one, for Jason on any of these topics or elements as it pertains to the Washington State Health Care Authority and the work that they are undertaking right now in various different areas? I see Gail has her hand up. Go ahead, Gail.

Thank you. Could you explain a little bit more about the 1115 waiver with the jail reentry?

I sure can. Yes. Okay. I'm sorry. I think you were fading out there for me.

I'll try and speak up. My microphone is not connected.

I can hear you fine now. Thank you.

Yeah. Okay. So the 1115 waiver update, the jail reentry program, could you talk about that a little bit in detail?

Of course I can. And let me... You know, it's hard to multitask here, but let me also include in the chat the various links to the material, and one of them is our reentry webpage. So, Gail, that can give you all of the detail, but I'm happy to give you any sort of higher level detail and go into any specific direction that you or others may be interested. I'm also putting in the chat here HR1 material, our website for that, and it's probably worth getting into a little bit more detail there too, particularly with regard to what's called medical frailty for the adult population stemming from Medicaid expansion, which is the focus there and rural transformation grant material. So here's your links and then Gail on re-entry particularly, I'm also going to find and provide, I think I have it here at my fingertips, the group of providers, excuse me, jails ready to go July 1. So let me start from sort of the beginning. I won't get into every detail here, but the waiver allows the state to pay Medicaid for services that the federal government does not otherwise allow Medicaid to cover. And in this case, it's 90 days prior to release for certain services. It's a fairly broad set of services, but it's pharmacy, MOUD, particularly medication for opioid use disorder and alcohol use disorder. It's targeted case management. And then one of the requirements is a 30-day supply upon release, not just a prescription, but in hand upon release from the carceral facility. So we have to tool up to make sure that these things are all in place. And Medicaid will pay and cover. And part of our waiver program, what we call capacity funding is available for local jails to help them tool up, help them resource and build that capacity to make sure they can offer those baseline services. In addition, Medicaid will cover the full pharmacy benefit in addition to many of the behavioral health and primary care related services, including lab services, even DME as needed. prior to release and so the jail itself could use internal licensed clinical staff and those staff can then bill for those services. The jail could choose to use a contracted external entity. Many use a behavioral health agency across the state today to handle MOUD and other behavioral health needs. Of course, many use a contracted pharmacy service. And then that service can then bill directly for Medicaid. And that's really the innovation here and the change is billing for Medicaid, of course, for the goal and purpose of better transition of care into the community to help people set up and reduce recidivism in the end. Gail, let me stop there. Does that sound like what you were looking for? Anything more you'd like to dive into?

You know, that's kind of what I was looking for. I had some knowledge of it, but, you know, when you talk about jail, which is different than the, you know, Department of Corrections situation, so I'm guessing it's the jails, not DOC.

Good question. Good question. It's actually both, and DOC also will go live July 1. Of course, DOC is a slightly different model because they are releasing after longer-term stays versus the jails who have fairly – our average stay for a Medicaid recipient in jail today is under 14 days statewide for a local jail. So that's a different sort of model than DOC. So they're developing different protocols, and it's been a wonderful – work with both entities across the state and our team will work with individual jails and ensure the technical assistance necessary. And as I mentioned, we have capacity funding to help those individual jails staff up. In addition, we have hired on a what we call our third party administrator. So it's a one of our managed care plan entities, in fact, who help with technical assistance for the jails and for DOC. And oh, by the way, our juvenile facilities, that might be the third group. and even the state juvenile rehabilitation administration, so the JRA institutions as well. So all of it applies, Gail. Thank you for the clarification. Good question. Anything else on reentry you'd like to cover? And again, I thought the one thing I might mention today on H.R. 1 is some of the timing on that. So it really takes place starting January 1 for people, for people who are enrolled in Medicaid. And then rolling forward, they have to ensure, and those who are required, so this would be, again, adult population, who really stem from Medicaid expansion in 2014 through the Affordable Care Act. So that new population of Washington, that's about six, 700,000 people. So they will have to go through what's called a community engagement verification. And many of you may have heard work requirement as explained. And I think in our space for behavioral health here, the key issue is an exception or a sort of automatic application of the individual if they have a behavioral health diagnosis. And so the law, and it was a fairly significant debate in Congress at this part, and it was added in the final piece of legislation to grant an exception for behavioral health conditions. And so that's good news. However, the rules to implement this have some more vague and or concerning items that we still need to work out. So we were just notified a couple of weeks ago about the new federal rules that CMS, the federal agency, will require of states to implement. And we're still working out what precisely that means. And the debate there is we were thinking it's basically by diagnosis codes, which is theoretically something that's straightforward to connect an individual's diagnosis with whether or not that is a diagnosis like a behavioral health diagnosis that is applicable for an exception for work requirement for that regular application that an individual would otherwise have to go to to prove that they are working. So that theoretically we could implement. However, the new rules talk about functional eligibility, whether or not the person is incapable of working. And we don't know how to apply that because that is not just purely a diagnosis element necessarily. So we're waiting on more detail from the federal government in terms of its intent there and how to apply that. And we're getting to time period that that's pretty critical in terms of implementation, especially for beginning January 1. There is an October 1 deadline for people who are not citizens, but here legally, we're not talking about undocumented in this case, but Medicaid will no longer cover for some of those who are in a green card status or visa status. and do not have either citizenship status at this stage. And so Medicaid will stop covering a group of people there starting October 1st. So that will be impactful. And then again, January 1, the large group of six, 700 people will start to require work requirements on an ongoing basis. In addition, the annual recertification, so re-enrollment process that's required, will move to every six months. So that will also be a critical sort of requirement for people to have to continue coverage. Those are some of the highlights. Of course, again, the links here in the chat, quite a bit more information. Fortunately, we have had some resources. to do some incredible public webinars and town hall sort of, and that is available online recorded if you'd like to learn more about these impacts. Gosh, let me stop there. Any questions on HR1 or reentry or otherwise, please?

Thank you, Jason. And thank you for the links on all those items as well. For HR1, I know you had briefly mentioned kind of sending out a survey regarding the medical frail codes and kind of getting feedback from the community health care providers. Authority sent out that feedback. Is there a next stage to that process that we can anticipate further information on?

Great question. I don't have that. I'm trying to remember and I don't. I can't remember what our precise next stage is on that. But as I sort of noted, we were also trying to figure out what those codes mean in conjunction with the new federal rules. So that is the big question right now that we're trying to grapple with as well. So I can say that, and we're grappling with that, working through, trying to understand that, and waiting for additional guidance from the feds on that. I'm certain we have some next steps, and I'm kind of looking right now to see if I... See if we have that, but I don't have that at my fingertips. Happy to certainly follow up on that one.

Yeah, no worries. It sounds like maybe a shifting of kind of the next stage of finding out how we define functional eligibility.

That's for sure.

That next push you did.

You know, and not to get into too much detail here, but the other thing that impacts us from an HR1 perspective is the financing. There are some new restrictions on what we call state-directed payments. And you may be familiar with the legislature having a 2%, a 7%, and a 14% increase over the last few years. Those have been implemented via state-directed payments. We believe that those would be allowed to go forward with the condition that we are able to prove effectiveness in terms of quality, access to care. So we really do have to do the work to prove effectiveness on this as we will have intensive review. In addition, we cannot be paying more than Medicare level rates for services. And so we'll have to go through an analysis and process there. I do not think my sense is, at least on the behavioral health side, that that's going to be too critical. But as you can imagine, some of the hospital rates that Medicaid pays and uses to state direct payments, there will be an impact over a period of time. So the hospital partners are particularly impacted there. So just a quick note on state-directed payments is another major policy shift HR1 implemented as well.

Thank you, Jason. Any other questions from other participants in the meeting today? A lot of information to download.

Incredible amount of work underway right now, yes.

not hearing or seeing any comments or questions from the group. Jason, thank you so much for your time this morning on all those different elements. Like you indicated, the state's doing a lot of different significant projects that will impact the landscape of our behavioral health field. as we move into the new year. So really appreciate all the work you and your team are doing and sharing about it here in this space.

Yes, likewise. Thank you all. And I'll stay on here for a little bit this morning and always look forward to listening and the discussion. Thanks again. Thank you.

All right. Moving on on our agenda, we have Dr. David Nielsen with New Alliance Behavioral Health to talk about their new CSU unit.

Morning, everybody. For those of you who don't know me, I'm David Nielsen, and I'm the Executive Director of Northeast Washington Alliance Behavioral Health. So New Alliance is actually a partnership with Stevens County, Ferry County, and Lincoln County. We provide behavioral health services in all three of the counties, and we're also the crisis system of care for all three counties. We're headquartered in Colville in Stevens County. where we also have a 16 bed inpatient evaluation and treatment facility. So I wanna give you a little bit of information about some of the goings on here at New Alliance. This will be my last time ever joining all of you in the Skrills. On July 8th, I will have my 30 year anniversary with Stevens County. And then at the end of the month, I'm riding off into the sunset, actually heading to the East Coast where my wife and I are looking forward to spending time with our two children and our almost seven grandchildren. in our retirement. So it's been great working with Spokane County for all of these years. We've really enjoyed the relationship, enjoy the support that we're getting in the crisis stabilization unit now. And I won't be here to see the doors opening for the project that I'm about to show you here. So Ashley, I'm going to try and share my screen. Is there anything you need to do at your end or do I just go ahead and share?

I believe you should be able to share. There we go.

Okay. So I'm here to talk with you about a crisis stabilization unit that will be opening in November of 2026. My going away present to the region here. So just by way of background, See if I can make my slide advance. Back in 2001, my predecessor, twice removed, had the opportunity to purchase a house that's located right in the backyard of our main headquarters here in Colville. So this gray building in the back, if you can see, that's the back of our headquarters in Colville. This actually used to be a beauty salon, and the executive director in 2001, when he came on the listing with a real estate agency, realized that he could purchase this to use it for our DMHPs back in the day to do psychiatric hospital diversion. So as you recall back in the day when we were doing civil commitments, most of people that we would involuntarily detained or sent to Eastern State Hospital in Spokane or to Sacred Heart Medical Center. And Lee Smutsler, the executive director back in 2001, said, hey, we could purchase this and we could use this to divert people out of the inpatient settings and keep them locally in the community, get them stabilized. So let's do that. So working with the Stevens County commissioners, he purchased this house and we turned it in 2001 into a four bed, stabilization facility. And at the time that the facility was purchased, there really was no licensing category for stabilization facilities with the Department of Health. So we just kind of as a behavioral health agency thought this is the right thing to do for our community. So let's do it. So it was purchased in 2001 and We actually staffed it with somebody who used to run the Stevens County Jail. And we had on-site staff 24 hours a day and started diverting people out of Sacred Heart and Eastern State Hospital. So going forward, this is kind of the inside of the place. It looks just like a house. And at the time, we would have four people stay there. Over time, we added more beds. So on the main part of the stabilization facility right now, we can have seven people stay for up to 14 days at a time. That's what it looks like on the inside and really just a kitchen. Nothing fancy, nothing that would qualify as a residential treatment facility. I became the executive director about 20 years ago, and after I became the executive director, we put an expansion on this facility so that it actually has a capacity of 13 people today. But we're operating in this weird gray zone where... If you look at the state's definition of stabilization services, stabilization services are provided to people in crisis to stabilize them, and they're done either at a residential facility or in a home or a home-like setting. And so we've been saying for years and years, well, we're providing these stabilization services in this home-like setting. But I felt increasingly uncomfortable with that over the years, believing we really need to get licensed as a behavioral health agency in a residential treatment facility, but didn't see a way that we could easily do it with this housing structure. So this is our headquarters in Colville back in the day when we were called Stevens County Counseling Services. And if you're to look immediately next door to the right of our headquarters, there's this building that was Stevens County Public Works. So some of you may recall former Stevens County Commissioner Wes McCart, who was a big advocate of behavioral health services. And we worked very closely with the ASO and with us for many, many years. And about five years ago, Commissioner McCart approached me and said, David, do you have any interest in purchasing this public works building? And what he really wanted me to do was to purchase the building and turn it into an inpatient drug and alcohol treatment facility. And we had that conversation shortly after we opened our ENT in Colville, which was a big project. And I was tired after that project. And I said, you know, Wes, thanks, but I am really not interested in putting in an inpatient drug and alcohol treatment program in Colville. So we took the opportunity to pass at that time. And then as I got closer and closer to retirement and was thinking more and more about we really should turn our crisis unit into a licensed facility, I went back to Wes and said, Wes, what about pursuing a commerce grant to purchase and renovate this building and once and for all open up a fully licensed residential treatment facility behavioral health agency that operates as a crisis stabilization unit? And West said, David, that's a great idea. Go ahead and apply for the grant. So a couple of years ago, we applied for that grant and we were funded through the commerce with two million dollars to renovate this facility and turn it into a crisis stabilization facility. Now, I won't get into all of the drama that happened, but suffice it to say that there was a contingent in Colville. and in Stevens County that was very opposed to this. They didn't know that for 23 years we had been providing stabilization services in Colville. They did not want us to provide stabilization services in Colville and the local motel owner of Benny's Colville Inn, which is right across the street with us, filed a lawsuit against Stevens County to try and block the conditional use permit that the city of Colville had granted for us to renovate this into a crisis stabilization facility. So the project took us a year longer than we thought after we were funded with commerce to go through the lawsuit, but ultimately we prevailed. The city has granted us the conditional use permit and we are now converting We now own this building, and we are converting it into what will become a 14-bed Alliance Crisis Stabilization Unit. So the gray building right next door here, that's our main office, and this is what's coming in the future. So just to give you some idea of what's coming, this is the floor plan. We've got five bedrooms running across the top that has two beds each plus two other bedrooms at the front of the building. One will be for people who come in who may be intoxicated. Another will be for people who are waiting for the full triage to be admitted into the facility. In the bottom left-hand corner here, we'll have a medical exam room. storage rooms, three different bathrooms. Coming along the top again, we've got the kitchen with a food storage area, a big open area for a TV area and an eating area, a couple of staff offices, a visitor's office in the bottom right-hand corner here, a telehealth room to connect for services after hours along with the staff area. And these are artist renditions of what it will look like when we do the inside. So we actually went out for a bit for the architects. We contracted with NAC Architecture out of Spokane, who we'd worked with in the past when we built our inpatient unit, the evaluation and treatment facility. They've been fantastic to work with. And after a public bid, we contracted with Leone and Keeble as the contractor to build the facility. And they've also just been fantastic to work with. We're very happy with our partnerships. So here you're looking at kind of the TV area and the dining area right across from where the staff office will be. Get an idea of what the colors will look like. The bedrooms here with the two beds and the storage area for clothes. Some of the staff break area inside with the coloring that will be going in there. This will be the door here going into the kitchen and actually trays of food will be served through this little window here to folks to bring out into the dining area. What we're looking at here the existing building is the public works building and in the backyard we're actually putting in a healing garden. That will be shared space between the crisis stabilization unit and then the other existing building on the left is our headquarters, so our staff will be able to go out into the healing garden and share time with the clients of the crisis stabilization unit. Once we contracted with Leon and Keeble, the first step was to get in and do full demolition of the inside of the facility. Even the ceiling is gone now. They pumped out all the insulation and it's a complete renovation. And inside now, this is close to what it looks like right now. They've got the walls up. We haven't put up the drywall for some time because we have to wait for a specific type of security door that allows staff to open the door either way so that it can't be barricaded. So you're kind of looking at this area here will be the dining area that you're looking at right here. This will be the room for patients who may be intoxicated or under the influence at the time that they come into the facility. And this is the current status of the outside of the building that will eventually look like this. So part of what I've been working on as I get ready to leave is writing all of the huge revision of our policies and procedures to become a licensed residential treatment facility and a crisis stabilization behavior health agency. All of those have been submitted to the Department of Health and we're waiting for the review with them right now. And we anticipate that all the construction will be done, that we will be fully licensed and operational on or about November 15th of 2026, and that will be the going away gift that I will leave to Martha fairly the incoming executive director who's actually been named the executive director of new alliance. As of May. 1st, the 2 of us are overlapping so I can give her some more support and guidance as she gets ready to take the reins and. bring on our new flagship facility for stabilization services in serving Stevens Ferry and Lincoln County. We're also expecting that we'll be doing some support for Ponderay and Spokane County clients as well. Historically, about 85% of the people that we serve come from Stevens Ferry or Lincoln County, about 5% from Spokane County, and about a half percent out of Pend Oreille County. And we envision that that will continue to be the case going forward. So we're excited about this project. It has been a long haul. I wish I could be here to see it open, but the timeline just wasn't on my side. So any questions with anybody?

David, you can still be here when it's time. So I'm just going to throw that out there. It's your choice, Matt.

You know, I would love to, but I think my wife would have something to say about that.

When is its anticipated open date, David?

November 15th, 2026. Give or take a couple of days.

Also, thanks for a great example of what it looks like to finish strong.

Well, thank you. I appreciate it. All right. Well, Justin, I'm going to pass it back to you guys then. Thank you very much for the opportunity.

Thank you, David. A huge impact you've had on our community, our regional service area, and the three counties, obviously, that new APH operates within. You'll be sorely missed in our ongoing scrolls from this point forward. Thanks for ending on a strong note here as well by sharing this exciting new project.

Well, thank you, and thank you for your guys' years of partnership and leadership. It's just been a great relationship. We've enjoyed working with Spokane very much.

Thank you. Okay, moving on to item number four, I'm going to go ahead and turn it over to Shannon Hallfield, Director of Pend Oreille County Counseling, for her topic here next.

Well, I have missed a ton of meetings, and I'm still newish to the meeting, so I just wanted to acknowledge, I have no idea how many times you have had the same discussion, so forgive me and thank you. I'm chronically aware, given the size of our county, that we don't have all of the services we need, right? There are service gaps. I was also impressed when first moving here how many services we do provide. And many of those services directly, Ponderate County Counseling Services provides. But about the time we get into our severely emotionally disturbed youth, we see the same thing also with adults as well, but particularly with the youth, it's a huge challenge. One, we just have a lack of additional resources. Coordinating resources is troublesome. It's very difficult when we have a child who has a mental health condition, but also has some potentially criminal behaviors, or for that matter, it's really unclear whether or not they are criminal at all, given their level of understanding of what they're doing, and also given the mental health conditions that they have. In our own little county, we have trouble coordinating to provide services. but also between counties. So when we have services that are, like some of our residents bump up against Spokane County and could go either direction. And so as I'm chronically aware of the service gaps or of the problems, I'm also simultaneously going, what is it we need to ask for? Or what is it we need to do? Or what's the solution? Or in a perfect world, or for that matter, in a more populated area, what is it that they have? And is there a version of that that could be a small version of that for our area? Or do we have to think of something new altogether? And I don't know. But what I keep getting back to is the importance of collaboration, coordination, and maybe chronically documenting these service gaps, or more importantly, how it impacts people specifically. And I kind of wanted to give a little bit of an example of this. I know we all have imagination. We can imagine what it looks like. But recently, it's been very obvious. We have a minor that we work with, somebody who is under the age of 13, who is in and out of home placement currently, who has lots of services to support them. And either it's not enough or it's the wrong services, one of the two. It's not been effective to meet all their needs, particularly when They'll go through periods of time where they're doing quite well, and then periods of time where it's gotten very dark and very heavy. And some of that dark and heavy is for them just within their own experience, but it also trickles over to their out-of-home placement where they're assaultive and where they are destructive of property. And so some of the things that we've seen here is, again, despite receiving... uh, wise services, despite the other wraparound services that they get in their out of home placement. Um, uh, there's not an appropriate next step. So theoretically it is clipped. They are waiting for a clip. So that has been, uh, agreed upon approved. That is the plan. But in the meantime, they, they have been to Martin hall, I think like four times, uh, they have, when in Martin Hall, they self-harm, and that is very distressful and certainly not good for them. And it's extreme. It's an extreme level of self-harm that they're engaging in. There's not a likelihood that they will probably be placed in an in-home placement. There are very few uh hospitals for to take um a child of that age at all in our area i mean i don't mean pondering county but i mean on this side of the state um and in general it's pretty hard to come by so uh mostly i'm saying we're about to when this person goes to clip i'm sure that they will be out of area um if they go to a um short-term hospitalization in the meantime they would have to be most likely sent across the state uh the i i am hoping that we have put a kibosh on the visits to martin hall i just don't see how they're helpful except for maybe keeping other people safe um but it's complex and it's painful and uh i realize that this is an extreme but it makes me think of you know at the lower level, how would we be addressing this or what other services can we provide before it gets to this place? And I have, so one, in some ways, this is just a, hey, guys, here's these problems. I'm sure you've seen them before. I'd like to feel better about them. A certain part of me does feel better when I just acknowledge, well, our system doesn't work for that. But I can't help but wondering what would make it work. And I appreciate all that we do for the majority of people or the most common situations. But these ones that are uncommon really, really get to me because they're, it might be this very small population, but for that population, it's their whole world, right? It's literally their life. I got really excited actually listening to David talk about his, like the journey to the Crisis Stabilization Center because a piece of me goes, oh, well, we figure out what we need and then we pursue that need. I still don't know what the need is 100%. I don't know what the solution. So I guess I'm kind of opening up conversation to what people have seen, solutions they have seen that work, ways maybe in counties where coordination or collaboration has been effective. All of those things. So mostly just bringing that here seems like an appropriate to have some version of that discussion.

Thank you, Shannon. I appreciate you bringing that forward in this space. And I think you're highlighting something that I would be brazen to say that all of our counties have experienced is experiencing individuals who have complex needs that aren't necessarily just one area of focus, right? That intermingle all those supportive services, whether that be DDA, DS, or family and youth services, whether that be behavioral health, you know, housing services, all of those criminal legal services and hospitalization, all of those unique services and how do we come together as communities to best support that individual with the supports you do have and then kind of where are those gaps in services to be able to help someone stabilize in that community. Because we know that simply sometimes those things just haven't evolved or don't exist, especially as we speak about the youth population. I think we see that frequently that there's a lot of specialized youth services that maybe aren't available statewide. I know we've talked in this space before about secure with job management, outpatient, inpatient SUD treatment services. And I know psychiatric hospitalization for youth under 13 is also something that we've discussed in this space as well due to limited inpatient opportunities for that population of individuals. Is there any feedback from the group, from any individuals in the group that you would like to share on maybe your experiences navigating some similar complex challenges in your communities?

I mean, I'll share this. I'm not going to have a great solution for you, Shannon, at this point in time. But one thing that I've noticed, and I'm with Excelsior, we're in Spokane. But one thing we've launched over the last few years is some of our telehealth platforms. And what we've realized in doing that across the state is we've had more rural participants choose that service than we realized. I think part of our responsibility as an agency like that is evaluating that and then coming and meeting with you and other people and saying, hey, what does this mean? How do we serve correctly? How do we meet the county that they're in and get to know those places better? And so I've had some interesting conversations this last little bit, most recently with Shane McGuire in Dayton, talking about their hospital system and how these might work and things like that. So I don't know. I think I'm curious to get into more conversations around it because we're just finding ourselves serving more in the rural communities than we thought we would. And so we need to lean into that and I think learn from you and see where we might have some intersects for that collaboration you're talking about.

Thank you, Drew. And I think, you know, and this might foster some offline connection as well, Shannon, with some of the participants here. But I think, you know, we also strive to have forums that kind of can bring forward these challenges that individuals and providers are experiencing as it pertains to youth. Places like our Family Youth Roundtable, our FISPRT quarterly meetings. I'm not sure if New ABH, I'm sorry, not New ABH, but Ponder Bay has been participating in those, which I believe so, especially with the WISE providers and our regional crisis collaboratives and other, you know, jail and transition and coordination meetings. other spaces where we can maybe bring those partnerships involved in those systems of care together to see what are some pathways for it. I think part of that too, as you identified, is really identifying what is the ask? What is the service or support that is missing here that would stabilize? And sometimes that's challenging to identify when there are complex needs identified.

And I guess if I were to ask a more specific question, it would be like, for the people who feel like I think there's always some unmet need, but the area of need that I'm talking about, what was the, what was the, what is the missing piece? I'm starting to feel silly. I'm like, I've been here two years and I'm still looking for like, what is the magic thing? If we had a magic thing, what would it be? And part of what brings this up really strongly is this particular situation, the guardian. So there's an out of home placement locally, but the guardian is across the state. And the guardian is the state. And so we've got caseworkers on the other side of the state saying, well, just do this. Just do this. Just do just do this. We're like, well, we don't have this, this, this and this. So. Great idea or or for that matter. Well, I guess that's that's what brings it brings it up is, OK, there's these potential missing pieces. Which one is the one that we start with? How do we start?

How do you eat an elephant, right?

What's the first bite for us?

Absolutely. And I'd be happy to talk about this offline too, Shannon, kind of maybe dive a little bit more detailed into specifics too and see what supports we also know about that can help identify kind of where that starting point is, right?

Yep. Thanks, Ashley. Appreciate it.

Yeah, this is Justin. You know, I think you hit on a complex issue that has not just one solution, but multiple. You're talking about an out of region placement. You know, there's some ownership on DCYF to provide either respite or ongoing care. There is a requirement as the guardian there to be participating in what that care would look like, especially when you're talking about complex trauma and behavioral issues that in the setting that they're currently in, the question is, can they be managed? The behavioral health component definitely plays a portion of that. But what is the primary, what is the driver? And if they're consistently being placed in a behavioral health facility, that is time limited, right? And then they are to be returned. So the question is, we need to look at both components. And that's been a pushback we've had in the state. The ownership on this And I know I've said this quite a bit, is to look at how do we partner to ensure that the mental health component is there? And it is. There are facilities and services that can be provided, which is why CLIP is there. But it can't be the end all. CLIP needs to return them. And so there needs to be coordination between those two systems. But More than anything, a real look at the state level on how do we mitigate what we're seeing for maybe a select few, but a very high utilization group. And is the current methodology not working? And then regionally, we need to look at, you know, Martin Hall is definitely a placement, but is it the best placement? And we've had this conversation for quite a bit of time. We could do and can be doing more at Martin Hall to provide for the care and well-being and to also sustain a safe environment. place where that can occur, right? But that's custodial. What we're looking at, Cliff, is being behavioral, mental health driven, right? And then you've got the placement, which is both a home setting that's supposed to address those needs. How can they all work together? So when we look at this, you just touched on something that has three separate parts that need to work in tandem. It often feels like a hot potato between the three. And then secondly, Eastern Washington, I think the recognition of a lack of resources. We do not have acute facilities that can provide that level of care other than them getting so acute that they have to be placed in a CLIP facility. And although we did have expansions of a CLIP facility with Illinois Northwest Behavioral Health looking at expanding care, it doesn't solve the problem when you only have six beds. Where's that intermediate? So I don't think... as we look at this janet you are there can be one solution certainly not solved by the local communities when we're recognizing that placements from out of region we're challenged with those aspects but how can we better partner in those and really looking at where that needs to be initiated the state needs to drive and i think our ask to that level needs to be a drive to say how can you uh first give the resources locally to address what you have placed in our region and then secondly how can we better communicate uh with those systems so that when when pondering county counseling is interacting with this youth Right. That the interaction for a crisis is is what a crisis is supposed to be time limited and to move them out of that into a setting that is safe and secure and not the catch all like an ER where you're just putting a band on something. I think that's the frank reality we need to address. But I can I can talk for hours about this as well, just as you kind of indicated. But I do think the driving force on this needs to start at the state level, recognizing that there is an issue. in local communities when we're talking about youth placed in DCYF. And we don't want to go back to what occurred that drove us to the wise level of care and how can we best be proactive in this. And I think we need to be partners with the state on that. I'm all for that. I think it's going to be a tough year as we look towards 2027's biennium. But in the meantime, right, that's a long term plan. I do think a more robust conversation with DCYF and with our health care is like, how do we work with that? And we've done that with adults as we work with Eastern State Hospital as well. So I do think there's a pathway forward. Not an easy one. As Drew kind of indicated, there isn't an answer that we can readily give, but there are certainly ones that we can coordinate better to mitigate that time in between where there is this kind of unknown.

Thank you so much, because that's so helpful in a couple of different ways. And one of the ways is I'm aware that there are so many things. I have to remember what our lane is. what we can do, what we can't do. And we have to know that really well. And we've seen that in lots of other areas besides this one. And not get too discouraged, right? In the meantime, going, well, this is all we can do right now. But that as far as advocating with the state or advocating with DCYF, advocating with healthcare authority, I think that that is something I would love for this format or any of the other formats where we coordinate for that to be intentional, many organizations advocating with the state for the things that we need. Because advocating with, I'm gonna use the same example, much of the meeting that I had with all of these parties, including the caseworker, the DCYF caseworker, is saying that's outside our purview. That's outside the law for us. That's outside of the law for our legal folks as well. This is what we can do. So essentially setting boundaries, clarifying roles and expectations. And I think that it's important for that individual case, but that caseworker, it's not like she's going to go back to her, like to DCYF as an organization or to the state as an organization and say, Hey, we need X, Y, or Z. They're going to go back and say, Oh, Eastern Washington can't provide or Ponderate County can't provide, or they don't do this. And so talking to the right people who represent the state or represent the organizations who do this. And so I guess that's what I'm asking for too, is I would like to know, do we have a format currently for advocacy with the state? And which meeting is that? And what, what, how do we, how do we do that? Or how do I get involved in that? is a secondary question. And maybe this is an offline question. I don't know if I've taken up too much time or any of those things, but if it is we need to advocate for the state, I would like to do that in a coordinated way.

Well, you bring up a great point. This is one of those avenues in which we could definitely work with HCA. But again, that scope is going to be limited as well, you know, because it's going to be what insurance carrier they have. And it's going to be specific to the behavioral health treatment and not all these other aspects that really are the driving force, right? There's a correctional aspect or custodial where... individual is engaging and is a risk, right? If they're injuring or currently acting in a manner which is unsafe for the milieu. You've got the, I'm assuming it's a one of those group or transitional homes as well, right? So then you've got that contractor working on behalf of DCOAF to provide that care that is directed to ensure certain levels of responsivity so that they're the main driving force, but then of course the state is the responsible guardian for that current time. And then you also have the treatment facilities and or Martin Hall facilities that are temporarily receiving them and then returning them. I just recently talked to one of the local hospitals here, and they're seeing the same issue with lengths of stays for more acute. So although we've done a really good job of preventing some of the non-acute with work with the state on expanding out stabilization services in the community, what they're seeing now is those acute services significant acute individuals where there is no other placement other than in a state facility requires more intensive care being kind of bubbling to the top, but they're staying longer now in the ERs and in the facilities. So is there a question of, do we work with them to say, how can we kind of address that issue? Is there any immediate level of care that we can work with that would require working with the hospitals and the providers locally to do that while also working with the different state agencies to address that. Again, we're going into a very challenging budget cycle. So the question was more gonna be, what can we do with what we've got or with slightly less than it is about what can we ask for? I think we need to be practical about that. But I do think there's mechanisms by which those entities could better coordinate reducing the time where they may have involvement in crisis or in between with uncertainty. So in that avenue, I think we could do that here as well as with partnership with DCYF.

Thank you.

Absolutely important item to bring forward. So thank you, Shannon. on that point. Any other feedback before we move on to agenda item number five here? Not seeing or hearing any other. Agenda item number five, we'll go ahead and turn it over to Gail to talk about the behavioral health community forum.

Thank you for giving me a few minutes to talk about this. And Shannon, I would just like to offer that We here in our Spokane region host a monthly behavioral health forum. Our July 8th forum is dedicated to talking about the lacks we have in our youth, serving communities, the acuity levels, the need for crisis. So I would really, I think I tried to reach out to you recently to send you a link to that, but just let me know and I'll send that back to you again. It's on July 8th from 3 to 4.30 p.m. Drew up in the tens, but our challenge then is going to be taking the discussion points that we have from this July 8th forum, rolling it up to our FSPRT gaps and needs. This is a longer waiting process, but it does take it up to the state FSPRT level and that then goes out to the other regions and it rolls up to the state. It was about four years ago or two years ago, I can't recall, but we were able to successfully lobby to get more money for non-emergency medical transportation in our state because of the lack of quality services we were seeing and the concerning drivers that we saw. So we were able to get that change, but it did take some time, but more money has now flowed to them. So I just wanted to offer that. That's going to be our specific discussion. You know, the What are our needs? What are our, what are, what do we need to see? What's going to be best for this situation? So there's that.

Thank you so much, Gail.

You bet. And I would love to have you there or one of your wise coordinators or any of your staff who would be able to come and at least provide your input that will get, like I said, taken to our fist bird. So, but on July 17th, we are, and can I just share this flyer real quick? Am I able to share?

Yeah, you should.

Okay, let me see if I can find, okay, here it is. It is a JPEG. There we go. Can you all see that?

We can see it.

Good. So this is something that every region is doing once this year. Ours is on July 17th. Thank you, Justin and Ashley, for one of you coming and speaking to the community about what the BHA itself provides. Because so many people have no idea who you are, what goes on, what are they benefiting from in the community. And I just am looking forward to this. We are really expecting a good turnout. We have some sponsors or some vendors that will be there. Everybody gets a swag bag. We're serving snacks and we'll have resource tables. It has a Northeast Community Center. We expect to have Better Health Together speaking as well. I'll be talking about mental health advance directives. one of my soap boxes that I stand on a lot. And we're just, I just wanted to make this group aware of this coming up. We hope to get a lot of feedback from the community. We hope to have some good questions asked. We really want to get a voice from what's happening. And again, this would be a great place to have additional voices or questions about what's lacking in our communities. Where are our gaps and needs? Where is it that we need to plug in more? of our limited resources if we can. So I'm just gonna stop sharing and just take it back to you. And if you have any questions, just let me know. I can put my email in the chat and I can send these to you and just feel free to reach out to me.

Wonderful, thank you, Gail. Any questions for Gail on the forum? We're looking forward to it, Gail. So thank you for bringing that to the space as well. All right, moving on to agenda item number six, which is SCRBHASO quarterly updates. And we won't belabor this too long. I know we've had a very robust discussion today and different meeting topics. And so jumping right into it, one of the first things we have listed here is House Bill 1813, as Jason with HCA was discussing. That was a hefty lift to get that in place for July 1. For the Spokane Regional VAJSO, we are in a very good place for that. Again, this is something we've talked about before in this space, but as a reminder, this is delegating additional crisis stabilization facility-based services to the VAJSO under the Crisis Continuum of Care from the managed care organizations. And so in terms of the services and the way individuals are receiving those services from providers, such as our Regional Crisis Stabilization Center, who does behavioral mental health stabilization, and as David discussed, the newly anticipated CSU opening up in Stevens County in November. There will not be a change in the way those services are provided or received by individuals seeking those services. However, on the back end, as it pertains to utilization management, contracting, funding, all of those elements, That will be funneled through the VAJSO. As we look towards the future, we do anticipate kind of incorporating some of that data into our quarterly crisis data dashboard to give a better landscape view of what we're seeing in our crisis system. So that is the 1813 update. For legislative updates, we don't have much in terms of legislative updates. Obviously, the legislative session has ended. But from the ASO perspective, we do recognize that, as Justin alluded to, we're going into a more challenging economic environment ahead of us. And with that, our position is not necessarily to request more, but to look at how we maintain funding stability for services and programs that are existing. strengthen them and ensure that that collaboration is happening between those areas, looking at areas of gap in coverage and areas of acute intensity as well. So that's kind of the focus that we have moving into this next legislative session. Curious to hear, I don't know if any commissioners or leaders from the counties have any priorities that they're looking at legislatively as that will be a gear up season coming here shortly. I don't know if anyone wants to share any other legislative priorities that you have moving into the new year. Maybe not. Moving on, Rural Health Transformation Project. I know Jason put some links on that in the chat as well and spoke briefly about that. The state did apply for Rural Health Transformation funding and was approved for that. There's many different initiatives from the BHASO perspective. Initiative 6, which is expanding behavioral health supports in the community. 6.1 specific towards expanding mobile crisis services in our rural communities. is something that the ASO is working closely with the healthcare authority, and we'll be working closely with some of our rural providers to look at how we can expand that mobile crisis outreach and support services in those regions in alignment with the requirements under CMS and federally for that funding. So more to come on that, but that's just kind of a precursor that that work has begun. We anticipate more solidification in what those plans are at our next squirrels to be able to be presented. And lastly, Step Forward is a program that was put together in Spokane County that we wanted to speak on. So for the BHASO, Step Forward is a voluntary pre-filing diversion program operated in partnership between the Spokane County Prosecuting Attorney's Office, as well as the Spokane County Regional BHASO Diversion, Deflection, and Reentry Team. That team currently does reentry work, jail transition work, as well as some prosecutorial diversion programs through DSHS. Now is partnering with the Spokane County Prosecuting Attorney's Office for individuals who may be arrested under a felony offense, but maybe as a result of a behavioral health need being identified. The Prosecutor's Office is reviewing those cases and determining if an individual may qualify for pre-filing diversion, and if so, they are directing them towards the DDR, again, voluntarily. that program to engage with our team to be able to connect those individuals to ongoing behavioral health supports in lieu of filing felony charges for those individuals. And so this is a new partnership and it's initiated in February and going well so far. Probably some more data to present in the future on that program. I'll pause here to see if there's any questions or comments or Justin if there's anything you want to add to those elements.

Gail Keirn, I asked a quick question.

Gail Keirn, Absolutely, you.

Gail Keirn, know it's been a quick a short partnership that had have there been any how many, if any, have been diverted so far during the step program the verdict is that a correct way to say that.

Gail Keirn, yeah no that's a great I think the last update I got which was at the beginning of the week, I think we have 25 active participants in that Program. and we're finding good success. Our team is working to, once that referral is received, be able to engage with those individuals if they're still in custody prior to the first arraignment hearing where they may be released from custody so that they can initiate that contact. We found great success the more we're able to connect with them in that setting. There's some that have already been released, but that connection is going well.

Which agencies are you partnering with on that?

It depends on the individual's preference and their identified need. And so any behavioral health agency, we do have some individuals who might get arrested on a charge here in Spokane County and return to another county. And so you've been connecting with agencies maybe in the county of residence until they return or if they are going back to another county.

Thank you.

Absolutely.

All right. There's no other questions or comments on those items. I'll move us into agenda item number seven, which is open discussion or walk on topics. So I'll go ahead and pause here to see if there's any walk on topics. Going once, going twice. Not hearing or seeing anything. We'll go ahead and move it to the public comment section of the agenda. Are there any public comments from community stakeholders? Not hearing or seeing anything there. If there's nothing further, then we will plan to meet at our next meeting, which is Friday, September 11th. Of course, if there's any agenda items in the interim, please feel free to reach out to us and we can get those added to the agenda. But really appreciate everyone's time today, as well as the robust discussion and updates.

Thanks, everyone.

Thank you. Thank you. Have a wonderful Friday, everyone.

Thank you. Wow. My meeting's over. Not over early.