Draft Pierce County Behavioral Health Improvement Plan (January 2024)

Pierce County Behavioral Health Improvement Plan January 2024

Previous versions: September 2021 Created plan, council approved December 2021

Introduction

In December 2020, the Pierce County Council passed Ordinance 2020-138s, creating an additional sales and use tax for behavioral health and therapeutic courts. Consistent with RCW 82.14.460, revenue for this tax may be used to fund mental health, substance use disorder, and therapeutic court treatment programs and services.

The ordinance requires the Human Services Department to develop a Behavioral Health Improvement Plan (BHIP) to guide funding priorities over the next six years. The BHIP is to be submitted to the Council and updated biennially. This document is intended to fulfill the BHIP requirements outlined in the ordinance.

Background and History

The behavioral health system in Pierce County has weathered several significant changes over the past few decades. Many of the county’s community providers have been in operation since the 1970s or earlier. In the early 1990s, the state moved mental health services to a managed care system under Regional Support Networks, while substance use disorder (SUD) funding remained within a separate county department.

In 2009, Pierce County decided not to renew its contract with the state to manage the Regional Support Network. After a competitive procurement process, Optum Health was awarded the contract. At that time, Pierce County also stopped providing direct mental health services: inpatient care, crisis triage, involuntary commitment, and crisis services In 2016, substance use disorder (SUD) and mental health funding was combined under the Pierce County Optum Behavioral Health Organization.

Another significant change occurred a few years later, when the state moved to an Integrated Managed Care (IMC) model. Responsibility for behavioral health services was split throughout Pierce County, between five Managed Care Organizations (MCOs) and the Behavioral HealthAdministrative Service Organization (BH-ASO), Beacon Health Options. In March 2020, Beacon Health Options was acquired by another organization and is now Carelon Behavioral Health. Carelon remains the BH-ASO for Pierce County. The BH-ASO provides services that help clients navigate through behavioral health treatment services when needed. BH-ASOs are funded through state and federal block grant funding and are required to make services available regardless of insurance status or income level.

Due to concerns about the lack of oversight of behavioral health in Pierce County, the county contracted with the Human Services Research Institute (HSRI) in 2016 to develop recommendations for improving the county’s system of care. The initial recommendations, updated in 2018, focused on creating a centralized coordinating body to address the county’s behavioral health needs. The county developed the Integration and Oversight Board to support and provide oversight of the transition to the IMC model. At the end of 2019, the Integration and

Oversight Board created a subcommittee, the Regional System of Care Committee (RSCC). The subcommittee, with membership from behavioral health providers, Carelon Behavioral Health, the Health Care Authority (HCA), Elevate Health, and Pierce County, drafted the RSCC Behavioral Health Strategic Plan in 2020. Key recommendations from the RSCC report included:

• Create a Pierce County Accountable Care Organization (ACO) Medicaid Pilot to increase coordination and ensure local control of funding. This recommendation is not currently supported by the HCA, and so is not considered an option at this time.

• Establish a regional data platform to collect and analyze data on social determinants of health, behavioral health, and physical health.

• Implement a local Behavioral Health Tax (1/10th of One Percent Tax).

In December 2020, the Pierce County Council approved the Behavioral Health Tax through Ordinance 2020-138s. The county began collecting the tax on July 1, 2021, and expects to distribute $42M to services in 2024-2025.

Pierce County’s Behavioral Health System Today

Two years into the transition to IMC, Pierce County has worked to address many of the issues identified in the initial HSRI analysis. The county, Elevate Health, Carelon Behavioral Health, and additional partners have advocated for greater coordination between physical and behavioral health. The county and others have funded the Crisis Recovery Center, Mobile Outreach Crisis Team, the Recovery Café, and the Mobile Community Intervention Response Team. These partnerships have also enhanced coordination of child and adolescent service collaboration via the development of Kids Mental Health Pierce County, a partnership representing over 100 agencies serving youth.

Appendix A outlines the current Behavioral Health Inventory in Pierce County. The list is an inventory of behavioral health providers that are known for providing behavioral health services or that are funded through the Behavioral Health Tax. This is not an inclusive list due to a lack of coordination between countywide behavioral health services.

December 2023 update: Now four years into the transition to IMC, Pierce County and its partners have significantly enhanced the crisis response system, particularly focusing on crisis prevention Among other achievements, an increased number of mobile crisis intervention and outreach teams allows for faster responses in the community. Two youth mobile outreach teams, created in 2023, support a professional response that matches the need of the community. The implementation of 988 the national suicide hotline creates one line to call for assistance. The graphic below shows the current workflow of the Pierce County crisis system.

Despite these gains, many of the gaps identified before IMC still exist today. These gaps, identified in detail in the Behavioral Health Needs Forecast section of this document, include unmet needs across the prevention and treatment spectrum. The increase in crisis response services has led to a rise in need for step-down services and temporary care management

services. Expansion of these services are the next stages to creating a comprehensive system of care.

The Future of Pierce County’s Behavioral Health System

Behavioral health needs arise from and are influenced by several factors. Any system designed to address these needs must employ a “whole person” approach that includes healthcare, employment, housing, and education. Pierce County’s goal is to foster an environment where those with behavioral health needs will have access to a full range of innovative, effective, and culturally competent services, including:

• Community education

• Prevention and early intervention

• Outpatient and community-based services

• Crisis and inpatient services

Figure 1 Crisis Services Workflow created by Carelon Behavioral Health

• Services for justice-involved populations

• Housing supports for those with behavioral health needs

The following outcomes outline our vision for the future of the behavioral health system in Pierce County. These goals are described in more detail in the Behavioral Health Needs Forecast and Six-Year Plan sections of this document. In 2024, the Behavioral Health Advisory Board (BHAB) will set up a subcommittee to review, condense, and prioritize the list below.

1. Those seeking behavioral health treatment will have access to services in a timely manner.

2. The behavioral health system will be responsive to the changing needs of the community.

3. Funding decisions will be based on assessments that involve local outcome data and stakeholder input.

4. Continued support for programs will be contingent on data showing interventions are evidence-based and effective.

5. Programs will be supported by a diverse collection of funders.

6. Interventions will be culturally competent and trauma informed.

7. Funders and providers will move toward data sharing and more integrated data systems.

8. Meeting housing needs will be an integral part of behavioral health interventions.

9. Access to employment services will be integrated into of all levels of care.

10. The system will include services tailored to the needs of veterans.

11. Funders and providers will support peer-operated services.

12. Funders will continue to support and expand effective school-based services and other interventions targeting youth.

13. There will be a greater focus on SUD treatment to address the increasing number of opioid overdose deaths.

14. All citizens will have access to behavioral health treatment, regardless of their insurance coverage or ability to pay for services.

15. Funders will support new and innovative approaches to wellness and prevention that include interventions at earlier ages as well as support for at-risk parents and those caring for children with complex behavioral and developmental needs.

16. Individuals will have access to inpatient facilities that provide treatment to those who are medically unstable, have dementia or developmental disabilities, live with traumatic brain injuries, or have a history of violence.

17. Funders will support programs that meet the individualized needs of all residents, including those operated by members from underserved populations, organizations focused on the needs of specific cultures and groups, and faith-based organizations.

18. There will be more options for step-down programs for those exiting inpatient care.

19. Funders will continue to support crisis stabilization facilities and other alternatives to hospitalization.

20. There will be continued support for and expansion of programs for justice-involved individuals.

21. Funders will seek opportunities to support overburdened systems such as county emergency rooms to provide safe, high quality and culturally competent triage services to individuals with high-risk behavioral health needs.

22. Behavioral health services will be equitable for all, culturally competent, and will take into account historical and systemic inequalities in our communities.

Behavioral Health Needs Forecast

Over the past seven years, Pierce County has continued to advocate for quality behavioral health services for its citizens. The county has supported studies, workgroups, and boards to assess the community’s behavioral health needs. The needs assessment here builds primarily on two previous community evaluations the HSRI 2016 study of the Pierce County behavioral health system (updated in 2018) and the RSCC 2020 Strategic Plan for Behavioral Health. In 2023, the BHAB reviewed this forecast and affirmed its continued relevance with no changes from the original report.

The forecast below relies on:

• Behavioral health data

• A behavioral health needs assessment survey completed August 2021

• Input from the Pierce County Behavioral Health Advisory Board

• Experience based on programs funded by the behavioral health tax since 2021 in Pierce County

The resources and deficiencies identified in this forecast are generally organized using the categories suggested by HSRI in its initial analysis of Pierce County’s human services environment. Based on stakeholder feedback and discussion, some categories were arranged differently and some new sections were added. Areas of need are organized into the following categories for both mental health and SUD:

• Community education and wellness

• Wellness, prevention, and early intervention

• Outpatient and community-based services

• Crisis and inpatient services

• Services for justice-involved populations

• Additional needs

Each category includes an assessment of current resources and needs followed by a forecast of those needs over the next four years

Note on Funding Strategies

The gaps and needs identified in this forecast exceed the capacity of those programs funded by Pierce County. No single funding source will be able to address the wide-ranging needs of our community. Many of the services are or should be covered by Medicaid or other grants. The solutions offered here and in the Six-Year Plan section require efforts and funding far beyond what the recently implemented Behavioral Health Tax can cover.

December 2023 update: While intentional and data-driven collaboration continues to improve the behavioral health system, HSRI’s 2020 evaluation is the most recent large-scale, system-wide appraisal; the remainder of this document continues to use it as the framework for assessing

community needs. Pierce County and its partners must continue to perform regular assessments of the system to strengthen and ensure its capacity to meet the need. No system wide assessment is set to happen in the near future. The City of Tacoma is currently assessing the behavioral health system within city limits. Smaller provider agency evaluations and research studies are happening throughout Pierce County. Pierce County Human Services is working to conduct an evaluation of the behavioral health tax and the impact to Pierce County

Data on Behavioral Health in Pierce County

Untreated or insufficiently treated behavioral health disorders leave a lasting impact on individuals, families, and our community. Measuring the outcomes of interventions funded by grants is key to knowing which prevention or treatment options work. The Six-Year Plan section of the BHIP contains details on potential metrics to determine program effectiveness.

Those community behavioral health measures currently available demonstrate the need for new and expanded services within Pierce County. The county trends higher than state or national averages on several behavioral health measures:

• From 2015-2019, the rate of drug overdose deaths in Pierce County was 17.2 per 100,000 people, higher than the state average of 15.3 (Washington State Department of Health). In 2021, there were 181 fentanyl-related deaths in Pierce County, surpassing a total of 103 in 2020 and 38 in 2019 (Tacoma-Pierce County Health Department). This coincides with a similar pattern statewide.

• Over the past 15 years, 17,502 Washington residents died from a drug overdose over the (between 2007-2021). Sixty-eight percent of those deaths involved an opioid. Since 2019, the annual number of opioid drug overdose deaths has nearly doubled, from 827 deaths in 2019 to 1,619 in 2021 (Washington State Department of Health).

• In 2019, Pierce County had a suicide rate of 20.1 per 100,000 people, while the state average was 16.4. Washington’s suicide rate has been higher than the national rate for more than 10 years (Washington State Department of Health)

• Pierce County’s rate of individuals with a Serious Mental Illness in 2019 was 24% higher than the state average (2019 Pierce County Needs Assessment).

• The most recent Healthy Youth Survey (2021) reported that 23% of 10th graders in Pierce County seriously considered suicide in the last year.

• In 2017, Pierce County had 59.6 mental health counselors per 100,000 people (Washington State Behavioral Health Workforce Assessment, 2017). Since then, workforce shortages have increased for most providers of public behavioral healthcare in Pierce County, particularly in higher level positions such as mental health professionals, psychologists, and psychiatrists

• The American Academy of Child and Adolescent Psychiatry suggests that 47 child and adolescent psychiatrists per 100,000 people are required to meet US community mental health needs. In 2021, Pierce County had nine child and adolescent psychiatrists as compared to Washington state, which had 11 per 100,000.

• Between 2015 and 2018, Mary Bridge Children's Hospital Emergency Department saw a 400% increase in children presenting to the emergency room with primary behavioral health needs.

December 2023 update: The data reported above is from 2021 and earlier, which is the most recent available. This highlights an ongoing issue in the behavioral health system: the lack of a unified data system. Multiple reporting steps and a variety of platforms holding the information place a burden on providers, who must enter the data into different systems, and limit data sharing abilities. This causes difficulty for agencies seeking a system-wide perspective.

Available data points toward trends that likely continue to the time of this update. In the past few years, the Washington State Department of Health reports that Washington has seen an increase in deaths related to drug overdoses and suicide. Additionally, youth behavioral health needs continue to increase while significant workforce shortages in behavioral health agencies across the state grow.

Community Education

Community education efforts are key to an effective behavioral health system. Efforts to decrease stigma around behavioral health increase the likelihood that families and individuals will reach out for help. At the same time, increasing community awareness of mental health and SUD resources ensures people will know where to turn when help is needed.

While there are several evidence-based approaches to increasing community education around behavioral health, few programs receive long-term funding. Examples of previously funded programs include Mental Health First Aid and the Prevent-Avert-Response initiative for suicide prevention. The National Alliance on Mental Illness also provides community education and support for individuals and families affected by mental illness.

Community Education: Projected Need Over 4 Years

Most state and federal behavioral health funding continues to target treatment and crisis intervention, while community education funds remain scarce. Current and projected needs in this area include:

• Fund outcome and evidence-based programs aimed at educating the community on behavioral health and decreasing stigma. These efforts should include school-based training and education.

• Support anti-stigma and behavioral health education campaigns, including for those from bilingual, Black, Indigenous, and People of Color (BIPOC), Lesbian, Gay, Bisexual, Trans, Queer (LGBTQ+), and disabled populations

December 2023 update: Teen Mental Health First Aid was one of the first education programs implemented with the Behavioral Health Tax. In its first 18 months of operations, the program has grown from two instructors to 46 instructors and offered over 68 trainings to youth from the ages of 15-18. This program focuses on helping youth learn how to talk about mental health,

recognize warning signs, know when and how to ask for help from an adult, and identify resources and professional help. In the next few years, providers will continue to expand this program. We must also prioritize similar training for adult Mental Health First Aid.

There is still a need for training and education around the impact of behavioral health to individuals and the community, especially by and for bilingual, BIPOC, LGBTQ+, and disabled populations. Efforts to identify needs and programs in this area are minimal in our community with most of the effort falling on small agencies in the area. Programs like Oasis, HopeSparks, and others.

Wellness, Prevention and Early Intervention

Wellness, prevention, and early intervention services are designed to reduce adolescent and adult serious mental illness and substance use disorders. Prevention strategies range from general health promotion (wellness) to targeted prevention interventions for those who have been or may be at risk of developing a substance use or mental health disorder. Examples of health promotion are teaching youth emotional awareness and regulation or encouraging positive school and community engagement. Targeted prevention includes interventions aimed at those already engaging in treatment or public education campaigns about the dangers of substance misuse.

Tacoma-Pierce County Health Department Wellness and Prevention Programs

The Tacoma-Pierce County Health Department (TPCHD) provides and supports several prevention and wellness programs, including:

• Alcohol and drug use prevention

• Youth resiliency programs

• The Pierce County Prevention Collaborative

• Community education including Mental Health First Aid

TPCHD also provides community education on several topics that address whole-person wellness. In addition to the programs above, TPCHD works to address social determinants of health and improve health equity.

Infant / Early Childhood Mental Health (IECMH)

The Early Support for Infants and Toddlers (ESIT) is a set of services available through Pierce County Human Services to families with children under the age of three who are experiencing a developmental delay. Pierce County and the ESIT provider community have been leaders in Washington State by embedding Infant / Early Childhood Mental Health into the system. They have accomplished this by focusing on building early and secure attachments between caregivers and children to help regulate stress, building early life resilience and reducing the impact of adverse childhood experience. Children can now qualify for ESIT based solely on socialemotional needs, which has dramatically increased the availability of mental health support to children and families early in life.

Bi-directional Clinical Integration

Elevate Health, through the Whole Person Care Collaborative, contracted with the University of Washington Advancing Integrated Mental Health Solutions Center to support strong partnerships between physical and behavioral health providers. The Bridge of Hope is one such partnership between HopeSparks and Pediatrics Northwest. This program is the first pediatric collaborative care model in the nation to create truly bi-directional integrated care. Bi-directional integrated care means the integration of behavioral health care and specialty physical health care, and the integration of primary and physical health care within specialty behavioral health settings

Behavioral Health Screening in Primary Care

Behavioral health needs are often first identified during appointments with physical health providers. There are several tools available to medical providers for screening and identifying behavioral health disorders during regular office visits. Many providers already integrate these screenings into annual check-ups. Regular screenings can be expanded to other settings where individuals encounter health care providers or social service professionals. Once a behavioral health need is identified, providers need to know where to refer the individual. A strong outpatient network and effective care coordination are key to ensuring people get the help they need.

Wellness, Prevention, and Early Intervention: Projected Need Over 4 Years

Despite the demonstrated effectiveness of wellness, prevention, and early intervention programs, funding for these programs will continue to be limited as more state and federal dollars are focused on treatment. Prevention dollars available to local jurisdictions are usually limited and have severe restrictions on how the funding can be utilized in the community. Projected needs in this area over the next six years:

• Fund existing programs that have shown success but have no long-term funding.

• Expand currently funded programs into other areas of the county.

• Create new and innovative approaches to wellness and prevention that include interventions at earlier ages and increasing support for at-risk parents and those caring for children with complex behavioral and developmental needs.

• Encourage a culture shift from focusing primarily on crisis and treatment to preventing behavioral health and overall wellness.

December 2023 update: Comprehensive Life Resources was awarded a federal grant in 2021 to become a Certified Community Behavioral Health Clinic employing a team of therapists, doctors, peers, and technicians who provide counseling, medical, dental, and life skills support TPCHD has continued to provide nursing services for infants and pregnant women in the community which allows for early monitoring and support of any behavioral health concerns. Integration between behavioral health and physical health continues to be a focus for the entire state of Washington. The increase in an aging population, lack of access to behavioral and physical health care, and a growing understanding of the connection between physical and behavioral health needs are all factors that highlight the need to continue efforts in this area.

Outpatient and Community Behavioral Health Services

Pierce County is home to a dedicated group of mental health and substance use disorder providers. Many agencies continue to pursue evidence-based practices and improve care despite the challenges presented by changes in payment models, increased need for behavioral health services, and the COVID epidemic.

Community behavioral health services encompass treatment modalities that support individuals at risk for inpatient mental health or SUD levels of care. Where possible, individuals needing behavioral health treatment should have access to care. When someone is hospitalized, a robust support system including step-down services can help prevent a return to inpatient care.

Pierce County has funded hospital diversion modalities like the Crisis Response Center, Mobile Outreach Crisis Team (MOCT), Mobile Community Intervention and Response Team (MCIRT), and the assisted outpatient treatment pilot project. Additional efforts to provide communitybased supports have included increasing the number of Program for Assertive Community Treatment teams in the county. Some of these programs are described below. County collaborations have also developed innovative and effective models to bring crisis resources to our youth via Kids Mental Health Pierce County.

MCIRT is staffed by mental health professionals, peer advocates, registered nurses and Psychiatric Registered Nurse Practitioners who provide support to divert high utilizers of emergency and law enforcement services into more appropriate care. In 2022, MCIRT served 1,956 individuals with roughly 53% of those referred by police and Emergency Medical Services

Community Behavioral Health Clinics address a range of clinical services delivered in the least restrictive environment and offer social determinants supports (e.g., housing, employment, social inclusion). Most Community Behavioral Health Clinics operate a multidisciplinary team which provides services in the community or, if funding allows, in a client’s home to bridge the gap between traditional outpatient treatment and more intensive inpatient treatment.

Wraparound with Intensive Services (WISe) is an evidence-based crisis-prevention program focused on youth. It uses a team approach to provide comprehensive behavioral health services and supports to individuals up to 21 years of age with complex behavioral health needs and their families. The goal of WISe is for youth to live and thrive in their homes and communities and reduce costly and disruptive out-of-home placements in hospitals and residential treatment facilities. The county began funding a WISe team for non-Medicaid individuals in July 2021.

School-Based Behavioral Health Treatment

During the school year, children and adolescents spend more time at school than any other single location besides home. An effective school-based behavioral health system includes partnerships with local treatment providers, streamlined referral processes, and on-site interventions. Early

identification and treatment of behavioral health disorders can lead to long-term prevention and a reduction in criminal justice system involvement.

The level of behavioral health intervention available in each of Pierce County’s 15 school districts varies. Some services are only available to those youth enrolled in Medicaid. Starting in July 2021, the county began funding school-based behavioral health services for those youth not covered by Medicaid. These services were targeted at nine school districts in East Pierce County.

The roadblocks to access to outpatient and community-based services in Pierce County are like those faced by other regions of the state:

• A workforce shortage across all behavioral health services, resulting in increased wait times for services and diminished access to care.

• Medicare-only individuals receive no coverage for most SUD services and access to only limited mental health providers.

• Veterans and active-duty personnel face similar challenges in access to care due to a limited number of providers.

• No centralized coordinating entity for services, especially Medicaid-covered treatment.

• Many high-intensity outpatient services, such as WISe and Program for Assertive Community Treatment teams, are not covered by private insurance.

Services to Veterans

Nearly ten percent of Pierce County residents are veterans, and the county is home to Joint Base Lewis-McChord, the fourth largest military base in the United States. The American Lake VA Medical Center is a hub for physical and mental health treatment for many of the region’s veterans. Veterans have disproportionate rates of substance use, behavioral health disorders, and suicide ideation and completions. Addressing the needs of this population in Pierce County should be part of any behavioral health system plan.

The county currently funds programs at the Cohen Center in Lakewood, which helps veterans and their families overcome behavioral health and other issues, including depression, anxiety, parenting concerns, and transition-from-service issues.

Employment Services

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), twothirds of individuals with a serious mental illness want to work, yet this population has historically had unemployment rates as high as 85%. Research has demonstrated wide-ranging positive effects of employment among those receiving behavioral health treatment, including decreased symptomology, increased confidence and independence, and reduced usage of higher levels of care. To realize the benefits of supportive employment, the county’s behavioral health system will need to support evidence-based programs like Individualized Placement and Support.

Recovery Support and Peer Services

While recovery support services help individuals in all stages of recovery, one often overlooked aspect of these services is their effectiveness in helping people maintain recovery. Feedback from the community included concerns that most behavioral health funding is focused on crisis or inpatient services, yet individuals will spend most of their time in recovery not in crisis.

When individuals facing behavioral health problems have adequate support systems, they are less likely to need more expensive interventions. Supporting recovery leads to crisis prevention.

According to SAMHSA, there are four major dimensions that support recovery:

• Health overcoming or managing one’s disease(s) or symptoms and making informed, healthy choices that support physical and emotional well-being.

• Home having a stable and safe place to live.

• Purpose conducting meaningful daily activities and having the independence, income, and resources to participate in society.

• Community having relationships and social networks that provide support, friendship, love, and hope.

Peer services have been shown to improve the quality of life, reduce treatment costs, and lower rates of involuntary commitment. Peers can be employed in a variety of roles including peer respite programs, peer bridgers (assisting people in transitioning from inpatient care), recovery cafés, crisis centers, and others.

Outpatient and Community Based Services: Projected Need Over 4 Years

• Continue funding school-based services to ensure all children and youth have access to behavioral health care.

• Offer SUD treatment to address the increasing number of overdoses and overdose deaths.

• Increase the number of providers offering behavioral health treatment to youth.

• Provide supportive employment services to assist in obtaining and maintaining employment.

• Programs for the families of those in behavioral health treatment.

• Supply transportation services for initial behavioral health assessments, and subsequent community-based treatment, as well dependable transportation to inpatient services when indicated.

• Fund multidisciplinary programs, including related costs not covered by traditional insurance or Medicaid such as transportation, outreach, and case management.

• Provide step-down services for those leaving inpatient mental health or residential treatment.

• Expand currently funded programs like the MCIRT team and non-Medicaid WISe service to all areas of the county.

• Create specialized crisis and behavioral health services for those with developmental disabilities and training for behavioral health clinicians around this topic.

• Fund outpatient programs that provide behavioral health treatment and supports for the uninsured and those services not covered by private insurance, Medicaid, Medicare, or the Veteran’s Administration.

• Support and expansion of peer-based approaches to behavioral health.

• Provide telehealth and in-person services tailored to the needs and preferences of the individual.

• Create a single access point for behavioral health services to navigate, refer, make appointments, and see client history and treatment plan

December 2023 update: Pierce County has allocated new tax revenue to increase school-based, non-Medicaid programs such as WISe and community-based programs such as MCIRT Pierce County continues to struggle, however, with a high need for step-down programs. Telehealth has grown substantially and has led to some decreased transportation issues Creating a single access point for behavioral health services has not happened but remains a priority.

Crisis and Inpatient Services

Crisis and inpatient mental health and SUD services are the highest level of care for individuals experiencing a behavioral health crisis. Services in this category include:

• Crisis intervention teams

• Crisis triage or stabilization

• Inpatient mental health (voluntary and involuntary)

• Residential treatment

• Withdrawal management (including secure withdrawal management)

Crisis and inpatient behavioral health services are the safety net for the most vulnerable and seriously ill. Pierce County has a robust set of crisis services. However, the crisis system utilization is often a proxy for determining the health of the entire system and Pierce County continues to rely on crisis services. According to Carelon, the rate of Involuntary Treatment Act (ITA) requests from the community has decreased from 274 per month in August 2022 to 216 per month July 2023. The number of involuntary placements decreased from 152 to 107 In 2022-2023, two of the hospitals providing ITA beds closed these units for a loss of 32 beds. Pierce County has too few residential respite services to act as a diversion from these crisis services or as step-down services after hospitalization to help reduce recidivism. A decrease in accessing ITA beds shows a significant impact from the other crisis intervention programs that have been created since 2019

Inpatient Care

The lack of inpatient mental health beds in Washington State has been a long-standing problem, resulting in long stays in hospital medical units or emergency departments. When individuals in need of the highest level of care are not able to access treatment, there is an increased likelihood they cycle through emergency department admits, have increased interaction with law enforcement, and suffer the long-term consequences of a lack of adequate treatment.

In the last few years, the region has invested in short-term (up to 90 days) inpatient crisis services. Pierce County now has two 16-bed evaluation and treatment (E&T) facilities offering acute treatment almost exclusively for those detained under the ITA for a mental health condition. Voluntary inpatient options for stays of up to 14 days include the 16-bed Crisis Recovery Centers in Fife, and the 16-bed Crisis Recovery Center in Parkland. Wellfound Behavioral Health Hospital will offer 120 inpatient beds

Pierce County is still missing key categories of inpatient care, particularly for those who are medically unstable, have dementia or developmental disabilities, live with traumatic brain injuries, or due to a history of violence cannot be in a group care setting such as the Crisis Recovery Center or a residential treatment facility. The lack of beds for some of these populations will be compounded by the state’s phase out of long-term beds at Western State Hospital. The loss of these beds will place additional pressure on all levels of the county’s behavioral health system.

Crisis Intervention Teams

MultiCare operates the county’s MOCT. This team is responsible for crisis services via phone and in person. In-person services include both crisis intervention counseling and ITA investigations. While response times have been an issue in recent years, data from early 2022 shows quicker response times from the team. Partnerships between crisis response teams and emergency departments in our county have also been helpful in reducing emergency room use.

Crisis Facilities

There are two crisis stabilization facilities in Pierce County. The Crisis Response Center in Fife has been operating since 2019 and the Crisis Response Center in Parkland opened in August 2021. These crisis centers provide a safe alternative to hospitalization for individuals in crisis. The centers are staffed by mental health professionals, psychiatrists, nurses, and peer counselors.

Over-Reliance on the Crisis System

Over-reliance on the crisis system results in unnecessary visits to emergency departments, law enforcement involvement, and worsening of behavioral health conditions for those lacking adequate care. In many cases, crisis system involvement correlates with a lack of effective lessrestrictive treatment alternatives. At the same time, a dearth of step-down options for those leaving the hospital or residential SUD treatment increases the likelihood of repeated reengagement with the system. The county should consider supporting organizations that are certified (e.g., through the Washington Alliance for Quality Recovery Residences) to provide safe housing for those leaving treatment.

Additional feedback from the community indicated that many individuals taken to crisis centers by law enforcement are instead in need of a sobering center. King County recently reopened its sobering center using American Rescue Plan funding. Another promising model is the SUD Diversion Center in Snohomish County, where individuals are diverted away from incarceration and referred to treatment. In 2023, behavioral health tax funds went to expand detox program beds. Other programs around crisis centers and on site supports for first responders continue to be prioritized.

Crisis and Inpatient Services: Projected Need Over 4 Years

While the gaps identified above are expected to continue over the next several years, there are potential interventions available to prevent over-reliance on the crisis system and reduce reengagement with the system.

• Support and advocate for inpatient treatment facilities that provide specialized treatment to those who are medically unstable, have dementia or developmental disabilities, live with traumatic brain injuries, or have a history of violence.

• Fund and support programs that provide co-occurring treatment.

• Ensure step-down options are available and encouraged for individuals exiting treatment.

• Support programs that provide alternatives to voluntary and involuntary inpatient care.

• Continue to fund co-responder programs.

• Consider supporting diversion models that have shown success in other counties like sobering center in King County or the SUD diversion center in Snohomish County.

• Encourage more Medicaid-funded step-down programs and fund similar programs for services that are not Medicaid-eligible.

• Continue supporting crisis stabilization facilities while ensuring these centers continue to accept referrals from families, law enforcement, and other first responders.

• Increase the number of providers offering medically managed withdrawal management.

• Improve care coordination by advocating for a single point of entry to behavioral health services.

December 2023 update: The past few years in Pierce County have seen two 16-bed psychiatric facilities close and one 16-bed facility move from inpatient crisis beds to an innovative model of care for adults with intellectual and/or developmental disabilities experiencing a behavioral health emergency. Wellfound has been delayed in opening the 120-bed unit and currently only has 72 beds available for the community. With the number of available inpatient psychiatric beds in Pierce County (88) failing to meet the average number of adults recommended for involuntary placement (approximately 107) each month, the needs of the community are still unmet. New mobile crisis response teams are being created throughout Pierce County in an attempt to decrease hospitalization needs. Next steps must focus on creating more holistic diversion programs to assist those bouncing between crises. Care coordination, warm hand-offs to programs, and communication are needed across all crisis response teams.

Services for the Justice-Involved

Pierce County is dedicated to coordinated, timely, and effective treatment for justice-involved individuals in need of behavioral health treatment. The Sheriff’s Department and Human Services Department have worked with local agencies to fund and support programs aimed at jail diversion and reducing recidivism. The county’s diversion program is based on the SAMHSA GAINS Center’s Sequential Intercept Model SIM. This model helps communities create interventions that divert individuals from involvement in the justice system and decrease recidivism by addressing gaps and needs at each point in the justice process. The model encompasses:

• Community resources that prevent initial law enforcement involvement

• Actions taken by law enforcement once the individual has law enforcement contact

• Interventions at the initial court hearings/detention period

• Jail and court programs

• Reentry programs

• Community corrections

Crisis Intervention for Justice-Involved Individuals

Law enforcement agencies regularly encounter individuals in a behavioral health crisis. Social service agencies and law enforcement agree that, with adequate intervention in place, the number of unnecessary interactions with law enforcement could be reduced. Toward this end, the county launched the Pierce County Sheriff’s Department co-responder program in 2017. This program pairs a Designated Crisis Responder with a sheriff’s deputy to respond to behavioral health calls to law enforcement, with the goal of diverting individuals from the jail or emergency department.

Any services for the justice-involved should consider the changing role of law enforcement in community outreach due to E2SHB 1310. The safety of behavioral health clinicians, the individuals they serve, and the community must be considered when designing outreach programs.

Therapeutic Courts

Pierce County has a long history of operating therapeutic court programs. These courts include:

• Felony Drug Court

• Felony Mental Health Court

• Pierce County District Court Drug Addiction Reduction Team

• Veterans Treatment Court

• Family Recovery Court

• Assisted Outpatient Treatment

• District Mental Health Court

The felony courts and Drug Addiction Reduction Team offer substance use disorder and mental health treatment as an alternative for those with non-violent felony charges. The treatment programs use evidence-based treatment approaches and require participation in court-monitored activities. Veterans Treatment Court provides life skills, treatment, and supervision for justiceinvolved veterans.

The Family Recovery Court offers treatment for substance-using parents subject to dependency cases. The Assisted Outpatient Treatment program offers court-monitored outpatient behavioral health treatment.

Trueblood Programs

The Trueblood settlement was borne out of a 2014 lawsuit against the Washington State Department of Social and Health Services (DSHS) challenging delays in competency evaluations and the restoration process. Pierce County has used settlement funds to support the following innovative programs:

• In-jail assessments for diversion

• Referrals to out-of-custody behavioral health treatment

• Release and re-entry planning

• Housing navigation and subsidies

• Forensic Projects for Assistance in Transition from Homelessness

• Forensic Housing and Recovery through Peer Services

• Enhanced mobile crisis team through MOCT

• Pierce County Co-Responders

The Trueblood funds can only be used to serve individuals who have waited in jail for competency evaluation or restoration services. Because access to this funding source ended on June 30, 2022, the county has been working to find other revenue sources for the programs, such as Greater Lakes jail diversion program, that have worked well.

Other Pierce County Programs for the Justice-Involved

Pierce County offers other justice-involved diversionary behavioral health services, including medication management and group therapy for those with a substance use disorder incarcerated in the Pierce County Jail.

Justice-Involved Services: Projected Need Over 4 Years

The need for behavioral health interventions for justice-involved individuals is not expected to decrease over the next six years. Recent changes to state law regarding law enforcement activities are expected to significantly increase dependence on behavioral health programs for those who are or are at risk of being involved with law enforcement. Specific needs include:

• Continued funding for programs previously funded by Trueblood where the program has been found to be effective.

• Continued support for therapeutic courts. Consider transferring cost savings from incarceration and prosecution to other programs or for expansion of therapeutic courts.

• Continued funding for and expansion of co-responder programs.

December 2023 update: Pierce County has been following Washington State trends by creating co-responder teams throughout the county. Lakewood Police Department, Tacoma Police Department, Puyallup Police Department, and Pierce County Sheriff’s Department have contracts with behavioral health organizations to ride along with the police and assist when individuals need behavioral health intervention The co-responders and similar programs increase the likelihood individuals will receive intervention services other than jail. Our next step is to continue growing other programs that can provide follow-up care coordination and assist individuals in getting connected to ongoing services. Service providers are struggling with significant workforce shortages in this area because the unique work environments and 24/7/365 schedule makes it difficult to find individuals qualified and willing to do the work.

Additional Needs in Pierce County

Three additional areas of need for the behavioral health system in Pierce County are housing and support services, workforce development, and access to data for care coordination.

Opioid Settlement

Pierce County is estimated to receive approximately $29 million in funding from multiple opioid settlement distributions over the next 17 years. These funds are results of settlements from opioid manufacturers and distributors who utilized misleading marketing and falsely portrayed opioids as a nonaddictive pain management solution. Eleven cities will also receive settlement funds,

whereas our communities with populations under 10,000 and unincorporated areas will be covered by the County’s allocation.

Opioid Settlement Fund Approved Uses

Per the settlement agreements, funds may be used for the following purposes:

1. Substance Use Disorder Treatment: Outpatient, detox, residential/inpatient, medication assisted treatment, school-based services, special services for the justice involved.

2. Treatment Supports: Case management, transportation, peer supports, supported employment.

3. Housing: Clean and sober housing, post-treatment stabilization, other housing supports.

4. Prevention Messaging: Education, awareness, prevention messaging.

5. Prevention Communication: Distribution and training around Naloxone and similar medications, support screening for fentanyl, other overdose prevention efforts.

6. Other uses: Training, leadership efforts, research on opioid abatement.

Pierce County Human Services is forming a subcommittee of the BHAB to help make recommendations about the use of these funds. A representative from each local government has been invited to participate on that subcommittee, ensuring collaboration. Those members who are pooling money with Pierce County will be voting members of the board while the other members are invited to be a part of ongoing coordination and communication around the community needs. We anticipate releasing an initial round of settlement funding in Summer 2024.

Housing and Support Services

Lack of stable housing for individuals with behavioral health disorders hinders their ability to fully engage in treatment, reduces their chances of success, and all but guarantees the overutilization of higher-cost services, such as emergency departments.

While there has been an increase in funding for housing-based projects, the behavioral health system must play a role by providing supportive services for individuals with behavioral health disorders who are facing homelessness. The department estimates more than 1,370 individuals experiencing homelessness need behavioral health services at any given time, with up to 4,000 unique clients each year.

Workforce Development

Pierce County has a significant behavioral health workforce shortage. Community-based behavioral health providers have had difficulty attracting and retaining well-qualified therapists and mental health professionals. One major cause is competition with hospitals and major health systems able to pay their employees higher wages than community organizations.

The reliance on Medicaid funding through the MCOs is one key difference between the community behavioral health system and other providers. As long as MCOs continue to pay low rates to providers, those agencies will not be able to pay high enough wages to attract or retain staff. These low wages relative to the amount of education, licensure, and training required will continue to discourage many from entering the behavioral health treatment field. There are significant shortages in all areas of the crisis system, from therapists and prescribers to

Designated Crisis Responders. Any workforce efforts should include efforts to increase the number of providers from diverse cultural backgrounds while ensuring wages are adequate to attract behavioral clinicians to Pierce County.

Data Access Challenges

As this plan is implemented and investments are made in the behavioral health system, Pierce County needs to be able to track outcomes, not only for the programs funded by the Behavioral Health Tax, but region-wide to ensure the investments are meeting the goals set forth in this plan. Pierce County has access to a few system-wide data points but is missing, among other things, comprehensive data on wait times, recidivism, housing, and employment status outcomes. One limitation we face in accessing this data is the lack of a central entity with authority over the regional behavioral health system. Prior to 2019, Pierce County’s publicly funded behavioral health services were managed by one organization, Optum Behavioral Health. As the managing organization, Optum had access to all member information including service usage, inpatient stays, housing status and employment status. When the behavioral health system integrated with the physical health system under Medicaid (Apple Health), all that data transferred to the Medicaid payors. What was once a central repository for managing the effectiveness of the behavioral health system, is now split between six payors with no one entity able to access all of the data.

Another challenge we face as a region is the lack of a closed-loop referral system. This is related to the lack of a central organizing entity but has even more practical implications. A closed-loop referrals system would allow a resident of Pierce County who has need of behavioral health services or treatment, to contact a central entity to initiate a referral for services or be referred by whichever agency they are working with. Once that referral was made, the initiating entity would see the progress of the referral and if/when that individual successfully accessed services. A referral system of this kind would not only improve access to behavioral health services but could aid the region in screening individuals and assessing the capacity of various sectors of the behavioral health system. Currently, there is no centralized referral system available in Pierce County.

Although Pierce County has no entity with access to comprehensive system-wide data, there are several organizations whose data we have access to which can act as proxy for the data we lack. For instance, Carelon Behavioral Health, the administrator of the publicly funded behavioral health crisis system, tracks and makes available data about crisis system usage such as number of ITAs (youth and adult) and lengths and number of hospitalizations. Mary Bridge Children’s Hospital also makes youth data available, such as the number of youths accessing the Emergency Department for behavioral health complaints. Other partners with access to data are Elevate Health, TPCHD, and the Medical Examiner’s Office. So, although system-wide data is no longer available to track outcomes in real time, through strategic metrics and effective partnerships, Pierce County strives to secure the data the needed to assess the effectiveness of its behavioral health services.

Other Needs: Projected Need Over 4 Years

• Outreach, advocacy, eviction prevention, rapid rehousing, case management, housing stabilization, crisis intervention and referrals for individuals and families who are struggling with substance abuse and mental health issues.

• On-site behavioral health services at shelters using a model that integrates the expertise of mental health, substance use, and primary care.

• Intervention and outreach to homeless youth struggling with substance abuse and mental illness to foster long-term stability and educational and career success.

• Clean and sober housing options for those leaving residential treatment.

• Coordination of efforts to improve behavioral health workforce training, development, and retention.

• Efforts to influence public policy around wages for behavioral health workers, including the Health Care Authority holding insurance companies accountable for a lack of network adequacy a shortfall due to insufficient payments to providers, meaning inability to pay fair wages.

• Improved communication around coordination of care, including increased data sharing to determine the community’s needs and which interventions are most effective.

December 2023 update: On-site behavioral health services at shelters continues to be a priority with the Behavioral Health Tax funds. Comprehensive Life Resources (CLR) has been leading a team of behavioral health counselors and outreach specialists going to Tacoma Rescue Mission shelters and New Hope day shelters and offering supports and services to those in the shelter. The CLR program is set to expand in 2024-2025 to other community shelters

Communication around coordination of care and data sharing continues to be inadequate, and we still see a lack of coordination of and access to data, creating barriers to treatment. Elevate Health was tasked with establishing a system in 2019-2020. Efforts fell through as community providers concerns around access to personal information was expressed. Pierce County will be looking into options and opportunities to create a system that will meet the need of the community and protect individual rights over the next four years

Pierce County invested Behavioral Health Tax funds in a project to support existing workforce and support training for new workforce. This project involves working with Workforce Central to create a system of supports for employers and employees. Workforce Central began the work to create this system at the end of 2023 and beginning in 2024 will receive Behavioral Health Tax dollars to assist in bringing those in the workforce and those needing employees together. Workforce Central is also creating a regular meeting of employers within the behavioral health field and creating open dialogues around the needs of the employers and how to expand access to workers.

Six-Year Plan to Address Behavioral Health Needs in Pierce County

A plan to address the needs identified in the six-year forecast must involve participation from the providers, stakeholders, and community members that make up the Pierce County behavioral health system. No one system or funder can solve all of the behavioral health needs of Pierce County.

It is the diversity of our system that will be the key to addressing these issues. Through a competitive procurement process, we can foster innovative and efficient approaches to behavioral health. Because funding for behavioral health services is limited and the community needs far outweigh available resources, the county and other funders should follow the guiding principles outlined below.

Selection and Award Policies and Processes for Behavioral Health Grants

1. Available funds should be released through a Request for Proposal (RFP) process that targets the specific funding priorities outlined below. Applicants will be asked to propose innovative and efficient programs that meet the identified needs. This allows organizations with expertise to identify solutions rather than funders prescribing a specific approach.

2. Contracts or funding agreements should include a value-based component requiring programs to meet targets to earn additional funding.

3. Contracts or funding agreements will be based on work completed or costs expended (e.g., staff and admin costs). If a contractor does not expend and invoice all funds attached to an award, those funds will remain with the county for reallocation during the next RFP cycle.

4. Whenever possible, the award process should be competitive. A competitive approach fosters efficiency and ingenuity.

5. Because no single organization can meet the community’s behavioral needs, when funds are available, awards to multiple organizations should be considered while balancing budgetary and economy of scale concerns.

6. Awards should not supplant services covered by other funders. For example, if a treatment is covered by Medicaid, Behavioral Health Tax funds would not pay for those services. Instead, providers and local organizations are encouraged to hold managed care organizations accountable for paying fair rates that cover the cost of providing treatment.

7. To ensure long-term viability, programs are encouraged to seek funding from multiple sources.

8. Programs should include outcome and/or evidence-based treatment approaches.

9. Funding should target the most vulnerable populations while maintaining a focus on the full continuum of care, including prevention and early intervention.

10. Available funds should be fully awarded each year, with the exception of a two-month operating reserve. Unspent funding will be allocated to new programs through the RFP process described above.

11. Initial awards resulted in one-year contracts. Requests to extend funding outside of a single year should follow a formal application process which will be reviewed. Once a program has demonstrated effectiveness with Behavioral Health Tax funding.

12. Funding will consider the needs of underserved populations in Pierce County and seek to address treatment inequalities due to demographics or location. The selection process should encourage applications from those organizations with a unique ability to reach traditionally underserved populations.

Existing Programs

Behavioral Health Tax Programs Funded in 2023

There were six funding priorities initially authorized under the Behavioral Health Tax. These were funded through December 31, 2023. The Pierce County BHAB voted to recommend funding these programs.

Behavioral Health Tax Programs Funded in 2024-2025

Providers submitted 60 applications for 2024-2025 tax dollars. Of those applications, 28 were granted funding after a thorough review from the Pierce County BHAB and Pierce County City Council. Twenty of the successful applications were previously funded in 2022-2023. That request was included in the Human Services program budget for 2024-2025.

Trueblood Programs

Some interventions addressing behavioral health in the justice system are currently funded by the DSHS Trueblood lawsuit. Trueblood funding ended on June 30th, 2022. A portion of these programs may qualify for funding under the county’s Behavioral Health Tax. Other aspects of existing programs may need to be supported by other funders. Jail Diversion programs that worked well with Trueblood funds were transferred to the Behavioral Health Tax through the RFP process when Trueblood funding was no longer available.

Timelines for Awarding Grants Under the Behavioral Health Tax

To create an efficient and consistent contract process, RFPs for funding under the Behavioral Health Tax should occur on a regular schedule. This allows for consistency in contracting and more specific and accurate information during the county’s budgeting process. Achieving this

consistency will require the county to stagger some contract timelines during the initial implementation phase. The contract timeline induces the following steps:

• Awards under the latest RFP process resulted in contracts with effective dates of January 1, 2024, through December 31, 2025.

• Spring 2025: Begin the RFP process for Behavioral Health Tax projects for calendar year 2026.

• Summer 2025: Funds awarded for calendar year 2026 funds and placed into 2026 budget.

o Any awards under the RFP process would result in contracts with effective dates of January 1, 2026, through December 31, 2027.

Quality Assurance and Reporting

1. All contracts and funding agreements will include output and outcome metrics.

2. Any contract or agreement with organizations receiving behavioral health funds will include measurable outcomes reportable on a regular basis.

3. Any program or county department receiving funds will report quarterly regarding progress on selected metrics. The report will include a short narrative addressing progress, challenges, or other topics identified by the department.

Data Update: July 2022 through May 2023

Based on preliminary data reported to Pierce County in May 2023, approximately 1,200 individuals received services from programs funded by the Behavioral Health Tax. The number of individuals receiving services has continued to grow each month since July 2022.

No single organization can fulfill the entire continuum of care, Pierce County continues to look for innovative and efficient providers operating in the community. So far, approximately 20 agencies receive funds from the tax to create, provide, and expand innovative programing.

All Pierce County residents are eligible for behavioral health services. Since July of 2022, most services have been provided in the Lakewood area. Improving access to care in rural areas and underserved communities is a priority for this fund source and the county continues to seek opportunities to reach the outlying areas of Pierce County.

Individuals of all ages are being served within the programs funded by the Behavioral Health Tax, with most of the funds focusing on ages 15 to 64.

Pierce County’s Research and Data Analysis team is in the process of creating a more formal evaluation of the overall benefits of the tax in Pierce County. The team will provide a systemlevel evaluation of the County’s funded providers. The goal of the evaluation is to determine the reach of the County’s investment across residents, the alignment of investments to current needs within the community, the quality of services provided, and the education, social, economic, and health outcomes of those served. This project will be completed before December 31, 2027.

Current data is updated and maintained at the Open Pierce County web page: Behavioral Health Tax | Open Pierce County (piercecountywa.gov).

Funding Priorities: Overview

Based on the needs identified in the forecast section of the BHIP, funding for behavioral health programs in Pierce County should focus on the areas outlined below. This section includes an overview of funding priorities identified through the BHIP assessment process. The following section lists the top priorities as identified by the BHAB. Funders should give special attention to those areas that have not been addressed by currently funded programs—substance use disorders, early intervention, and prevention.

The metrics described under each priority are a starting point for determining the effectiveness of interventions and understanding the county’s behavioral health needs. More specific metrics will be developed with individual contractors based on the goals of the program and available date.

2023 Update: All programs funded under the Behavioral Health Tax are providing data based on the proposed metrics. The first round of raw data was supplied to the County in January 2024. The first half of 2024 will be spent analyzing that data.

Community Education

Priorities:

• Fund evidence-based programs aimed at educating the community on behavioral health and decreasing stigma. These efforts should include school-based training and education.

• Support anti-stigma and behavioral health education campaigns, including for those from bilingual, BIPOC, LGBTQ+, and disability communities.

2023 updates and revisions: TPCHD introduced Teen Mental Health First Aid to seven of the 12 high schools in Pierce County outside of Tacoma. By increasing awareness of behavioral health signs and symptoms, this training can assist youth in accessing resources, knowing how to ask for help, and decreasing stigma. TPCHD also received funding to build and promote fentanyl and opioid awareness campaigns. We persist in recognizing the necessity of bolstering anti-stigma campaigns, particularly within bilingual, BIPOC, LGBTQ+, and disability communities

2022-2023 BEHAVIORAL HEALTH TAX Funded Programs: In 2022-2023, the Behavioral Health Tax funded several programs that are examples of providing community education. Asia Pacific Cultural Center and Asian Counseling Treatment Services received funding to provide services in Pierce County. Included in those services was community education to families and individuals experiencing behavioral health symptoms. TPCHD provided education: to teens with Mental Health First Aid courses; to at-risk mothers and babies regarding well-being after the birth of a child; around fentanyl awareness, including prevention education, life-saving steps, and behavioral health resources; to raise awareness of behavioral health symptoms and attempts to reduce emergency room visits for youth related to behavioral health concerns.

2023 Metrics: Community Education

Number of individuals trained through an evidence-based approach to community education (e.g., Mental Health First Aid).

Number of trainings provided to schools, students, parents, or other community members regarding behavioral health awareness and reducing stigma.

Wellness, Prevention, and Early Intervention

Priorities:

• Support county-wide screening and intervention for school-age youth.

• Fund existing programs that have shown success but have no long-term funding.

• Expand existing wellness, prevention, and early intervention programs into other areas of the county.

• Support new and innovative approaches to wellness and prevention that include interventions at earlier ages, including support for at-risk parents and those caring for children with complex behavioral and developmental needs.

• Support behavioral health screening in primary care and social service settings.

2023 updates and revisions: The Behavioral Health Tax is funding several programs to increase access to screenings and interventions, such as programs at Asian Counseling Treatment Services, Behavior Bridges, Communities in Schools of Lakewood, Comprehensive Life Resources, Perinatal Support Washington, TPCHD Next steps include continuing these programs and increasing parental involvement and education.

2022-2023 BHTC Tax Funded Programs: In 2022-2023, the BH Tax funded several programs that address wellness, prevention, and early intervention priorities. Behavior Bridges, Communities in Schools of Lakewood, and Comprehensive Life Resources-School Connect focus on youth and school-based services. Additionally, United Way provides two behavioral health resource navigators that are connected to the South Sound 211 call center. The navigators can do quick screenings and determine the needs of individuals who call into the call center.

2023 Metrics: Wellness, Prevention, and Early Education

Number of in-school behavioral health services provided in schools, by district.

Improved scores on evidence-based outcome measures for those participating in the program.

Number of individuals receiving a Screening, Brief Intervention, and Referral to Treatment SUD screening.

Rates of suicide in Pierce County by age, educational district, and veteran status.

Increase in parental involvement in academic and social activity from baseline using the Daily Living Activities-20 assessment

Multiple metrics from the Healthy Youth Survey

Number of individuals receiving screening for behavioral health.

Outpatient and Community-Based Treatment

Priorities:

• Continue funding for school-based services to ensure all children and youth have access to behavioral health care.

• Provide SUD treatment for adults and youth to address the increasing number of overdoses and overdose deaths.

• Offer programs for the families of those in mental health and SUD treatment.

• Supply transportation services for initial SUD assessments, and subsequent communitybased treatment, as well dependable transportation to inpatient when indicated.

• Fund multidisciplinary programs, including those costs not covered by traditional insurance or Medicaid (transportation, outreach, case management).

• Support step-down services for those exiting inpatient mental health or residential SUD treatment.

• Create specialized crisis and behavioral health services for those with developmental disabilities. Many of these services could be covered by Medicaid or state funds, but there is a lack of training for behavioral health clinicians around this topic.

• Fund outpatient programs that provide services for the uninsured and those not covered by private insurance, Medicaid, Medicare, or the Veteran’s Administration.

• Support and expand employment programs for those with behavioral health disorders.

• Expand peer counseling and peer-operated programs.

• Support programs that reduce out-of-home placements for children.

• Support parents caring for children with complex behavioral and developmental needs.

• Consider the merits of a single access point for behavioral health services.

2023 updates and revisions: We have a continued need to create access to all behavioral health services regardless of insurance coverage, increase supports for families, share more data, and continue conversations around a single access point The Pierce County BH Tax paid for programs such as Horses Guiding Humans Foundation’s - Healing the Herd which provides experiential equine assisted psychotherapy, Lutheran Community Services Northwest which provided culturally attuned outpatient and community based behavioral health services for asylum seekers, and many other programs throughout Pierce County. Next, Pierce County and its partners must create a system of care that reaches all County residents and creates access points regardless of the individuals’ identified needs.

2022-2023 Behavioral Health Tax Funded Programs: The BH Tax funded 27 programs during 2022-2023, 21 of which focused on some level of outpatient and community-based treatment A few examples of these programs include expanding programs to the non-Medicaid populations, providing culturally attuned services to refugees and immigrants lacking insurance coverage, and supporting youth drop-in programs

2023 Metrics: Outpatient and Community Based Treatment

Improved scores on evidence-based outcome measures for those participating in the program.

Percentage of youth in behavioral health programs that graduated high school.

Number of individuals served, services provided by zip code, age, insurance status, and veteran status.

Average time from request for services to first outpatient BH appointment.

Number of individuals served under trauma-informed/trauma-focused programs.

Number of individuals receiving services through an evidence-based treatment.

Number of individuals initiating SUD or mental health treatment.

Number of individuals receiving SUD treatment.

SUD treatment penetration rate (12-17 age range, 18-64 age range)

Increase in SUD treatment penetration rate (opioid) (18-64 age range).

Number of peer specialists employed.

Percentage of individuals in behavioral health treatment that are employed.

Number of individuals in behavioral health treatment who received an employment service.

Number of individuals receiving an employment service that obtained employment.

Crisis and Inpatient Services

Priorities:

• Support and advocate for inpatient treatment facilities that provide treatment to those who are medically unstable, have dementia or developmental disabilities, live with traumatic brain injuries, or have a history of violence.

• Fund and support programs that provide co-occurring treatment.

• Encourage more Medicaid-funded step-down programs and fund similar programs for services that are not Medicaid-eligible.

• Continue supporting crisis stabilization facilities and other alternatives to inpatient care while ensuring these centers continue to accept referrals from providers, families, law enforcement, and other first responders.

• Increase the number of providers offering medically managed withdrawal management.

2023 updates and revisions: Two hospitals providing inpatient treatment closed, each of which had 16 inpatient beds, reducing the number of available beds throughout Pierce County. Fortunately, other hospitals are expanding or opening to offer inpatient beds and more long-term beds. Our next step is to continue increasing step-down programs and ongoing supports after crisis and hospitalization.

2022-2023 Behavioral Health Tax Funded Programs: In 2022-2023, the Behavioral Health Tax funded several programs that are examples of inpatient and crisis services. Multicare Mary Bridge Children’s Hospital expanded Youth Engagement Services (YES), a collaborative treatment model that provides behavioral health navigation and brief intervention to eligible school-aged youth presenting to Pierce County Multicare Emergency Departments with behavioral health complaints. The Pierce County Sheriff’s Department has two programs for community supports. The co-responder program falls under crisis services and focuses on working alongside law enforcement during 911 responses to behavioral health crisis. Seneca Family of Agencies operates the non-Medicaid WISe teams. These teams provide 24/7 intensive mobile behavioral health services to non-Medicaid eligible high-risk youth and families.

2023 Metrics: Inpatient and Crisis Services

Number of referrals from 211 to behavioral health by type of referral.

Number of individuals presenting to the emergency department for behavioral health issues (by department, age, and reason for visit).

Number of individuals receiving an ITA evaluation who were referred to a less restrictive level of care.

Number and location of single bed certifications and average number of days individuals are on SBCs in Pierce County per month.

Average response time from request to face to face by crisis type by month.

Percentage of individuals presenting to the emergency department for a behavioral health concern who received a follow-up service after discharge (7 days and 30 days).

Percentage of individuals exiting inpatient behavioral health treatment who received a followup service after discharge (7 days and 30 days).

Percentage of individuals exiting inpatient behavioral health treatment who were readmitted after discharge (7 days and 30 days).

Number of calls to the crisis line by month.

Number of crisis services provided per month by type of service and age range.

Number of youth in crisis requiring in-home services to prevent emergency department usage. Number of individuals with comorbid disorders, autism spectrum disorder, dementia, or a neurocognitive disorder receiving long-term inpatient care or on an SBC due to a lack of appropriate placement.

Number of individuals in crisis whose presenting problem was primarily due to a need for housing services.

Number of individuals in crisis whose presenting problem was primarily due to a need for sobering services

Total number of ITA investigations conducted via telehealth

Percentage of emergent mobile crisis outreach service requests/referrals that were responded to within two hours.

Percentage of urgent mobile crisis outreach service requests/referrals that were responded to within twenty-four hours.

Services for Justice-Involved Populations

Priorities:

• Consider funding programs previously funded by Trueblood when the program has been found to be effective. Funding should be limited to direct behavioral health services.

• Fund therapeutic courts. Consider transferring cost savings from incarceration and prosecution to other programs or for expansion of therapeutic courts.

• Continue funding for and expansion of co-responder programs.

• Consider additional Crisis Intervention Team training for law enforcement.

• Increase coordination between law enforcement and behavioral health providers.

2023 updates and revisions: The Behavioral Health Tax continues to fund jail diversion and crisis intervention programs. Increasing coordination between law enforcement, courts, and behavioral health providers is an ongoing need in Pierce County. Since 2022, the number of active participants in the therapeutic court systems has decreased, while the number of individuals who may qualify for services has increased. Next steps to address the needs of justice-involved individuals are to identify where misalignments are happening in the system and create ways to provide education, supports, and any other services for those in need.

2022-2023 Behavioral Health Tax Funded Programs: In 2022-2023, the Behavioral Health Tax funded several programs that provide services for those involved in the justice system. CLR

offered assisted outpatient treatment to individuals in the involuntary treatment court but discontinued these services in mid-2023. Multicultural Child and Family Hope Center and Pierce County Alliance are providing supports for individuals involved in mental health and drug court services. Greater Lakes Mental Health Care provided services to individuals in jail and cycling through the competency system (formerly funded by Trueblood). The Greater Lakes program focuses on diversion from the jail system and maintaining community supports. The Pierce County Sheriff’s Department has two programs for community supports. The Alternative Response Team, one of the programs connected to The Pierce County Sheriff’s Department, focuses on working in the community with non-emergency and non-criminal 911 calls by connecting individuals to community supports and reducing 911 calls.

Proposed Metrics: Services for those Involved in the Justice System

Improved scores on evidence-based outcome measures for those participating in the program.

Pre-intervention jail bed days versus post-intervention jail bed days.

Number of 911 calls and time spent on the call due to a behavioral health concern.

Number of people diverted from jails or hospitals through mental health responders.

Recidivism rates for individuals involved in behavioral health programs for the justice involved.

Graduation rates for individuals in therapeutic courts.

Number of individuals served by the co-responder program, including percentage diverted from jail.

Behavioral Health Housing Supports

Priorities:

• Outreach, advocacy, eviction prevention, rapid rehousing, case management, housing stabilization, crisis intervention and referrals for individuals and families who are struggling with substance abuse and mental health issues.

• On-site behavioral health services at shelters using a model that integrates the expertise of mental health, substance use, and primary care providers.

• Intervention and outreach to homeless youth struggling with substance abuse and mental illness to foster long-term stability and educational and career success.

• Step-down programs for those exiting inpatient treatment.

• Clean and sober housing options for those leaving residential treatment.

2023 updates and revisions: The Behavioral Health tax is funding an innovative program to provide on-site behavioral health services at shelters and other homeless outreach sites, but stepdown programs, clean and sober housing and short-term housing supports are still needed.

2022-2023 Behavioral Health Tax Funded Programs: In 2022-2023, the Behavioral Health Tax funded several programs address the need for behavioral health housing supports. Services that fall under the above-mentioned outpatient and community-based services section also provide housing support services. CLR’s behavioral health shelter program provides a focused approach to providing housing support services and connecting to ongoing behavioral health services after housed.

2023 Metrics: Housing and Behavioral Health

Number of individuals in behavioral health treatment receiving housing vouchers.

Number of individuals in behavioral health treatment receiving housing support services.

Percentage of individuals in behavioral health treatment who maintained housing for at least six months.

Behavioral Health Policy and Advocacy

Priorities:

• Improve behavioral health workforce training, development, and retention.

• Influence public policy around wages for behavioral health workers, including the HCA, holding insurance companies accountable for a lack of network adequacy—a shortfall due to insufficient payments to providers, meaning inability to pay fair wages.

• Continue to foster increased collaboration among providers. Collaboration ensures individuals get the care they need in a timely manner while reducing the overall cost of care.

2023 updates and revisions: The Pierce County behavioral health staff regularly convene or attend collaborative meetings within Pierce County and across Washington State to identify additional ways to improve the county’s behavioral health system.

Data Needs

Priorities:

• Identify proxy data for the county-wide data to which we don’t have access and identify agencies/organizations who provide that data.

• Work with law enforcement, first responders and South Sound 911 to get aggregated data on system usage by those with behavioral health struggles.

• Obtain data that helps determine whether individuals diverted from higher levels of care were able to access needed services.

• Work with MultiCare to come up with crisis system recidivism data.

• Research a closed-loop referral system and begin talking with providers about the best way to implement county-wide. Partner with organizations who may already be engaged in this work, such as Carelon Behavioral Health and Elevate Health.

2023 updates and revisions: We continue to struggle to meaningfully share data across programs and providers. Providers utilize several different data collection systems, and they often interpret the guidelines around data sharing differently. County staff will continue working on data sharing and data standardization. The process of creating a place for data is a difficult one with varying levels of access. The process to improve Pierce County’s ability to create a system may involve higher levels of legislation and supports.

Funding priorities for Pierce County are based on the recommendations from Pierce County partners, the 2016 HSRI study, and the BHAB.

2023 update: Pierce County Human Services plans to utilize a work group established by the BHAB to continue to set and rank funding priorities over the next few years.

1. Continue to Fund Existing Behavioral Health Tax Programs

The Pierce County BHAB voted in July 2023 to recommend 28 programs to the Council for funding through the Behavioral Health Tax. Eighty percent of funds went to supporting existing projects. Council authorized funding through December 31, 2025.

2. Fund SUD Treatment

Currently funded Behavioral Health Tax programs address a variety of gaps and starting in 2025, funds from the State opioid settlements will start to be disbursed in Pierce County. The Human Services Department plans to release an RFP for those funds in first quarter 2024. When refining our priorities, we will also consider what services are already covered by Medicaid or other payers. For example, most withdrawal management, residential, and outpatient SUD services are covered by Medicaid or state funding. Additional funds can support the services and costs that Medicaid do not cover. Providers may also require assistance starting up or expanding programs prior to being able to bill Medicaid. SUD needs include:

a. Support for cross-agency collaborations to increase services to smaller communities.

b. A withdrawal management and diversion center to reduce incarceration and inappropriate usage of crisis facilities.

c. A step-down facility for those individuals exiting inpatient SUD treatment.

d. Mobile medical/behavioral health vans

e. Transportation services for community-based assessments and treatment.

f. Utilization of administrative funds to support research on successful opioid use interventions and to collect and analyze provider performance data.

g. Funding for a Social Service Program specialist.

h. Support Medical Examiner’s office Pathologist Full-Time Employee: The pathologist will be able to collect data and information about overdoses and other drug-related deaths to inform the BHAB subcommittee about opioids and other service needs.

3. Expand School-Based Services

Pierce County has 14 school districts, excluding those within Tacoma city limits. Schoolbased services for those without Medicaid or other insurance are currently available through the Behavioral Health Tax in nine districts. These programs could be expanded in both geography and scope of services. Programs may include additional screening, anti-stigma education, and prevention services.

4. Recovery Support and Peer Services

Recovery support and peer services are an integral part of a complete behavioral health system. These services are not currently funded by the Behavioral Health Tax. Since 2019, state reimbursement through Medicaid and other funding has become more available for peer services. The therapeutic courts are utilizing peer services to decrease recidivism. Peer

support services are being utilized through other outpatient services. Awards under the tax would pay for services not currently funded by Medicaid.

5. Housing Supports

Without safe and stable housing, individuals in behavioral health treatment are more likely to experience re-hospitalization, continued substance use, and law enforcement involvement. The Behavioral Health Tax should address behavioral health treatment and outreach for those experiencing homelessness. Services funded by the tax would coordinate with other programs that provide shelter, housing services, rental assistance, and other housing supports. Behavioral health supports should include:

• On-site behavioral health services at shelters using a model that integrates the expertise of behavioral health and primary care.

• Supportive employment services to assist in obtaining and maintaining employment.

• Intervention and outreach to homeless youth struggling with substance abuse and mental illness to foster long-term stability and educational and career success.

6. Fund Step-Down Facility Options

Community input included several mentions of the need for “step-down” facilities or services for those individuals exiting inpatient behavioral health treatment. Treatment provided in a safe setting with adequate supports significantly decreases the chances of recidivism to inpatient care.

Other Top Priorities

1. Therapeutic Courts: Pierce County has several therapeutic courts that divert individuals from further involvement in the justice system.

2. Single Entry Point: Research a closed-loop referral system and begin talking with providers about the best way to implement such a system county-wide. Partner with organizations who may already be engaged in this work such as Carelon Behavioral Health and Elevate Health.

3. A Withdrawal Management Center or Diversion Center: Community input indicated there may be a need for more withdrawal management beds or diversion facilities to divert individuals from incarceration and reduce inappropriate usage of crisis facilities.

4. Community Education: Evidence-based programs aimed at educating the community on behavioral health and decreasing stigma. These efforts should include school-based training and education.

5. Prevention: Support new and innovative approaches to wellness and prevention that include interventions at earlier ages, including support for at-risk parents and those caring for children with complex behavioral and developmental needs.

6. Early Intervention and Screening: Support behavioral health screening in primary care and social service settings.

7. Opioid settlement funds: The State Opioid and Overdose Response Plan, recommendations from Pierce County Opioid Abatement Council, and Pierce County Opioid Task Force are assisting in refining priorities.

Behavioral Health Improvement Plan Timeline

Year One (First Six Months): July 1 to December 31, 2021

2023 update: Over the course of July 1 to December 31, 2021, Pierce County and its partners took various actions to develop the BHIP. This included convening the BHAB, releasing a stakeholder survey, finalizing contracts under the Behavioral Health Tax, beginning the performance audit process, and presenting the final BHIP for BHAB and Pierce County Council approval.

Year One (Second Six Months): January 1, 2022, to June 30, 2022

2023 update: The second six months of year one was spent finalizing auditing, quality assurance, and quarterly reporting processes. During this time, updates to existing Pierce County funded behavioral health contracts were amended to include performance-based payments and the RFP based on the BHIP needs assessment and six-year plan was opened to the community.

Year Two: July 1, 2022, to June 30, 2023

2023 update: Year two included reviewing outcomes and metrics for existing programs and making decisions about continued funding. Pierce County determined available funds and funding targets for the coming year and adjusted metrics and reporting based on program experience and community needs. This was also when the County released and awarded funding through the RFP for 2024 programs.

Year Three: July 1, 2023, to June 30, 2024

• Performance Audit Committee biennial audit for Behavioral Health Tax.

• July-December 2023: Complete biennial update to the BHIP based on stakeholder and BHAB input and program experience.

• Review outcomes and metrics for existing programs and make decisions about continued funding. Determine available funds and funding targets for the coming year.

• Adjust metrics and reporting based on program experience and community needs.

• Spring 2024: Release RFP for calendar year 2025 programs.

• Summer 2024: Funds awarded for calendar year 2025 funds and placed into 2025 budget.

• Opioid settlement funds timeline:

o December 2023-February 2024: Develop Notice of Funding Availability (NOFA), scoring tools, and recruit for review panel.

o February 2024: Release NOFA.

o March 2024-April 2024: Review, score and propose funding awards; present recommendations; send out award letters; and start drafting contracts.

o May 2024-June 2024: Negotiated and write contracts.

o July 1, 2024: Contracts for opioid funds begin.

Year Four: July 1, 2024, to June 30, 2025

• Review outcomes and metrics for existing programs and make decisions about continued funding. Determine available funds and funding targets for the coming year.

• Adjust metrics and reporting based on program experience and community needs.

• Spring 2025: Release RFP for calendar year 2026 programs.

• Summer 2025: Award funds for calendar year 2026 funds and enter 2026 budget.

Year Five: July 1, 2025, to June 30, 2026

• Performance Audit Committee biennial audit for Behavioral Health Tax.

• July-September 2025: Complete biennial update to the BHIP based on stakeholder and BHAB input and program experience.

• Review outcomes and metrics for existing programs and make decisions about continued funding. Determine available funds and funding targets for the coming year.

• Adjust metrics and reporting based on program experience and community needs.

• Spring 2026: Release RFP for calendar year 2027 programs.

• Summer 2026: Award funds for calendar year 2027 funds and enter 2027 budget.

Year Six: July 1, 2026, to June 30, 2027

• Performance Audit Committee comprehensive assessment of Behavioral Health Tax.

• Deadline to extend sunset of taxing authority (October 1, 2027).

• Review outcomes and metrics for existing programs and make decisions about continued funding. Determine available funds and funding targets for the coming year.

• Adjust metrics and reporting based on program experience and community needs.

• Spring 2027: Release RFP for calendar year 2028 programs.

• Summer 2027: Award funds for calendar year 2028 and enter 2028 budget.

Appendix A Placeholder:

Behavior Bridges Preventing Behavioral Health Crises for Neurodiverse Populations

a variety

Catholic Community Services Family, Assessment & Stabilization Team (FAST)

Community-based Behavioral Health Treatment

Catholic Community Services Outreach and Relationships

Community-based Behavioral Health Treatment

Intensive support services are provided to families with children at risk of out of home placement. This is a short-term (up to 90 days) community-based alternative to psychiatric hospitalization or foster care placement. Intended outcomes are increased safety, stabilization, and ensuring children have a permanent family resource.

Provides on-site behavioral health services, outreach and supports to individuals living at CCS shelter sites, including the Nativity House Shelter/Apartments, the Puyallup Hotel Shelter, and the Stability Site.

Catholic Community Services Wraparound with Intensive Services (WISe)

Community-based Behavioral Health Treatment

Central Pierce Fire Department Central Pierce FD CARES

Outpatient Behavioral Health Services

WISe is an approach to helping children, youth, and their families with intensive mental health care. Services are available in home and community settings and offer a system of care based on the individualized need of the child or youth.

CARES programs (Community Assistance Referral and Education Services) programs aim to decrease non-emergent calls to 911 by those whose needs are better served through low-acuity care management and connection to social services. Central Pierce FD CARES aims to lower the number of repeat, non-emergency 911 calls by addressing underlying problems and connecting patients to physical health, behavioral health, and social services.

Clover

Communities

One-to-one counseling for Clover Park Technical College students. Also includes group therapy through support groups.

The Lakewood Youth Wellness Program will be incorporated at each of the five sites CIS Lakewood currently serves through our model of "Integrated Student Supports" providing 3 Tiers of Supports for students and school communities. The Program will provide Tier 1 (school-wide education and awareness events, training to CISL staff) Tier 2. targeted small group and Tier 3. individualized case management and wellness supports.

X Newly-Funded Program for 2425

Adult Homeless Pierce County BHTC

Pierce County

Youth Medicaid Youth Medicaid Pierce County

Adult

Community-based Behavioral Health Treatment

MCIRT is a mobile outreach program comprised of mental health professionals, case managers, peer advocates, registered nurses and psychiatric ARNPs who provide support and wrap around services to high utilizers of emergency and law enforcement services. MCIRT is not a crisis intervention team. The goal is to reduce 911/emergency utilization by individuals whose needs are better served through non-emergency services by connecting them with longterm, non- crisis services.

An RTF is a voluntary inpatient facility for the longer-term treatment of mental health disorders.

PACT provides community-based comprehensive individualized services to persons with severe and persistent mental illness who may not respond to traditional outpatient psychiatric case management, who have a recent history of high hospital and/or jail use, and current functional impairments in daily living. Services provided include care coordination, medication management, transportation, vocation and housing support, and 24/7 crisis intervention.

Consejo Counseling Consejo Counseling Outpatient Mental Health Treatment

Individual Counseling- meet with students to address behavioral health issues that impact school performance or functioning. Psychiatric evaluation and medication management as needed. Crisis interventionStudents experiencing crisis during the school day will have access to a CLR treatment team member for support. Either in person or telehealth. Case management.

WISe is an approach to helping children, youth, and their families with intensive mental health care. Services are available in home and community settings and offer a system of care based on the individualized need of the child or youth.

Outpatient mental health treatment includes such services as individual counseling, group therapy, and peer counseling all of which are provided in an outpatient setting.

Consejo Counseling Consejo Counseling Outpatient Substance Use Disorder Treatment

Outpatient substance use disorder treatment may include such services as individual counseling, group therapy, peer counseling, IOP and Medication Assisted Treatment all of which are provided in an outpatient setting to assist an individual in the treatment of their substance use disorder.

Crossroads Treatments Center Crossroads Treatments Center Outpatient Substance Use Disorder Treatment Outpatient substance use disorder treatment may include such services as individual counseling, group therapy, peer counseling, IOP and Medication Assisted Treatment all of which are provided in an outpatient setting to assist an individual in the treatment of their substance use disorder.

Adult; Youth BIPOC; NonEnglish Speakers Medicaid; Commercial Pierce County

Adult BIPOC; NonEnglish Speakers Medicaid; Commercial Pierce County

Adult Medicaid; Commercial Pierce County

First 5 Fundamentals Family Connects Prevention

referrals for medication assisted treatment and other medical services. There are currently 2 fixed outreach sites in Pierce County.

Family Connects is an evidence-based model that supports all families with a newborn through voluntary nurse support visits (or telehealth) during the infant’s first three (3) months of life. This includes screenings for Postpartum Depression, substance abuse, and domestic violence. Referrals to other community resources can be made as necessary.

For The Culture Counseling Services Intensive Outpatient 2.1 Outpatient Substance Use Disorder Treatment Intensive Outpatient, IOP is a 12 month program. Clients will engage in three-three hour group sessions per week, individual sessions with an assigned therapist, and random urinalysis. Clients will receive three hours per week of Dialectal Behavioral Therapy (DBT), in order to learn how to manage impulsive behavior, emotional responses, and self-destructive urges.

For The Culture Counseling Services

Outpatient 1.0 Outpatient Substance Use Disorder Treatment

Outpatient, OP, is a 6 month program. Clients that enter treatment at Outpatient level, will begin with two-two hour groups per week, and individual sessions with an assigned therapist. Clients will also submit random urinalysis. While in Outpatient, clients will work on continued relapse prevention and refusal skills.

X Newly-Funded Program for 2425

Adult Perinatal and PostPartum Pierce County BHTC Pierce County

Adult BIPOC Medicaid Pierce County

Adult BIPOC Medicaid Pierce County

For The Culture Counseling Services

Youth SUD Outpatient Substance Use Disorder Treatment

Serves youth in the community. We are working to build community partnership with local middle and high schools, to provide direct services to youth on site at school. For The Culture utilizes Global Appraisal of Individual Needs (GAIN) to assess and diagnosis youth. Youth age 1318 meets the age limit for services. For The Culture also provide services to young adults age19-25. We offer LGBTQ services to individuals that identify as part of this community at the time of assessment. Youth have the opportunity to engage in group therapy and individual therapy. Youth will also submit random urinalysis while engaging in the program. For The Culture offers youth services for individuals in need of Outpatient or Intensive Outpatient Services.

Foundations for Multicultural Solutions Community Programs Community-based Education and Outreach Education and awareness on issues impacting the community.

Foundations for Multicultural Solutions Substance Abuse Disorders Treatment Outpatient Substance Use Disorder Treatment Outpatient substance use disorder treatment may include such services as individual counseling, group therapy, peer counseling, IOP and Medication Assisted Treatment all of which are provided in an outpatient setting to assist an individual in the treatment of their substance use disorder.

Youth BIPOC Medicaid Pierce County

Adult; Youth BIPOC; NonEnglish Speakers Pierce County

Adult; Youth BIPOC; NonEnglish Speakers Pierce County

Greater Lakes Mental Healthcare Community Reentry Program (CRP)

Justice-involved Behavioral Health Services

Greater Lakes Mental Healthcare Felony Mental Health Court

Justice-involved Behavioral Health Services

An intensive community-based forensic wraparound program assisting those with a mental health or co-occurring substance use disorder with 5 or more arrests in a 12month period. The population served have typically failed engaging in more standard outpatient services. The CRP team consists of clinicians, peers, case managers, medical assistants for physical health, and psychiatric nursing including a Psychiatric ARNP who provide frequent engagement during incarceration and intensive outreach once clients are released. The team also offers help finding housing and building community supports to increase participants’ chances of avoiding future arrests. The goal of the program is to keep clients both out of jail and out of the hospital through intensive outreach and community supports and is more diversion focused than the Jail Transitions Services program.

Greater Lakes Mental Healthcare Forensic Assertive Community Treatment (FACT)

Justice-involved Behavioral Health Services

Assist individuals experiencing a mental health or substance use disorder who have been charged with a non-violent felony and/or misdemeanor to participate in treatment and rehabilitation. The goals of the Jail Diversion program are to 1) prevent clients who are likely to require competency restoration, from entering jail in the first place and 2) assist jailed clients in transitioning into treatment and services in the community. With full client engagement, this program can lead to reduced or dropped legal charges.

Pierce County Felony Mental Health Court is designed to treat felony defendants whose chronic mental illness caused their criminal behavior. Pierce County Superior Court partners with Greater Lakes Mental Health Forensic Assertive Community Team (FACT) to team provide 24/7 mental health services, medication management, 1:1 weekly therapy, substance abuse treatment, regular UA’s, peer support and housing assistance. The program is a minimum of 18 months to graduate and successful graduates may have their charges dismissed or will receive and exceptional sentence allowing the individual to remain in the community.

Greater

Greater

Outpatient mental health treatment includes such services as individual counseling, group therapy, and peer counseling all of which are provided in an outpatient setting.

An E&T is a secure, involuntary 16-bed facility for the evaluation and short-term treatment of individuals 18 and older who present an acute risk of harming self or others or are gravely disabled due to a mental health crisis. There are 4 E&Ts in Pierce County which accept only those with primary mental health diagnosis. Since we currently have no institution to send those with an impairment caused primarily by a SUD diagnosis in Pierce County, individuals will be sent out of county depending on bed availability.

Adult Justice-Involved Medicaid; Carelon; Local Funding

Adult Justice-Involved Pierce County General Fund; Grants

Pierce County

Pierce County

Adult Justice-Involved Medicaid; Carelon Pierce County

Adult; Youth Medicaid; Medicare; Commercial

Pierce County

Adult Medicaid; Carelon Pierce County

X

Assist individuals experiencing a mental health or substance use disorder who have been charged with a non-violent felony and/or misdemeanor to participate in treatment and rehabilitation. The goals of the Jail Diversion program are to 1) prevent clients who are likely to require competency restoration, from entering jail in the first place and 2) assist jailed clients in transitioning into treatment and services in the community. With full client engagement, this program can lead to reduced or dropped legal charges.

Greater

Adult

The JTS program is a short-term (up to 90 days) transitional service supporting those being released from incarceration who struggle with a mental health or substance use disorder. While an individual is incarcerated, the JTS team provides metal health and substance use assessment, case management, and release planning including helping clients identify goals that promote recovery. Once an individual is released the JTS team assists them in reaching those goals by obtaining/maintaining housing, pursuing vocational/educational goals, developing effective natural supports and in obtaining, maintaining, and/or using appropriate mental health, medical and community resources. The team also provides outreach, counseling, independent living skills training, and assists with crisis intervention and stabilization. All services are provided under the supervision of a Mental Health Professional. Services provided as part of this program are intended to facilitate safe and effective transition from incarceration into community services. Can serve anyone regardless of insurance status.

PACT provides community-based comprehensive individualized services to persons with severe and persistent mental illness who may not respond to traditional outpatient psychiatric case management, who have a recent history of high hospital and/or jail use, and current functional impairments in daily living. Services provided include care coordination, medication management, transportation, vocation and housing support, and 24/7 crisis intervention.

Adult

Pierce County Greater

An RTF is a voluntary inpatient facility for the longer-term treatment of mental health disorders. Adult

X Newly-Funded Program for 2425

Youth BIPOC; MiddleSchoolers Pierce County BHTC Pierce County

Greater

Health Services

HopeSparks Family Services

HopeSparks

Children's Behavioral Health Services

Outpatient Behavioral Health Services

HopeSparks provides crucial, preventive, and evidence-based behavioral healthcare for children and families.

Horses Guiding Humans Heal with the Herd Outpatient Mental Health Treatment Engages participants in unmounted equine assisted psychotherapy activities aimed at targeting their mental health obstacles by using solution focused strategies with a herd of horses and other farm animals.

Integrated Therapy Services Integrated Therapy Services Outpatient Mental Health Treatment

Outpatient mental health treatment includes such services as individual counseling, group therapy, and peer counseling all of which are provided in an outpatient setting. Has a specialized program for perinatal wellness.

Key Peninsula Fire Department Key Peninsula FD CARES Outpatient Behavioral Health Services CARES programs (Community Assistance Referral and Education Services) programs aim to decrease non-emergent calls to 911 by those whose needs are better served through low-acuity care management and connection to social services. Central Pierce FD CARES aims to lower the number of repeat, non-emergency 911 calls by addressing underlying problems and connecting patients to physical health, behavioral health, and social services.

LifeStance Health Mental Health Counseling Outpatient Mental Health Treatment Outpatient mental health treatment includes such services as individual counseling, group therapy, and peer counseling all of which are provided in an outpatient setting.

LifeStance Health Substance Abuse Disorders Treatment Outpatient Substance Use Disorder Treatment

Outpatient substance use disorder treatment may include such services as individual counseling, group therapy, peer counseling, IOP and Medication Assisted Treatment all of which are provided in an outpatient setting to assist an individual in the treatment of their substance use disorder.

Metropolitan Development Council (MDC)

Tacoma Detox Acute Withdrawal Management

Metropolitan Development Council (MDC)

The Center for Substance Abuse Recovery

Outpatient Substance Use Disorder Treatment

Acute Withdrawal Management medically assists individuals through the symptoms of withdrawal from various substances as well as connecting them to appropriate services to address the substance use disorder after the withdrawal period.

Outpatient substance use disorder treatment may include such services as individual counseling, group therapy, peer counseling, IOP and Medication Assisted Treatment all of which are provided in an outpatient setting to assist an individual in the treatment of their substance use disorder.

MultiCare Behavioral Health Alternative Response Team Crisis Behavioral Health Services

ART clinicians partner with the Pierce County Sheriff’s department to respond to situations where a person is suspected of being in mental health crisis. They also partner with 911 and the Sheriff’s Department to conduct training on effectively working with individuals in mental health crisis.

Youth Families; Age 3 to 21 Medicaid; Commercial; Grants

X 170 Adult; Youth Veterans, Service Members, and Family

Pierce County

Pierce County BHTC Pierce County

Adult; Youth Families; Perinatal and Post-Partum; LGBTQ+ Community

Adult

Medicaid; Commercial Pierce County

Key Peninsula

Adult; Youth Families; Perinatal and Post-Partum; LGBTQ+ Community

Commercial; Medicare Pierce County

Adult; Youth Families; Perinatal and Post-Partum; LGBTQ+ Community

Commercial; Medicare Pierce County

Adult; Youth Ages 13 and Older Medicaid; Carelon; Pierce County BHTC

Pierce County

Medicaid; Carelon Pierce County

MultiCare Behavioral Health Asian Counseling Services Outpatient Mental Health Treatment

Outpatient mental health treatment includes such services as individual counseling, group therapy, and peer counseling all of which are provided in an outpatient setting.

Adult Immigrants from Cambodia, Korea, Vietnam and the Pacific islands

Medicaid; Commercial Pierce County

Outpatient Substance Use Disorder Treatment

Outpatient substance use disorder treatment may include such services as individual counseling, group therapy, peer counseling, IOP and Medication Assisted Treatment all of which are provided in an outpatient setting to assist an individual in the treatment of their substance use disorder.

MultiCare Behavioral Health Lakewood CoResponder Justice-involved Behavioral Health Services

Co-responders are behavioral health professionals who work with law enforcement agencies to aid and improve their response to those with mental health and/or substance use disorders. Each agency has created its own model while keeping a shared goal of providing appropriate alternatives to arrest and jail time for those experiencing a behavioral health crisis. The co-responders work to stabilize the situation and provide limited case management to connect the individual with services addressing the underlying issues leading to their crisis.

MultiCare Behavioral Health Luckett House Residential Treatment Facility An RTF is a voluntary inpatient facility for the longer-term treatment of mental health disorders.

MultiCare Behavioral Health Mobile Outreach Crisis Team Crisis Behavioral Health Services

MOCT is part of MultiCare Behavioral Health and provides crisis outreach services for persons age 18 and over, including faceto-face evaluations by a Designated Crisis Responder (DCR) for involuntary detainment. Members of the MOCT team provide initial assessments to determine if the individual in crisis will accept a less restrictive alternative to hospitalization and refer to those alternative services. If the individual appears to meet involuntary detainment criteria (danger to self, danger to others, gravely disabled), the DCR will assess and detain if necessary.

MultiCare Behavioral Health MultiCare Behavioral Health Outpatient Mental Health Treatment Outpatient mental health treatment includes such services as individual counseling, group therapy, and peer counseling all of which are provided in an outpatient setting.

MultiCare Behavioral Health Pierce County CoResponder Justice-involved Behavioral Health Services

Co-responders are behavioral health professionals who work with law enforcement agencies to aid and improve their response to those with mental health and/or substance use disorders. Each agency has created its own model while keeping a shared goal of providing appropriate alternatives to arrest and jail time for those experiencing a behavioral health crisis. The co-responders work to stabilize the situation and provide limited case management to connect the individual with services addressing the underlying issues leading to their crisis.

Family Hope Center Tacoma Recovery Center Outpatient Substance Use Disorder Treatment Outpatient substance use disorder treatment may include such services as individual counseling, group therapy, peer counseling, IOP and Medication Assisted Treatment all of which are provided in an outpatient setting to assist an individual in the treatment of their substance use disorder.

Integrated Health Medication Assisted Treatment Medication Assisted Treatment Medication Assisted Treatment (MAT) is the use of medications in combination with counseling and therapy to address an individual's substance use disorder. All medications used in MAT are approved by the FDA.

Adult Justice-Involved Lakewood

Adult Medicaid; Carelon Pierce County

Adult Medicaid; Carelon Pierce County

Adult; Youth Medicaid; Medicare; Commercial

Pierce County

X 2000 Adult Justice-Involved Carelon; Pierce County BHTC Pierce County

X 97 Adult Pierce County BHTC Pierce County

Multicultural

Northwest

Adult Medicaid Pierce County

Outpatient Behavioral Health Services

Northwest Integrated Health Substance Abuse Disorders Treatment Outpatient Substance Use Disorder Treatment

Outpatient substance use disorder treatment includes such services as individual counseling, group therapy, peer counseling and Medication Assisted

Treatment all of which are provided in an outpatient setting to assist an individual in the treatment of their substance use disorder.

Outpatient substance use disorder treatment may include such services as individual counseling, group therapy, peer counseling, IOP and Medication Assisted Treatment all of which are provided in an outpatient setting to assist an individual in the treatment of their substance use disorder.

Oasis Youth Center Mental Health Voucher Program Outpatient Behavioral Health Services

Olalla Recovery Centers Gig Harbor Counseling Outpatient Substance Use Disorder Treatment

Oasis is a drop-in and support center dedicated to the needs of LGBTQ+ youth to transform their lives by creating a safe place to learn, connect, and thrive.

Outpatient substance use disorder treatment may include such services as individual counseling, group therapy, peer counseling, IOP and Medication Assisted Treatment all of which are provided in an outpatient setting to assist an individual in the treatment of their substance use disorder.

Olalla Recovery Centers Olalla Guest Lodge Inpatient Substance Use Disorder Treatment

Inpatient treatment is more intensive, less flexible treatment than outpatient treatment where the individual lives at the treatment facility while completing a structured set of treatment goals. Most residential programs will include group and individual counseling, drug monitoring and case management.

Pierce County Alliance Assisted Outpatient Treatment Justice-involved Behavioral Health Services

Pierce County Alliance Felony Drug Court Justice-involved SUD Services

Provides community-based behavioral health services under an Assisted Outpatient Treatment (AOT) involuntary court order to individuals with a severe mental illness or substance use disorder who have demonstrated difficulty adhering to prescribed treatment on a voluntary basis. They assign clients to an ACT-like treatment team to include at least a psychiatrist, mental health professional (MHP) and peer support specialist. For clients already enrolled in PACT (Program for Assertive Community Treatment), AOT court intervention will be utilized in coordination with PACT services.

Assist individuals experiencing a mental health or substance use disorder who have been charged with a non-violent felony and/or misdemeanor to participate in treatment and rehabilitation. The goals of the Jail Diversion program are to 1) prevent clients who are likely to require competency restoration, from entering jail in the first place and 2) assist jailed clients in transitioning into treatment and services in the community. With full client engagement, this program can lead to reduced or dropped legal charges.

Adult Medicaid Pierce County

Adult Medicaid Pierce County

Youth LGBTQ+ Youth Pierce County

Adult; Youth AIAN Medicaid; Commercial; Tribal

Adult AIAN Medicaid; Commercial; Tribal

Pierce County

Pierce County

Adult Justice-Involved Medicaid; Pierce County BHTC Pierce County

Pierce County Alliance Recovery Navigators Community-based Education and Outreach

Assist individuals experiencing a mental health or substance use disorder who have been charged with a non-violent felony and/or misdemeanor to participate in treatment and rehabilitation. The goals of the Jail Diversion program are to 1) prevent clients who are likely to require competency restoration, from entering jail in the first place and 2) assist jailed clients in transitioning into treatment and services in the community. With full client engagement, this program can lead to reduced or dropped legal charges.

A completely voluntary; designed to provide assistance for anyone dealing with adverse life issues that may arise from substance abuse and/or mental health problems. It offers intensive personal support by licensed peers to access the foundational pillars of recovery for any behavioral health issues.

X

Pierce Transit Hardship Assistance Response Team (HART)

Community-based Behavioral Health Treatment

Pierce Transit’s goal is to field a Hardship Assistance Response Team (HART) consisting of Pierce Transit Public Safety staff and contracted behavioral health professionals. This team would assist individuals using Pierce Transit services, on or near Pierce Transit property, that experience mental health, substance abuse, and/or insecure housing issues in the Pierce County defined project area.

Pride Counseling Northwest Mental Health Counseling Outpatient Mental Health Treatment Outpatient substance use disorder treatment includes such services as individual counseling, group therapy, peer counseling and Medication Assisted

Treatment all of which are provided in an outpatient setting to assist an individual in the treatment of their substance use disorder.

X Newly-Funded Program for 2425

Adult Adult Carelon Pierce County

Adult Pierce County BHTC Pierce County

Adult; Youth LGBTQ+; Adolescents Private Pay Pierce County

Progress House Association PHA Clubhouse Community-based Education and Outreach

Serves individuals living with mental illness. This population can include people who have been diagnosed with various mental health conditions such as schizophrenia, bipolar disorder, major depression, and anxiety disorders, among others. Offers access to resources, peer mentoring, case management, life coaching, and a sense of community.

Wellness Center Prosperity Outpatient Outpatient Substance Use Disorder Treatment Outpatient substance use disorder treatment may include such services as individual counseling, group therapy, peer counseling, IOP and Medication Assisted

Treatment all of which are provided in an outpatient setting to assist an individual in the treatment of their substance use disorder.

Inpatient treatment is more intensive, less flexible treatment than outpatient treatment where the individual lives at the treatment facility while completing a structured set of treatment goals. Most residential programs will include group and individual counseling, drug monitoring and case management.

County Puyallup Tribal Health Authority Kwawachee Counseling Center Outpatient Mental Health Treatment Kwawachee Counseling Center (KCC) is a WA state licensed facility and a safe place where, during difficult times, crisis, or illness, clients can begin to find some purpose in these turning points in life. KCC provides a full range of preventative and treatment options to address your mental health needs.

Rainer Recovery Medication Assisted Treatment

Assisted Treatment Medication Assisted Treatment (MAT) is the use of medications in combination with counseling and therapy to address an individual's substance use disorder. All medications used in MAT are approved by the FDA.

Rainer Recovery Substance Abuse Disorders Treatment Outpatient Substance Use Disorder Treatment Outpatient substance use disorder treatment may include such services as individual counseling, group therapy, peer counseling, IOP and Medication Assisted Treatment all of which are provided in an outpatient setting to assist an individual in the treatment of their substance use disorder.

Sea Mar Community Health Centers Sea Mar Community Health Centers Outpatient Mental Health Treatment

Sea Mar Community Health Centers Tacoma Treatment Center Inpatient Substance Use Disorder Treatment

Outpatient mental health treatment includes such services as individual counseling, group therapy, and peer counseling all of which are provided in an outpatient setting.

Inpatient treatment is more intensive, less flexible treatment than outpatient treatment where the individual lives at the treatment facility while completing a structured set of treatment goals. Most residential programs will include group and individual counseling, drug monitoring and case management.

SeaMar Community Health Centers SeaMar Community Health Centers Outpatient Substance Use Disorder Treatment Outpatient substance use disorder treatment may include such services as individual counseling, group therapy, peer counseling, IOP and Medication Assisted Treatment all of which are provided in an outpatient setting to assist an individual in the

WISe and TCM are approaches to helping children, youth, and their families with intensive mental health care. Services are available in home and community settings and offer a system of care based on the individualized need of the child or youth.

Adults Medicaid; Commercial Pierce County

Adults; Youth Medicaid; Commercial Pierce County

Adult; Youth BIPOC; NonEnglish Speakers Medicaid; Commercial Pierce County

Adult BIPOC; NonEnglish Speakers Medicaid Pierce County

Outpatient Behavioral Health Services

CARES programs (Community Assistance Referral and Education Services) programs aim to decrease non-emergent calls to 911 by those whose needs are better served through low-acuity care management and connection to social services. As part of the CARES program, TFD has partnered with Tacoma Police Department to coordinate a crisis response team to support first responders with community interactions with patients suffering from acute behavioral and/or substance abuse needs through behavioral health case management. The case manager or mental health providers can co-respond or selfdispatch and arrive on the scene with first responders to provide much needed support to first responders and community members alike. TFD CARES is the only program of its kind in the state to be a licensed Behavioral Health Agency through Department of Health.

Tacoma Pierce County Health Department Child Wellness Community-based Education and Outreach

A series of complementary upstream prevention efforts developed through the framework of Positive Childhood Experiences (PCEs). Provides socialemotional learning resources to children, youth, families, and community partners who work with youth. Services include social-emotional learning opportunities for caregivers, mental health toolkits and other community engagement, and a revision of the resource guide being created in the '22/'23 funding cycle.

Tacoma Pierce County Health Department Family Nurse Partnership/Black Infant Health

Prevention

An evidence-based model that supports families with a newborn through voluntary nurse support visits (or telehealth) while pregnant and/or during the infant’s first three (3) months of life. This includes screenings for Postpartum Depression, substance abuse, and domestic violence. Referrals to other community resources can be made as necessary.

Tacoma Pierce County Health Department MedsFirst Medication Assisted Treatment Medication Assisted Treatment (MAT) is the use of medications in combination with counseling and therapy to address an individual's substance use disorder. All medications used in MAT

X 65 Adult BIPOC; Perinatal and Post-Partum Medicaid; Pierce County BHTC Pierce County

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Community-based Education and Outreach

Web-based, youth-centered fentanyl awareness social marketing campaign. The campaign aims to increase awareness about fentanyl risks, improve access to life-saving opioid poisoning (overdose) prevention education and offer behavioral health resources. Using the social marketing campaign as a springboard, the TPCHD will also work with school districts and organizations to effect policy change to increase prevention and reduce stigma around fentanyl treatment.

Short-term community support for recovery during transition from inpatient treatment back to the community.

County Telecare Mental Healthcare Telecare Community Alternative Teams (TCAT)

Mobile Behavioral Health Services

A community based, short-term (up to 90 days) wraparound service to minimize inpatient stays or divert from emergency rooms for Medicaid and Carelon clients. TCAT provides transition services, crisis outreach, psych medication support, and case management, transportation, for discharge from inpatient mental health treatment facilities. Staff is multidisciplinary and includes an MHP, Peer Recovery Coaches, and Case Managers.

An E&T is a secure, involuntary 16-bed facility for the evaluation and short-term treatment of individuals 18 and older who present an acute risk of harming self or others or are gravely disabled due to a mental health crisis. There are 4 E&Ts in Pierce County which accept only those with primary mental health diagnosis. Since we currently have no institution to send those with an impairment caused primarily by a SUD diagnosis in Pierce County, individuals will be sent out of county depending on bed availability.

CARES programs (Community Assistance Referral and Education Services) programs aim to decrease non-emergent calls to 911 by those whose needs are better served through low-acuity care management and connection to social services. Central Pierce FD CARES aims to lower the number of repeat, non-emergency 911 calls by addressing underlying problems and connecting patients to physical health, behavioral health, and social services.