Report — Department of Commerce, Services for People Leaving Long-Term Civil Commitment (2023)
Summary
This report to the Legislature from the Housing Division of the Department of Commerce, dated April, 2023, covers community behavioral health services for people leaving long-term civil commitment settings, as directed by Section 128 (139) of Chapter 297, Laws of 2022. That section provided $75,000 for fiscal year 2022 and $125,000 for fiscal year 2023 for a report on facilities and residential settings for individuals discharged from state psychiatric hospitals. Key findings by HCA regional districts are that North Central, Olympic, and Great Rivers regions have relatively low service availability, while Spokane, North Sound, Southwest, and Thurston-Mason show relative parity or slightly favorable availability.
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Report on community behavioral health services for people leaving
long-term civil commitment settings per Section 128 (139) of
Chapter 297, Laws of 2022
April, 2023
HOUSING DIVISION Report to the Legislature
Director Mike Fong
V3.2
Acknowledgments
Department of Social and Health Services, www.commerce.wa.gov
Research and Data Analysis Division
David Mancuso, Director For people with disabilities, this report is available on
request in other formats. To submit a request, please
Jim Mayfield, Senior Research Scientist call 360-725-4000 (TTY 360-586-0772)
Taylor Danielson, Research Associate
Project Committee
Kristin Byrne, Department of Social and Health
Services, Aging and Long-Term Support
Administration, Home and Community Services
Kimberly Castle, Health Care Authority
Dan Overton, Department of Health
Matt Mazur-Hart, Department of Commerce
Bea-Alise Rector, Department of Social and Health
Services, Aging and Long-Term Support
Administration
Jeff Spring, Department of Commerce
Travis Sugarman, Department of Health
Scott Tankersley, Health Care Authority
Jamie Tong, Department of Social and Health
Services, Aging and Long-Term Support
Administration, Home and Community Services
Washington State Department of Commerce
Corina Grigoras, Assistant Director, Housing
Division
Tedd Kelleher, Policy Director, Housing Division
Taylor Webb, Policy Coordinator
Taylor.Webb@commerce.wa.gov
HOUSING DIVISION
1011 Plum St. SE
P.O. Box 42525
Olympia, WA 98504-2525
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Table of contents
Executive summary...................................................................................................................................... 2
Introduction ................................................................................................................................................. 3
Analysis of regional distribution relative to the LTCC population................................................................. 10
Summary and next steps............................................................................................................................ 33
Appendix A: Glossary ................................................................................................................................. 36
Appendix B: Descriptions of in-scope housing and related supportive services ........................................... 38
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HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Executive summary
Legislative mandate
Section 128 (139) of Chapter 297, Laws of 2022, directed the Department of Commerce to develop a report on
the behavioral health, long-term care facilities and residential settings that support individuals once they are
discharged from state psychiatric hospitals:
$75,000 of the general fund—state appropriation for fiscal year 2022 and $125,000 of the general fund—state
appropriation for fiscal year 2023 are provided solely for the department of commerce to develop a report on the
behavioral health and long-term care facilities and residential settings that provide services within the continuum of
care for individuals who are discharged from state psychiatric hospitals. For the purposes of this subsection,
"continuum of care" means transitional housing or residential placements that provide supportive services and skill
development needed for individuals to be permanently housed, and permanent supportive housing or residential
placements that provide individuals with an appropriate place to live with services available as needed. The report
must map the geographic location of each facility or residential setting, and it must highlight geographic gaps in
service availability. In preparing the report, the department must coordinate with the department of social and health
services, the department of health, and the health care authority. The department must submit its report to the
governor and appropriate legislative committees no later than December 1, 2022.
The Department of Commerce contracted with the Department of Social and Health Services (DSHS) Research
and Data Analysis Division (RDA) to perform the necessary analyses and draft the required report. By looking at
HCA regions, an analysis of discharges shows where people have a lack of housing and service availability and
where services better match the need.
Key findings by HCA regional districts
North Central, Olympic, and Great Rivers regions have relatively low service availability.
King and Greater Columbia have relatively low service availability among the larger regions.
Spokane, North Sound, Southwest, and Thurston-Mason regions show relative parity or slightly
favorable relative service availability.
Services supporting people discharging from long-term civil commitment (LTCC) settings are more
widely available in the Pierce region.
Next steps
A second phase of work, scheduled to be completed by June 2023, will examine the use of other HCA housing
programs and ALTSA specialized contract utilization data if relevant data are available. Finally, we will look at
the overlapping use of the various in-scope housing and related supportive services to provide a more
comprehensive picture of service utilization patterns.
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HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Introduction
Background
Section 128 (139) of Chapter 297, Laws of 2022, directed the Department of Commerce to develop a report on
behavioral health and long-term care facilities and residential settings that provide services within the
continuum of care for individuals discharged from state psychiatric hospitals. Continuum of care was defined
to mean transitional housing or residential settings that provide supportive services and skill development
needed for individuals to be permanently housed, and permanent supportive housing or residential settings
that provide individuals with an appropriate place to live with services available as needed. The Legislature
further directed that the report must map the geographic location of each facility or residential setting and
highlight geographic gaps in service availability.
The Legislature also directed that the work be conducted in coordination with the Department of Social and
Health Services (DSHS), the Department of Health (DOH), and the Health Care Authority (HCA). The
Department of Commerce contracted with the DSHS Research and Data Analysis Division (RDA) to conduct the
analyses and draft the required report. RDA has extensive experience linking and analyzing data across
relevant service settings. A cross-agency work group was established to review and help inform report content,
including Department of Commerce, DSHS, HCA, and DOH members.
Study population
Although the proviso language referenced people discharging from state psychiatric hospitals, the work group
recognized that most non-civil conversion patients admitted to a long-term civil commitment (LTCC) setting
are currently served in HCA-contracted community hospitals. These community-based settings include
Evaluation and Treatment (E&T) facilities, licensed community psychiatric hospitals, and other acute hospital
settings. This study interprets the in-scope population to include people discharging from a civil setting at a
state psychiatric hospital or from HCA-contracted LTCC settings.
Figures 1 and 2 below provide a perspective on the monthly census of people residing in a civil setting at
Western State Hospital (WSH) (371 people), Eastern State Hospital (ESH) (109), or an HCA-contracted LTCC
setting (124). From a monthly patient census perspective, patients who have shifted from a forensic to civil
legal authority (civil conversions) at WSH or ESH reflect the largest share of the LTCC population.1 However, in
part because lengths of stay in HCA-contracted LTCC settings tend to be much shorter than those at the state
hospitals, people discharging from HCA-contracted LTCC settings comprise a large and growing proportion of
total LTCC discharges.
1 "The Center for Forensic Services (CFS) serves clients who have been committed to the hospital under the chapter 10.77 RCW. These
include defendants who are undergoing an inpatient evaluation for competency to stand trial and/or mental state at the time of the
criminal offense. CFS also provides competency restoration treatment and treatment for clients who have been found Not Guilty by
Reason of Insanity (NGRI)." From: Washington State Department of Social and Health Services, WSH -- Center for Forensic Services,
https://www.dshs.wa.gov/bha/division-state-hospitals/wsh-center-forensic-services
3
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Figure 1: Census counts at WSH and ESH, first-of-month snapshots, Jan. 1, 2017,
through Sept. 1, 2022
800
700
TOTAL CENSUS
600
500 475
400
WSH Other Civil
304
300
WSH Civil Conversions
200
ESH Other Civil
100 67
ESH Civil Conversions
0 42
2017 JAN 2018 JAN 2019 JAN 2020 JAN 2021 JAN 2022 JAN
MAR MAY JUL SEP NOV MAR MAY JUL SEP NOV MAR MAY JUL SEP NOV MAR MAY JUL SEP NOV MAR MAY JUL SEP NOV MAR MAY JUL SEP
Source: DSHS Research and Data Analysis.
Notes: Civil Census counts include in-residence patients and exclude patients released on Authorized Leave or Medical Discharge. Civil Conversions
counts reflect the number of in-residence civil patients who converted from forensic to civil legal authority after a defendant's felony charges are
dismissed due to a lack of competency to stand trial, and the individual is then found to meet criteria under chapter 71.05 RCW for civil commitment.2
2 Department of Social and Health Services, Behavioral Health Administration, Office of Forensic Mental Health Services, "Washington
State Legal System Guide to Forensic Mental Health Services," (2016),
https://www.dshs.wa.gov/sites/default/files/BHSIA/WSH/WA%20State%20Legal%20System%20Guide%20to%20Forensic%20Mental%
20Health.pdf
4
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Figure 2: HCA-Contracted Long-Term Civil Commitment3 monthly census, first day of
the month
140
124
120
TOTAL ALL SETTINGS
100
80
60
Evaluation & Treatment 49
46
40
Community Psychiatric Hospital
29
20
Acute Hospital
0 2018 SEP
OCT
NOV
DEC
2019 JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
2020 JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
2021 JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
2022 JAN
FEB
MAR
APR
MAY
JUN
JUL
Source: DSHS Research and Data Analysis.
Notes: Based on admit and discharge dates for completed stays and inferred from authorization data for admissions that were still committed at the
time.
Research approach
A cross-agency work group was established to review and help inform report content. The work group included
members from the Department of Commerce (Commerce), the DSHS, the Health Care Authority (HCA), and the
Department of Health (DOH). The work group determined that the in-scope study population should include
people discharging from a civil setting at state psychiatric hospitals and HCA-contracted long-term civil
commitment (LTCC) settings.4 The work group also identified community behavioral health and housing-
related services and supports provided by HCA, Commerce and DSHS as in-scope for this study.
Psychiatric inpatient, acute hospital, crisis, and institutional services (such as nursing homes funded by DSHS'
Aging and Long-Term Support Administration (ALTSA) and Development Disabilities Administration (DDA)
residential habilitation centers) were determined to be outside the scope of report requirements.
3 The Health Care Authority (HCA) contracts with community hospitals and freestanding evaluation and treatment facilities to maintain
beds for 90-180-day involuntary, inpatient, psychiatric treatment. Individuals, mandated by a court process for civil commitment stays
of 90-180 days, may receive long-term inpatient care from a community hospital or freestanding evaluation and treatment center
contracted with HCA for this program, regardless of Medicaid managed care enrollment. From: Washington State Health Care Authority,
90- and 180-day civil commitment beds, https://www.hca.wa.gov/billers-providers-partners/program-information-providers/90-and-180-
day-civil-commitment-beds
4 "Civil Commitment means the determination by a court that a person should be detained for a period of either evaluation or treatment,
or both, in an inpatient or a less restrictive setting (RCW 71.05.020). The presence of a mental disorder is a prerequisite for civil
commitment. Other criteria frequently include dangerous behavior toward self or others, grave disability, and the need for treatment."
Source: Office of Forensic Mental Health Services, "Washington State Legal System Guide to Forensic Mental Health Services,"
https://www.dshs.wa.gov/sites/default/files/BHSIA/WSH/WA%20State%20Legal%20System%20Guide%20to%20Forensic%20Mental%
20Health.pdf
5
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
We set in-scope, need-based benchmarks based on the residence of people discharged from an LTCC setting
for three years from 2019-2021. This method allowed us to consider service availability and needs for each
health care region with a three-year population average. We examined the use of services by people released
from LTCC settings in December 2021 by region and compared that data with the benchmarks.
Measurement approach
We assess the use of in-scope services and supports in December 2021 by the HCA purchasing region shown
in Figure 3, relative to the regional distribution of people recently discharged from an LTCC setting, as reported
in Table 1. We do not formally assess each service type's absolute level of need. Determining an absolute level
of need for any given service would be challenging, given that the level of need for any given service directly
depends on the availability of related services that may act as substitutes or complements. For example, a
person who may benefit from a particular supportive housing program might also be effectively served through
alternative housing supports and/or intensive community behavioral health services. Similarly, for a given
housing support or facility-based service setting to be effective, other intensive community behavioral health
services may be needed to stably house people recently discharged into those settings from an LTCC.
Health Care Authority regions
The list of regions and the counties in each follows:
Spokane: Adams, Ferry, Lincoln, Pend Oreille, Spokane, and Stevens counties
Labeled in some maps as Better Health Together
Pierce: Pierce County
Labeled in some maps as Elevate Health
Great Rivers: Cowlitz, Grays Harbor, Lewis, Pacific, and Wahkiakum counties
Greater Columbia: Asotin, Benton, Columbia, Franklin, Garfield, Kittitas, Walla Walla, Whitman, and Yakima
counties
King: King County
Labeled in some maps as HealthierHere
North Central: Chelan, Douglas, Grant, and Okanogan counties
North Sound: Island, San Juan, Skagit, Snohomish, and Whatcom counties
Olympic: Clallam, Jefferson, and Kitsap counties
Southwest: Clark, Klickitat, and Skamania counties
Thurston-Mason: Thurston and Mason counties
6
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Figure 3: HCA service areas
WHATCOM
SAN JUAN
PEND
OKANOGAN FERRY STEVENS
OREILLE
SKAGIT
ISLAND North Sound
CLALLAM AMG, CCW, CHPW, MHW, UHC
North Central
Olympic Community SNOHOMISH AMG, CCW, MHW
Spokane
of Health AMG, CHPW, MHW
AMG, MHW, UHC CHELAN DOUGLAS
JEFFERSON KING LINCOLN SPOKANE
MASON
King
KITSAP AMG, CCW, CHPW,
MHW, UHC
GRAYS Thurston
HARBOR Mason PIERCE
AMG, MHW, KITTITAS GRANT
UHC Pierce ADAMS WHITMAN
AMG, CCW, MHW, UHC
PACIFIC FRANKLIN
LEWIS
Great Rivers GARFIELD
AMG, MHW, UHC BENTON COLUMBIA
WAHKIAKUM YAKIMA
COWLITZ Southwest
AMG, CHPW, WALLA WALLA ASOTIN
MHW Greater Columbia
AMG, CCW, CHPW, MHW
KLICKITAT
SKAMANIA
CLARK
7
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Table 1 describes a three-year (2019-2021) total number of people released from LTCC in each region. The
total (in column "Unduplicated count 2019-2021") is then divided by the number of regions to determine each
region's share of LTCC patients. The regional share is a metric used in most subsequent tables.
Table 1: Distribution of residence region at admission among recent LTCC
discharges, calendar year 2019 through 2021
Region 2019 2020 2021 Unduplicated count 2019-2021* Regional share of LTCC clients**
Spokane 189 208 308 517 23.1%
Pierce 79 89 86 242 10.8%
Great Rivers 36 42 68 134 6.0%
Greater Columbia 110 112 118 276 12.3%
King 141 118 127 370 16.5%
North Central 30 28 28 74 3.3%
North Sound 97 72 70 222 9.9%
Olympic 84 55 54 121 5.4%
Southwest 58 34 48 114 5.1%
Thurston-Mason 33 58 95 170 7.6%
Total 857 816 1,002 2,240 100%
*Unduplicated by person based on the last discharge in the 2019-21 period. Regional attribution based on most recent county of admission.
**Regional share of unduplicated people discharged from an LTCC in calendar years 2019, 2020, or 2021.
In-scope housing and related supportive services
As a group, people discharging from LTCC settings have diverse and extensive support needs spanning the
continuum of health and human service programs. The cross-agency work group identified the following
services as within the analytic scope of this report:
HCA-funded community behavioral health services:
Mental health residential treatment services
Behavioral health intensive treatment facilities
Program of Assertive Community Treatment (PACT)
Foundational Community Supports (FCS) supportive housing
Department of Commerce housing supports:
Rapid Rehousing
Transitional Housing
Permanent Housing
8
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Permanent Supportive Housing
Community Behavioral Health Rental Assistance (CBRA)
DSHS ALTSA services:
Assisted living
Adult residential care
Adult family home
Enhanced services facilities
In-home services
Governor's Opportunity for Supportive Housing (GOSH)
Specialized contracts with behavioral supports
Clients in ALTSA Long Term Support Services (LTSS) settings who also receive Medicaid Managed
Care Organization (MCO)-funded exceptional care support
DSHS DDA services:
Residential programs
State-operated living alternatives (SOLA)
Psychiatric inpatient, acute hospital, crisis, and institutional services (such as nursing homes funded by ALTSA
and DDA residential habilitation centers) were determined to be outside the scope of report requirements.
The remainder of this section provides additional programmatic detail for in-scope housing supports and
related services. A glossary of program abbreviations and acronyms is in Appendix A. Note that clients may
receive multiple types of in-scope services concurrently, and we do not attempt to describe the distribution of
the various possible service combinations. For example, a former LTCC patient may be receiving GOSH
services while residing in an adult family home or receiving ALTSA in-home services.
9
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Analysis of regional distribution relative to the LTCC
population
We examine the utilization of in-scope services in December 2021 by people recently discharged from LTCC
settings, with a focus on the following questions:
Statewide, which settings served the most people recently discharged from an LTCC setting?
ALTSA LTSS with MOC-funded exceptional wraparound support; see Table 13
ALTSA Adult Family Homes; see Table 10
For which services do recent LTCC patients comprise a higher proportion of the statewide service
population?
GOSH 60%; see Table 11, and ALTSA Community Residential Services 59%; see Table 7; (this
information is typically included in the text that precedes the tables).
How do regional shares of recent LTCC clients in specific service settings differ from the regional share
of the LTCC population, as identified in Table 1?
This is answered throughout the report in the columns labeled "Share difference."
In-scope HCA-funded community behavioral health services
Table 2 describes the use of HCA mental health residential treatment services by recent LTCC patients.
Statewide, 75 HCA mental health residential treatment clients in December 2021 were recently discharged
from an LTCC setting, representing 12% (75 of 639) of the mental health residential treatment population.
Relative to the regional share of the overall LTCC population, mental health residential treatment service use
was greatest in the Pierce and King regions. Relative use was lower in the Spokane, Thurston-Mason, and
Southwest regions.
10
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Table 2: Regional distribution of recent LTCC patients among December 2021 HCA
mental health residential clients
Recent LTCC Regional share of recent Share
Region All clients clients Regional share LTCC clients* difference
Spokane 60 11 14.7% 23.1% -8.4%
Pierce 99 20 26.7% 10.8% 15.9%
Great Rivers 4 1 1.3% 6.0% -4.6%
Greater Columbia 52 10 13.3% 12.3% 1.0%
King 289 18 24.0% 16.5% 7.5%
North Central 10 1 1.3% 3.3% -2.0%
North Sound 81 9 12.0% 9.9% 2.1%
Olympic 31 4 5.3% 5.4% -0.1%
Southwest 8 0 0.0% 5.1% -5.1%
Thurston-Mason 5 1 1.3% 7.6% -6.3%
Total 639 75 100% 100% 0%
*Unduplicated by person based on the last discharge in the 2019-21 period. Regional attribution based on most recent county of admission.
Table 3 describes the use of PACT services by recent LTCC patients. The distribution of PACT teams by region
is displayed in Figure 4. Statewide, 136 PACT clients in December 2021 were recently discharged from an
LTCC setting, representing 16% (136 of 836) of the PACT population. Relative to the regional share of the
overall LTCC population, the use of the PACT program was greatest in the Spokane and Olympic regions.
Relative use was lower in the Greater Columbia, King, and Pierce regions.
11
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Table 3: Regional distribution of recent LTCC patients among December 2021 HCA
PACT clients
Recent LTCC Regional Regional share
Region All clients clients share of recent LTCC clients* Share difference
Spokane 104 40 29.4% 23.1% 6.3%
Pierce 78 9 6.6% 10.8% -4.2%
Great Rivers 133 9 6.6% 6.0% 0.6%
Greater Columbia 113 10 7.4% 12.3% -5.0%
King 91 16 11.8% 16.5% -4.8%
North Central 42 2 1.5% 3.3% -1.8%
North Sound 139 12 8.8% 9.9% -1.1%
Olympic 46 18 13.2% 5.4% 7.8%
Southwest 73 10 7.4% 5.1% 2.3%
Thurston-Mason 17 10 7.4% 7.6% -0.2%
Total 836 136 100.0% 100% 0.0%
*Unduplicated by person based on the last discharge in the 2019-21 period. Regional attribution based on most recent county of admission.
12
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Figure 4: Selected HCA Community Behavioral Health facilities
See
Puget
Sound
Insert
See
Spokane
County
Insert
See Clark
County OCTOBER 2022
Insert DSHS Research and Data Analysis Division
Facility Type
In-Patient Evaluation Treatment Child Beds (11 Facilities)
In-Patient Evaluation Treatment Adult Beds (48 Facilities)
Puget Sound Insert
Crisis Triage Voluntary Beds (7 Facilities)
Crisis Triage Involuntary Beds (2 Facilities)
Crisis Stabilization Unit Beds (8 Facilities
HCA Medicaid Purchasing Regions
Clark County Insert Spokane County Insert
Source: DOH Licensing Data
Note: Elevate Health is the Pierce County region; Healthier Here is the King County region; Better Health Together is the multi-county Spokane region.
13
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Table 4 describes the use of FCS Supportive Housing services by recent LTCC patients. Statewide, 56 FCS
Supportive Housing clients in December 2021 were recently discharged from an LTCC setting, representing 1%
(56 of 5,979) of the FCS Supportive Housing population. Relative to the regional share of the overall LTCC
population, the use of the FCS Supportive Housing program was greatest in the Spokane region and relatively
low in the North Sound and Thurston-Mason regions.
Table 4: Regional distribution of recent LTCC patients among December 2021 FCS
Supportive Housing clients
Recent LTCC Regional Regional share of recent Share
Region All clients clients share LTCC clients* difference
Spokane 1,462 20 35.7% 23.1% 12.6%
Pierce 589 4 7.1% 10.8% -3.7%
Great Rivers 1,023 5 8.9% 6.0% 2.9%
Greater Columbia 710 8 14.3% 12.3% 2.0%
King 766 9 16.1% 16.5% -0.4%
North Central 151 0 0.0% 3.3% -3.3%
North Sound 485 2 3.6% 9.9% -6.3%
Olympic 247 5 8.9% 5.4% 3.5%
Southwest 254 2 3.6% 5.1% -1.5%
Thurston-Mason 292 1 1.8% 7.6% -5.8%
Total 5,979 56 100.0% 100% 0.0%
*Unduplicated by person based on the last discharge in the 2019-21 period. Regional attribution based on most recent county of admission.
In-scope Commerce-funded housing services
Table 5 describes the use of selected Commerce-funded housing services by recent LTCC patients, including
rapid rehousing, transitional housing, permanent housing, permanent supportive housing, and CBRA services.
These analyses are based on linked HMIS data for clients who have consented to allow their identifying
information to be used for analysis. Clients encountering the homeless crisis system are asked to complete a
consent form that allows the housing service provider to enter the client's identifying information into HMIS.
Clients may refuse to provide this information without penalty and may alter their decision at any time. Overall,
the percentage of clients who consent to provide identifying information is roughly 80%, with consent rates
declining in recent years. RDA maintains a database containing information on clients who encountered the
homeless crisis system for the Department of Commerce and links these data with RDA's Integrated Client
Databases. The overall linkage rate for these data — including clients who do not provide consent — is
approximately 60%. The remaining 40% of clients who received Commerce-funded housing services but were
not linked to DSHS service records are excluded from these analyses.
14
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Table 5: Number of recent LTCC clients among people receiving selected Commerce-
funded housing supports in December 2021
Rapid Transitional Permanent Permanent
Rehousing Housing Housing Supportive Housing CBRA
Recent Recent Recent Recent Recent
All All All All All
Region LTCC LTCC LTCC LTCC LTCC
Spokane 820 2 124 0 323 1 864 6 76 1
Pierce 1,331 0 125 0 447 1 649 3 43 0
Great Rivers 550 0 58 0 40 0 201 0 89 0
Greater Columbia 838 1 95 0 19 0 308 2 3 0
King 2,441 2 845 0 1,617 0 4,176 11 11 0
North Central 295 0 118 0 72 0 70 0 2 0
North Sound 1,109 2 86 0 545 0 1,703 7 82 3
Olympic 340 1 124 0 154 0 190 6 40 3
Southwest 480 1 191 0 49 0 660 3 17 0
Thurston-Mason 548 0 47 0 88 1 102 2 9 0
Total 8,752 9 1,813 0 3,354 3 8,923 40 372 7
The analyses reported in Table 5 indicate the overlap between the populations using these services and the
LTCC population is modest.
15
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Table 6 focuses on permanent supportive housing (the Commerce program serves the largest number of
recent LTCC patients). Statewide, in December 2021, 40 permanent supportive housing5 clients were identified
as recently discharged from an LTCC setting, representing about half of 1% (40 of 8,923) of the permanent
supportive housing population. Relative to the regional share of the overall LTCC population, the use of
permanent supportive housing was greatest in the King, Olympic, and North Sound regions. Relative use was
lower in the Spokane, Greater Columbia, and Great Rivers regions.
Table 6: Regional distribution of recent LTCC patients among people receiving
Commerce Permanent Supportive Housing services in December 2021
Recent LTCC Regional share of Share
Region All clients clients Regional share recent LTCC clients* difference
Spokane 864 6 15.0% 23.1% -8.1%
Pierce 649 3 7.5% 10.8% -3.3%
Great Rivers 201 0 0.0% 6.0% -6.0%
Greater Columbia 308 2 5.0% 12.3% -7.3%
King 4,176 11 27.5% 16.5% 11.0%
North Central 70 0 0.0% 3.3% -3.3%
North Sound 1,703 7 17.5% 9.9% 7.6%
Olympic 190 6 15.0% 5.4% 9.6%
Southwest 660 3 7.5% 5.1% 2.4%
Thurston-Mason 102 2 5.0% 7.6% -2.6%
Total 8,923 40 100.0% 100% 0.0%
*Unduplicated by person based on the last discharge in the 2019-21 period. Regional attribution based on most recent county of admission.
5 Administrative data on clients housed through permanent supportive housing programs are incomplete. Clients may be housed
through site-based programs funded through the Housing Trust Fund and/or using capital dollars; information on these clients are not
captured in state data systems and are not available for analysis in this iteration of the report.
16
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
In-scope ALTSA-funded community-based services and supports
Table 7 describes the use of selected ALTSA-funded housing services by recent LTCC patients, including
assisted living, adult residential care, adult family home, and enhanced services facilities. The table shows that
a relatively large number of recent LTCC patients reside in ALTSA adult residential care (217) and adult family
home (370) settings. The table also shows that a very high proportion (40 of 68, or 59%) of the relatively small
patient population in ALTSA ESF facilities were recently discharged from an LTCC setting. Several additional
ESF facilities are in development, and Table 8 shows the regional distribution of the planned facilities.
Table 7: Number of recent LTCC clients among people receiving ALTSA community
residential services in December 2021
Assisted living Adult residential care Adult family home Enhanced service facilities
All Recent LTCC All Recent LTCC All Recent LTCC All Recent LTCC
Region clients clients clients clients clients clients clients clients
Spokane 542 5 780 93 722 28 38 20
Pierce 308 0 655 58 1,352 89 0 0
Great Rivers 322 0 80 0 238 10 0 0
Greater Columbia 570 1 493 31 468 27 2 1
King 638 1 174 14 2,568 83 0 0
North Central 239 0 157 11 133 1 0 0
North Sound 380 0 520 3 1,843 64 8 7
Olympic 170 0 114 0 190 5 0 0
Southwest 407 1 137 4 1,168 32 12 4
Thurston-Mason 158 0 138 3 449 31 8 8
Total 3,734 8 3,248 217 9,131 370 68 40
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HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Table 8: Planned ALTSA Enhanced Services facilities
Facility City County Region Expected opening* Beds
Greenacres ESF Spokane Spokane Spokane Fall 2023 16
Emerald City ESF Lakewood Pierce Pierce Fall 2022 16
Reliance ESF Tacoma Pierce Pierce 2024 16
Safe Haven ESF Graham Pierce Pierce 2024 16
Sound Health ESF Auburn King King Fall 2023 16
Heartsaved ESF Marysville Snohomish North Sound Spring 2023 16
Respect Care ESF Burlington Skagit North Sound Summer 2023 16
Lake Whatcom ESF Bellingham Whatcom North Sound Fall 2023 16
*Unduplicated by person based on the last discharge in the 2019-21 period. Regional attribution based on most recent county of admission.
18
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Table 9 describes the use of ALTSA adult residential care services by recent LTCC patients. Statewide, 217
adult residential care clients in December 2021 were recently discharged from an LTCC setting, representing
7% (217 of 3,248) of the adult residential care population. Relative to the regional share of the overall LTCC
population, the use of the adult residential care program was greatest in the Spokane and Pierce regions.
Relative use was lower in the King, North Sound, Thurston-Mason, Great Rivers, and Olympic regions.
Table 9: Regional distribution of recent LTCC patients among people receiving ALTSA
adult residential care services in December 2021
Regional share of Share
Region All clients Recent LTCC clients Regional share recent LTCC clients* difference
Spokane 780 93 42.9% 23.1% 19.8%
Pierce 655 58 26.7% 10.8% 15.9%
Great Rivers 80 0 0.0% 6.0% -6.0%
Greater Columbia 493 31 14.3% 12.3% 2.0%
King 174 14 6.5% 16.5% -10.1%
North Central 157 11 5.1% 3.3% 1.8%
North Sound 520 3 1.4% 9.9% -8.5%
Olympic 114 0 0.0% 5.4% -5.4%
Southwest 137 4 1.8% 5.1% -3.2%
Thurston-Mason 138 3 1.4% 7.6% -6.2%
Total 3,248 217 100.0% 100% 0.0%
*Unduplicated by person based on the last discharge in the 2019-21 period. Regional attribution based on most recent county of admission.
19
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Table 10 describes the use of ALTSA adult family home services by recent LTCC patients. Statewide, 370 adult
family home clients in December 2021 were recently discharged from an LTCC setting, representing 4% (370 of
9,131) of the adult family home population. Relative to the regional share of the overall LTCC population, the
use of adult family home services was greatest in the Pierce, North Sound, King, and Southwest regions.
Relative use was lower in the Spokane, Greater Columbia, Olympic, North Central, and Great Rivers regions.
Table 10: Regional distribution of recent LTCC patients among people receiving
ALTSA Adult Family Home services in December 2021
Recent LTCC Regional share of Share
Region All clients clients Regional share recent LTCC clients* Difference
Spokane 722 28 7.6% 23.1% -15.5%
Pierce 1,352 89 24.1% 10.8% 13.3%
Great Rivers 238 10 2.7% 6.0% -3.3%
Greater Columbia 468 27 7.3% 12.3% -5.0%
King 2,568 83 22.4% 16.5% 5.9%
North Central 133 1 0.3% 3.3% -3.0%
North Sound 1,843 64 17.3% 9.9% 7.4%
Olympic 190 5 1.4% 5.4% -4.1%
Southwest 1,168 32 8.6% 5.1% 3.6%
Thurston-Mason 449 31 8.4% 7.6% 0.8%
Total 9,131 370 100% 100% 0.0%
*Unduplicated by person based on the last discharge in the 2019-21 period. Regional attribution based on most recent county of admission.
20
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Table 11 describes the use of ALTSA GOSH services by recent LTCC patients. Statewide, 215 GOSH clients in
December 2021 were recently discharged from an LTCC setting, representing 60% (215 of 359) of the GOSH
population. Relative to the regional share of the overall LTCC population, the use of the GOSH program was
greatest in the Thurston-Mason, Spokane, and Great Rivers regions. Relative use was lower in the King,
Olympic, and Southwest regions.
Table 11: Regional distribution of recent LTCC patients among people receiving
ALTSA GOSH services in December 2021
Recent LTCC Regional share of Share
Region All clients clients Regional share recent LTCC clients* Difference
Spokane 90 61 28.4% 23.1% 5.3%
Pierce 56 27 12.6% 10.8% 1.8%
Great Rivers 42 22 10.2% 6.0% 4.3%
Greater Columbia 34 24 11.2% 12.3% -1.2%
King 20 10 4.7% 16.5% -11.9%
North Central 6 4 1.9% 3.3% -1.4%
North Sound 35 18 8.4% 9.9% -1.5%
Olympic 1 1 0.5% 5.4% -4.9%
Southwest 11 4 1.9% 5.1% -3.2%
Thurston-Mason 64 44 20.5% 7.6% 12.9%
Total 359 215 100.0% 100% 0.0%
*Unduplicated by person based on the last discharge in the 2019-21 period. Regional attribution based on most recent county of admission.
21
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Table 12 describes the use of ALTSA in-home services by recent LTCC patients. Statewide, 146 ALTSA in-
home service clients in December 2021 were recently discharged from an LTCC setting, representing less than
0.5% (146 of 46,023) of the in-home service population. Relative to the regional share of the overall LTCC
population, the use of ALTSA in-home services was greatest in the Greater Columbia, Thurston-Mason, and
Spokane regions. Relative use was lower in the King, Olympic, and North Sound regions.
Table 12: Regional distribution of recent LTCC patients among people receiving
ALTSA in-home services in December 2021
Recent LTCC Regional share of Share
Region All clients clients Regional share recent LTCC clients* difference
Spokane 4,581 40 27.4% 23.1% 4.3%
Pierce 5,764 19 13.0% 10.8% 2.2%
Great Rivers 2,800 11 7.5% 6.0% 1.6%
Greater Columbia 5,047 25 17.1% 12.3% 4.8%
King 13,033 10 6.8% 16.5% -9.7%
North Central 1,581 3 2.1% 3.3% -1.2%
North Sound 5,944 8 5.5% 9.9% -4.4%
Olympic 1,567 3 2.1% 5.4% -3.3%
Southwest 3,808 10 6.8% 5.1% 1.8%
Thurston-Mason 1,898 17 11.6% 7.6% 4.1%
Total 46,023 146 100.0% 100% 0.0%
*Unduplicated by person based on the last discharge in the 2019-21 period. Regional attribution based on most recent county of admission.
22
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Table 13 describes the total number of people and recent LTCC patients served in ALTSA LTSS settings who
also receive MCO-funded exceptional care supports to remain in their setting. Statewide, 402 MCO-funded
clients in December 2021 were recently discharged from an LTCC setting, representing 26% (402 of 1,551) of
the MCO-funded population. Relative to the regional share of the overall LTCC population, the use of MCO-
funded exceptional care supports was greatest in the Pierce region. Relative use was lower in the Great Rivers,
Greater Columbia, Thurston-Mason, North Central, and Olympic regions.
Table 13: Clients in ALTSA LTSS settings who also receive MCO-funded exceptional
care wraparound support, December 2021
Recent LTCC Regional share of Share
Region All clients clients Regional share recent LTCC clients* difference
Better Health Together 281 107 26.6% 23.1% 3.5%
Pierce 391 106 26.4% 10.8% 15.6%
Great Rivers 39 5 1.2% 6.0% -4.7%
Greater Columbia 99 33 8.2% 12.3% -4.1%
King 366 70 17.4% 16.5% 0.9%
North Central 5 0 0.0% 3.3% -3.3%
North Sound 155 30 7.5% 9.9% -2.4%
Olympic 32 10 2.5% 5.4% -2.9%
Southwest 126 24 6.0% 5.1% 0.9%
Thurston-Mason 57 17 4.2% 7.6% -3.4%
Total 1,551 402 100% 100% N/A
*Unduplicated by person based on the last discharge in the 2019-21 period. Regional attribution based on most recent county of admission.
23
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Table 14 describes the utilization of ALTSA specialty contract beds in state fiscal year 2022. Except for ESF
services, we could not link client-level specialty contract bed utilization data with LTCC discharge data in time
for this report, so we could not present analyses analogous to the previous tables. We would expect significant
overlap with the LTCC population and with people identified as being served in other ALTSA LTSS settings.
Table 14: Monthly utilization of ALTSA specialized contracted supports, SFY 2022
Specialized contracted supports Average caseload counts SFY 2022 Year-end caseload SFY 2022
Enhanced Services Facility 72 80
Adult Family Home - Specialized Behavior Supports 818 871
Adult Family Home - Expanded Community Services 846 856
Assisted Living Facility - Expanded Community Services 668 671
Specialized Dementia Care Program Plus 34 38
Community Stability Supports N/A 210
24
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
In-scope DDA-funded community-based services and supports
Table 15 describes the use of DDA-funded personal care and residential program services by recent LTCC
patients. Statewide, 31 DDA residential program clients in December 2021 were recently discharged from an
LTCC setting, representing less than 1% (31 of 4,519) of the DDA residential program population. Nine percent
of the December 2021 population of DDA SOLA clients (19 of 212) were recently discharged from an LTCC
setting. A relatively high proportion of recent LTCC patients participating in DDA residential or SOLA programs
were served in the Pierce region.
Table 15: Number of recent LTCC clients among people receiving selected DDA
services in December 2021
DDA residential program DDA State Operated Living Alternative (SOLA)
Region All Clients Recent LTCC Clients All Clients Recent LTCC Clients
Spokane 609 6 33 2
Pierce 568 11 38 7
Great Rivers 204 2 1 0
Greater Columbia 544 0 28 0
King 1,030 4 55 5
North Central 122 0 0 0
North Sound 694 2 12 3
Olympic 199 0 25 0
Southwest 229 0 0 0
Thurston-Mason 320 6 20 2
Total 4,519 31 212 19
25
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Supplemental facility data and maps
Table 16 summarizes the regional distribution of beds associated with LTSS facilities contracted with ALTSA
to provide specialized behavioral supports. Note that counts in this table represent the overall number of beds
in the contracted facility and not the number of beds expected to be associated with a specialized contract at
any given point in time. Figure 5 maps these specialized contract facility locations. Table 17 summarizes the
regional distribution of beds associated with selected out-of-scope community behavioral health facilities for
informational purposes. These include inpatient evaluation and treatment facility beds, along with crisis
stabilization and triage beds. Figure 6 maps these behavioral health facility locations.
Table 16: Bed counts for LTSS facilities with ALTSA-specialized behavioral supports
contracts
Adult Family Adult Family Assisted Living
Home - Home - Facility -
Expanded Specialized Expanded Community Enhanced Specialized
Regions (in bold) Community Behavioral Community Stability Services Dementia Care
and counties Services Support Services Supports Facility Program Totals
Spokane 925 827 1,413 168 56 30 3,419
Adams 24 18 - - - - 42
Ferry - - - - - - -
Lincoln - - - - - - -
Pend Oreille - - - - - - -
Spokane 895 803 1,370 146 56 30 3,300
Stevens 6 6 43 22 - - 77
Pierce 1,366 798 251 15 - 85 2,515
Pierce 1,366 798 251 15 - 85 2,515
Great Rivers 139 60 26 - - - 225
Cowlitz 45 6 - - - - 51
Grays Harbor 6 6 26 - - - 38
Lewis 82 42 - - - - 124
Pacific 6 6 - - - - 12
Wahkiakum - - - - - - -
Greater Columbia 479 313 908 80 - - 1,780
Asotin 24 24 12 - - - 60
Benton 134 88 282 - - - 504
26
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Adult Family Adult Family Assisted Living
Home - Home - Facility -
Expanded Specialized Expanded Community Enhanced Specialized
Regions (in bold) Community Behavioral Community Stability Services Dementia Care
and counties Services Support Services Supports Facility Program Totals
Columbia - - 30 - - - 30
Franklin 59 48 161 - - - 268
Garfield - - - - - - -
Kittitas - - - - - - -
Walla Walla 11 - - - - - 11
Whitman 118 118 115 80 - - 431
Yakima 133 35 308 - - - 476
King 1,971 1,000 192 94 - 60 3,317
King 1,971 1,000 192 94 - 60 3,317
North Central 76 59 212 - - - 347
Chelan 6 6 77 - - - 89
Douglas 6 6 79 - - - 91
Grant 64 47 56 - - - 167
Okanogan - - - - - - -
North Sound 1,676 995 299 - 16 - 2,986
Island 12 - 55 - - - 67
San Juan - - - - - - -
Skagit 18 12 31 - - - 61
Snohomish 1,582 953 - - 16 - 2,551
Whatcom 64 30 213 - - - 307
Olympic 142 36 43 - - - 221
Clallam 6 - 43 - - - 49
Jefferson 6 6 - - - - 12
Kitsap 130 30 - - - - 160
Southwest 624 209 38 - 28 - 899
27
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Adult Family Adult Family Assisted Living
Home - Home - Facility -
Expanded Specialized Expanded Community Enhanced Specialized
Regions (in bold) Community Behavioral Community Stability Services Dementia Care
and counties Services Support Services Supports Facility Program Totals
Clark 601 209 38 - 28 - 876
Klickitat 23 - - - - - 23
Skamania - - - - - - -
Thurston-Mason 379 271 64 - 15 57 786
Mason 15 - - - - - 15
Thurston 364 271 64 - 15 57 771
28
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Figure 5: LTSS facilities with ALTSA-specialized behavioral supports contracts
See
Puget
Sound
Insert
See
Spokane
County
Insert
See Clark
County OCTOBER 2022
Insert DSHS Research and Data Analysis Division
Facility Type
Specialized Dementia Care Program Plus (SDCP+)
Community Stability Supports (CSS)
Puget Sound Insert Enhanced Services Facility (ESF)
Assisted Living Facility Expanded Community Services (ALF ECS)
Adult Family Home Specialized Behavior Supports (AFH SBS)
Adult Family Home Expanded Community Services (AFH ECS)
HCA Medicaid Purchasing Regions
Clark County Insert Spokane County Insert
Source: DOH Licensing Data
Note: Elevate Health is the Pierce County region; Healthier Here is the King County region; Better Health Together is the multi-county Spokane region.
29
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Table 17: Beds at selected HCA community behavioral health facilities
Inpatient adult Inpatient child
Regions (in bold) Crisis stabilization evaluation and evaluation and Crisis triage Crisis triage
and counties unit treatment treatment voluntary involuntary Totals
Spokane 18 149 69 16 - 252
Adams - - - - - -
Ferry - - - - - -
Lincoln - - - - - -
Pend Oreille - - - - - -
Spokane 18 133 69 16 - 236
Stevens - 16 - - - 16
Pierce 32 134 27 - - 193
Pierce 32 134 27 - - 193
Great Rivers 6 54 - - - 60
Cowlitz - 22 - - - 22
Grays Harbor - 16 - - - 16
Lewis 6 16 - - - 22
Pacific - - - - - -
Wahkiakum - - - - - -
Greater Columbia 8 97 10 - 16 131
Asotin - - - - - -
Benton - 32 - - 16 48
Columbia - - - - - -
Franklin - - - - - -
Garfield - - - - - -
Kittitas - - - - - -
Walla Walla 8 - - - - 8
Whitman - - - - - -
Yakima - 65 10 - - 75
30
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Inpatient adult Inpatient child
Regions (in bold) Crisis stabilization evaluation and evaluation and Crisis triage Crisis triage
and counties unit treatment treatment voluntary involuntary Totals
King - 525 18 - - 543
King - 525 18 - - 543
North Central 20 15 - - - 35
Chelan 20 15 - - - 35
Douglas - - - - - -
Grant - - - - - -
Okanogan - - - - - -
North Sound - 235 15 45 8 303
Island - - - 5 - 5
San Juan - - - - - -
Skagit - 31 - - - 31
Snohomish - 184 15 32 - 231
Whatcom - 20 - 8 8 36
Olympic - 15 10 16 - 41
Clallam - - - - - -
Jefferson - - - - - -
Kitsap - 15 10 16 - 41
Southwest 20 62 12 8 - 102
Clark 20 62 12 8 - 102
Klickitat - - - - - -
Skamania - - - - - -
Thurston-Mason - 152 10 - - 162
Mason - 32 - - - 32
Thurston - 120 10 - - 130
31
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Figure 6: Selected HCA Community Behavioral Health facilities
See
Puget
Sound
Insert
See
Spokane
County
Insert
See Clark
County OCTOBER 2022
Insert DSHS Research and Data Analysis Division
Facility Type
In-Patient Evaluation Treatment Child Beds (11 Facilities)
In-Patient Evaluation Treatment Adult Beds (48 Facilities)
Puget Sound Insert
Crisis Triage Voluntary Beds (7 Facilities)
Crisis Triage Involuntary Beds (2 Facilities)
Crisis Stabilization Unit Beds (8 Facilities
HCA Medicaid Purchasing Regions
Clark County Insert Spokane County Insert
Source: DOH Licensing Data
Note: Elevate Health is the Pierce County region; Healthier Here is the King County region; Better Health Together is the multi-county Spokane region.
32
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Summary and next steps
A relatively large proportion of people recently discharged from long-term civil commitments were served in
ALTSA-funded settings. Adult family home (370 clients), adult residential care (217 clients), and GOSH (215
clients) settings served the largest number of people recently discharged from a long-term civil commitment,
often in combination with Medicaid MCO-funded exceptional care payments (402 clients). We note that ALTSA
services include only personal care and, in some cases, behavior supports and nursing services. ALTSA does
not provide behavioral health treatment, and people transitioning from a long-term civil commitment to ALTSA
services generally require community behavioral health supports in their ALTSA service setting.
ALTSA ESF and GOSH programs are highly focused on serving people recently discharged from long-term civil
commitments. Recently discharged LTCC patients represented approximately 60% of both the ALTSA ESF and
GOSH populations in December 2021 – a far higher proportion than observed for any other in-scope housing-
related services and supports.
The PACT program (136 clients), mental health residential services (75 clients), and FCS supportive housing
services (56 clients) funded through the Health Care Authority provided a significant level of support to people
recently discharged from long-term civil commitments. In the future, planned Intensive Behavioral Health
Treatment Facilities are expected to serve a significant number of people previously discharged from long-
term civil commitment settings.
Relatively few people recently discharged from long-term civil commitments are served by Commerce-funded
housing programs. The largest overlap was found in the Permanent Supportive Housing program (40 clients).
Few recently discharged long-term civil commitment patients used other in-scope Commerce-funded services.
Assessing overall regional differences in service availability
We developed an index for assessing regional differences in the availability of the services and supports used
most extensively to serve people previously in a long-term civil commitment. The index is based on the
availability of:
HCA-funded mental health residential treatment services
HCA-funded PACT services
ALTSA-funded adult residential care and adult family home services (typically associated with MCO
exceptional care payments and/or specialized contract services)
ALTSA-funded ESF services
ALTSA-funded GOSH services
These services were selected because they are associated with the largest volume of recently discharged
LTCC patients or are targeted to serve that population in the case of ALTSA-funded ESF services. The index is
based on observed utilization as of December 2021.
The index reflects the ratio of a region's share of recent long-term civil commitment patients served in the
relevant settings relative to the region's share of the overall population of people discharged from a long-term
civil commitment. A value of 100% indicates that a region's share of services and supports shows parity with
its share of the long-term civil commitment population. It is important to note that the index identifies regions
where services are more or less available relative to other regions. The index does not reflect the level of
service availability relative to need.
33
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Figure 7 shows how this service availability index varies by region. Table 18 summarizes the data underlying
the index values. The index shows:
North Central, Olympic, and Great Rivers regions have relatively low service availability.
King and Greater Columbia have relatively low service availability among the larger regions.
Spokane, North Sound, Southwest, and Thurston-Mason regions show relative parity or slightly
favorable relative service availability.
Services supporting people discharging from LTCC settings are more widely available in the Pierce
region.
Figure 7: Regional share of selected services and supports relative to the regional
share of the LTCC population
200%
178%
180%
160%
140%
121%
120%
108% 108%
104%
101%
100%
79%
80%
67%
60% 55%
49%
40%
20%
0%
34
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Table 18: Regional distribution of LTCC clients in selected service settings,** relative
to regional LTCC population share, as of December 2021
Region Recent LTCC patients Projected regional share Regional share* Ratio
Spokane 253 24.0% 23.1% 104%
Pierce 203 19.3% 10.8% 178%
Great Rivers 42 4.0% 6.0% 67%
Greater Columbia 103 9.8% 12.3% 79%
King 141 13.4% 16.5% 81%
North Central 19 1.8% 3.3% 55%
North Sound 113 10.7% 9.9% 108%
Olympic 28 2.7% 5.4% 49%
Southwest 54 5.1% 5.1% 101%
Thurston-Mason 97 9.2% 7.6% 121%
Total 1,053 100% 100% N/A
*Regional share of unduplicated people discharged from a long-term civil commitment in CY 2019, 2020, or 2021
**Selected settings include HCA-funded mental health residential treatment services, HCA-funded PACT services, ALTSA-funded adult residential care
and adult family home services (typically associated with MCO exceptional care payments and/or specialized contract services), ALTSA-funded ESF
services; and ALTSA-funded GOSH services.
Next steps
A second phase of work, scheduled to be completed by June 2023, will examine the use of other HCA housing
programs if program participation data are available for linkage to LTCC patient data. We will also explore
linking ALTSA specialized contract utilization data, where feasible, to LTCC patient data to examine the
intersection of the two populations in greater detail. Finally, we will look at the overlapping use of the various
in-scope housing and related supportive services to provide a more comprehensive picture of service
utilization patterns.
35
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Appendix A: Glossary
Term Definition
ALTSA DSHS Aging and Long-Term Support Administration
AMI Area Median Income
CBRA Community Behavioral Health Rental Assistance provided through the Department of Commerce
CSS Community Stability Supports services funded through DSHS ALTSA
DDA DSHS Development Disabilities Administration
DOH Washington State Department of Health
DSHS Washington State Department of Social and Health Services
EARC Enhanced adult residential care funded through DSHS ALTSA
ECS Expanded Community Services funded through DSHS ALTSA
ESF Enhanced services facilities funded through DSHS ALTSA
ESH Eastern State Hospital, administered by the DSHS Behavioral Health Administration
FCS Foundational Community Supports services funded through HCA
GOSH Governor's Opportunity for Supportive Housing funded through DSHS ALTSA
HARPS Housing and Recovery through Peer Services program funded through HCA
HCA Washington State Health Care Authority
HMIS Homeless Management Information System managed by the Department of Commerce
HUD United States Department of Housing and Urban Development
36
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Term Definition
Long-term civil commitment under the Involuntary Treatment Act in a State Hospital or community
LTCC
setting
LTSS Long-term services and supports provided through DSHS ALTSA or DDA programs
Medicaid managed care organization responsible for providing community behavioral health services
MCO
for enrolled beneficiaries
Medicaid Transformation Project - 1115 Waiver Supporting the FCS program and several other
MTP
initiatives
PACT Program of Assertive Community Treatment services funded through HCA
PATH Projects for Assistance in Transition from Homelessness program funded through HCA
PSH Permanent supportive housing services provided through the Department of Commerce
RDA The DSHS Research and Data Analysis Division
SBS Specialized Behavior Support services funded through DSHS ALTSA
SDCP Specialized Dementia Care Program funded through DSHS ALTSA
SOLA State-operated living alternatives residential program administered by DSHS DDA
WSH Western State Hospital, administered by the DSHS Behavioral Health Administration
37
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Appendix B: Descriptions of in-scope housing and
related supportive services
In-scope HCA programs
Mental health residential treatment services
These services are a specialized form of non-hospital rehabilitation service that provides a sub-acute
psychiatric management environment for people who cannot be safely served in a less restrictive environment
but do not meet hospital admission criteria. The provider is sited at the residential location (e.g., boarding
homes, supported housing, or cluster housing) for extended hours to provide direct mental health care
services. Therapeutic interventions in individual and group formats may include medication management and
monitoring, stabilization, and cognitive and behavioral interventions designed to stabilize and help the
individual return to more independent and less restrictive treatment.
Behavioral health intensive treatment facilities
These facilities provide ongoing care to individuals who no longer benefit from treatment in an LTCC setting
but need further treatment and support to fully integrate back into their community. These facilities have beds
for up to 16 people to receive active rehabilitative treatment. Clinical staff provide recovery-based treatment
using evidence-based practices, independent living skills training, social skills, and community integration.
These facilities are staffed 24/7 with a clinical team. The first of these facilities began operating in the fall of
2022. Utilization data associated with these facilities are not yet available for analysis. The location and
scheduled opening of planned behavioral health intensive treatment facilities are described in Table 19.
Table 19: Planned HCA intensive behavioral health treatment facilities
Project title Beds Project type Planned opening date* County Region
Tricity IBHTF 16 New construction 12/31/2023 Benton Greater Columbia
Aristo IBHF 16 Acquisition/renovation 8/1/2023 King King
Oakridge House Intensive
16 Renovation 3/2/2023 Kitsap Olympic
Behavioral Health Facility
Tacoma IBHTS 16 Renovation 2/1/2023 Pierce Pierce
Relief Health Intensive Behavioral
16 New construction 12/31/2023 Spokane Spokane
Treatment
Cascade Intensive Behavioral
16 New construction 4/1/2023 Stevens Spokane
Health
Supreme Living - Olympia #2 15 New construction 12/15/2022 Thurston Thurston-Mason
* Planned opening dates are subject to change.
38
HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
PACT
The Program for Assertive Community Treatment (PACT) is a person-centered, recovery-oriented mental
health service delivery model that has received substantial empirical support for reducing psychiatric
hospitalizations, facilitating community living, and enhancing recovery for people with serious mental illnesses.
PACT is designed for people with the most severe and persistent mental illnesses, severe symptoms and
impairments, and not benefiting from traditional outpatient programs. PACT services are provided through a
multidisciplinary team, including mental health professionals, registered nurses, peer supports, and a
psychiatric care provider. Full teams serve up to 100 people, and half teams serve up to 50. The distribution of
PACT teams by region is displayed in Figure 8.
Figure 8: HCA PACT teams
Lake Whatcom Center Compass – Snohomish
Compass - Skagit Telecare
LEGEND
Lifeline Connections
Full Team
Half Team
WHATCOM
SAN JUAN
Downtown Emergency OKANOGAN FERRY STEVENS
PEND
SKAGIT OREILLE
Services Center
ISLAND North
CLALLAM Sound
AMG, CCW, CHPW,
Olympic Community MHW, UHC North Central
of Health SNOHOMISH
AMG, CCW, MHW Spokane
AMG, CHPW, MHW
Kitsap Mental AMG, MHW, UHC
KING
CHELAN DOUGLAS
Health Services JEFFERSON
LINCOLN SPOKANE
MASON
Ikron KITSAP King
AMG, CCW,
Navos Southeast GRAYS Thurston CHPW, MHW,
HARBOR Mason UHC
AMG, MHW, KITTITAS GRANT
PIERCE
Greater Lakes UHC
Pierce ADAMS WHITMAN
AMG,
CCW, MHW,
Comprehensive THURSTON UHC
Life Resources
PACIFIC FRANKLIN
LEWIS
Great Rivers GARFIELD
AMG, MHW, UHC BENTON COLUMBIA
WAHKIAKUM YAKIMA
COWLITZ Southwest
AMG, CHPW, WALLA WALLA ASOTIN
MHW Greater Columbia
Behavioral Health AMG, CCW, CHPW, MHW
Resources KLICKITAT Frontier
SKAMANIA Behavioral
Cascade CLARK Lourdes Health x2
Columbia Multicare Comprehensive
River Seamar - Pierce Healthcare
Source: DOH Licensing Data
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HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
FCS supportive housing
FCS services are one component of the Health Care Authority's broader 1115 Medicaid Transformation Project
(MTP), implemented in 2017. The FCS is operated in partnership with ALTSA and DDA, and a proportion of FCS
supportive housing clients also receive long-term services and supports through DSHS programs. Under the
MTP's 1115 Medicaid Waiver, Medicaid beneficiaries with behavioral needs and/or who require assistance
with three or more activities of daily living6 are potentially eligible for a range of additional person-centered
supported employment and supportive housing services not currently available through Washington's
Medicaid State Plan. These services promote self-sufficiency and community integration by helping
beneficiaries obtain and maintain housing and employment. Analyses in this report focus on the supportive
housing component of the FCS program. Supportive housing services include pre-tenancy supports that focus
on locating housing for a client based on their preferences, needs, and financial situation. Tenancy-sustaining
services help connect clients to additional resources and promote community reintegration and independent
living.
We note that detailed client-level data for other HCA housing programs were not available to be analyzed in
this report. We anticipate producing a supplemental report in June 2023 that may include additional
information related to these programs. These programs include the Housing and Recovery through Peer
Services (HARPS) program, which provides supportive housing services and short-term housing bridge
subsidies to at-risk individuals who are exiting or at risk of entering inpatient behavioral health settings.
Another example is the Projects for Assistance in Transition from Homelessness (PATH) program, which
assists individuals in accessing housing, mental health services, substance abuse treatment, disability
benefits, and other services to stabilize and facilitate recovery.
In-scope Commerce programs providing permanent and transitional
housing assistance
Washington's homeless crisis response system comprises a network of local, county, and state organizations
that provide services to individuals or households experiencing housing instability within a given county or
region. Service providers in a community are typically funded using a combination of state, federal, and private
money. Local homeless crisis response systems may offer a range of preventative and crisis services,
including, but not limited to, homelessness prevention, eviction rental assistance, emergency shelters, street
outreach services, permanent housing, and non-housing services. The specific types of services offered may
vary across providers based on the needs of the communities they serve, the requirements of external funders,
and existing federal and state statutes.
The Department of Commerce oversees and supports this work in several ways. Commerce provides technical
assistance to all state- and federally-funded housing service providers in Washington, manages the state's
Homeless Management Information System (HMIS) for 34 counties, and disburses state and federal funds to
grantees who may subcontract with other entities to provide services. Programs funded using state monies
are subject to additional reporting and performance requirements and are responsible for addressing
disparities in access to services by underserved populations (e.g., Black, Indigenous, People of Color, people
with disabilities, people who are LGBTQ+, etc.). Additionally, services paid for using state funds may be subject
to specific eligibility criteria.
6 Examples of activities of daily living include bathing, dressing, grooming, meal preparation, and household chores.
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HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
While Washington State's homeless crisis response network includes various services, this report focuses on
services intended to provide long-term housing resources, community reintegration, and client independence.
Consequently, short-term housing services designed to meet the immediate housing needs of clients in crisis—
such as emergency shelters and related services—are out of scope for these analyses. Similarly, outreach, non-
housing services, and homelessness prevention/eviction rental assistance programs are not included in this
study because they are designed to address client needs beyond housing or to retain already housed clients in
the community.
Commerce housing programs examined in this report include the following.
Transitional housing
This program provides subsidized, temporary housing to individuals and households experiencing
homelessness. Transitional housing programs typically provide housing for up to two years and are designed
to help clients move into permanent housing.
Rapid rehousing
This program supports rental assistance projects intended to quickly move individuals and households
experiencing homelessness into permanent housing. Clients enrolled in these projects may receive short- and
medium-term rental assistance and housing identification, relocation, and stabilization services to help the
family quickly move into—and achieve stability in—permanent housing.
Permanent supportive housing (PSH)
PSH provides subsidized, time-unlimited housing and optional support services to homeless individuals or
households with at least one member with a long-term/indefinite disabling condition that impedes their ability
to live independently. Qualifying conditions include:
1. Mental health or substance use disorders
2. Post-traumatic stress disorder
3. Physical, developmental, or emotional impairment
4. Traumatic brain injuries
5. Human Immunodeficiency Virus or acquired immunodeficiency syndrome (HIV/AIDS)
PSH providers must verify and document7 the disabling condition before program entry. Dependent on the
funding source, individuals may or may not be required to meet the Department of Housing and Urban
Development's (HUD) chronically homeless definition to receive services.8 PSH may be provided either in rental
assistance for independent units (scattered site housing) or through facility-based/master lease models.
7 Acceptable documentation includes written verification from a licensed professional, Social Security Administration, Social Security
Disability Insurance, Veteran Disability Compensation check receipts, and/or other documentation approved by Commerce.
8 PSH programs funded through Washington’s CHG do not require individuals to meet the definition of chronic homelessness to qualify
for PSH. However, Permanent Supportive Housing for Chronically Homeless Families (PSH CHF) do require that enrollees have some
form of disabling condition and be homeless continuously for at least 12 months or on at least four separate occasions in the past
three years for a total of at least 12 months. Stays in institutional settings that are less than 90 days in length are not considered a
break in a client’s homelessness span if they were homeless before entering the facility.
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HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
Permanent housing
This program provides permanent housing to individuals and households experiencing homelessness and
provides time-unlimited rental assistance as long as participants meet the basic tenancy obligations. Clients
enrolled in a permanent housing project may be eligible for supportive housing services in addition to rental
assistance or housing vouchers. In contrast to permanent supportive housing, however, these projects do not
limit eligibility to individuals with disabilities or households with at least one household member with a
disabling condition.
For all four programs, a household's annualized gross income9 must be less than or equal to 80% of the Area
Median Income (AMI) as defined by HUD to qualify for services. This income assessment may occur at either
the time of program enrollment (for PSH and permanent housing programs) or recertification (for transitional
housing and rapid rehousing programs).
We also provide information on the Community Behavioral Health Rental Assistance (CBRA) program, a cross-
agency collaboration between Commerce, HCA, and ALTSA. CBRA provides long-term rental subsidies to high-
risk individuals with complex behavioral health needs. Priority populations include individuals who are
discharging, need to discharge, or have been discharged from a state psychiatric hospital or community
psychiatric setting within the past twelve months. Lead grantees are responsible for facilitating relationships
between sub-grantees and discharge planners at state and community-based psychiatric hospitals to help
clients connect to housing upon exit from the facility. A household is eligible for CBRA if: 1) their household
income is at or below 50% AMI; they have a documented behavioral health condition; 3) they are eligible for
voluntary, person-centered pre-tenancy supports and/or tenancy sustaining services through ALTSA and/or the
FCS or HARPS programs; and 4) they have a documented need for a long-term housing subsidy that cannot be
met using some other suitable10 resource.
In-scope DSHS ALTSA programs
Adult family homes
Adult family homes are small group-care residential settings licensed to care for two to eight unrelated adults
who do not need 24-hour skilled nursing supervision. Some offer specialized care for individuals with mental
health disorders, developmental disabilities, or dementia. Adult Family Homes have on-site staff qualified to
meet the care needs of their residents and assume responsibility for their safety and well-being. Room, board,
laundry, supervision, and assistance with activities of daily living are provided based on an individual's specific
needs. Resident independence and involvement are encouraged by providing a range of daily activities and
services tailored to resident preferences.
Assisted living facilities
Assisted living facilities are community-based facilities licensed by the state that house seven or more
individuals. Assisted living facilities provide private apartments to residents and emphasize independence and
personal choice. Individuals must be provided intermittent nursing services and assistance with medication
administration and personal care. Room, board, laundry, supervision, and assistance with activities of daily
9 This includes the combined income of all adult household members and the unearned income attributable to minors.
10 “Suitable” resources promote housing choice, do not cause undue hardship for the participant and meets the individual's housing
needs.
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HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
living are provided based on an individual's specific needs. Resident independence and involvement are
encouraged by providing a range of daily activities and services tailored to resident preferences.
Adult residential care
Adult residential care facilities are licensed as Assisted Living Facilities and provide medication assistance
and personal care for residents who may need limited supervision for their own safety. Enhanced Adult
Residential Care (EARC) facilities may specialize in dementia care, including medication administration and/or
personal care. No more than two residents share a room in an EARC facility, and intermittent nursing care may
be provided.
Enhanced service facilities
Enhanced service facilities are licensed residential facilities that provide a community option for individuals
with complex care needs and behavioral challenges that do not require an institutional setting. ESFs have high
staffing ratios and provide residents with more intensive behavior supports, personal care, and nursing
services than are typically found in other licensed long-term care settings. Individuals may be referred to an
ESF if they are exiting a state or community psychiatric hospital or do not have other community options due
to their complex physical and behavioral support needs.
In-home services
In-home services include chore and personal care services delivered in the client's home and ancillary services
essential to living at home. Services may be provided through a contracted agency or individual providers.
Services assist low-income, disabled, or frail adults with the activities of daily living. Personal care includes
Medicaid State Plan and waiver services. Ancillary services may include adult day care, client training,
community transition, environmental modification (necessary physical adaptations to the client's home), home
health aides, home-delivered meals, personal emergency response system equipment installation and
monitoring, special medical equipment, skilled nursing, in-home nurse delegation and transportation.
GOSH
GOSH provides housing search, intensive supportive housing services, coordination of care, and housing
subsidies to ALTSA clients discharged or diverted from ESH and WSH. Individuals are eligible for GOSH if they
are discharging or diverting from a state hospital and want to live independently, are willing to work with a
supportive housing provider, and are eligible for ALTSA services. The GOSH program adheres to client choice
and independence principles, person-centered planning and services, harm reduction, and voluntary
participation in services. GOSH also emphasizes the importance of social and community integration, service
continuity through housing loss or institutional stays, assertive engagement with program participants, using a
trauma-informed approach and motivational interviewing, with ongoing and frequent home visits while an
individual is enrolled in the program.
ALTSA specialized behavior support contracts
Specialized Dementia Care Program Plus
The Specialized Dementia Care Program Plus program provides an elevated combination of both medical and
behavioral support services to people in a contracted Specialized Dementia Care Program (SDCP) setting. The
services in this contract are for individuals diagnosed with declining dementia or major neurocognitive
disorder who present with complex medical needs and significant behaviors requiring frequent interventions
and support to maintain stability. These services provide personal care, behavior support planning, medication
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HOUSING-RELATED SUPPORT FOR PEOPLE DISCHARGING FROM LONG-TERM CARE
management, and enhanced nursing services with a dedicated RN/LPN on-site 40 hours per week and 24/7 on-
call nursing coverage.
Specialized Behavior Support (SBS)
SBS services are specific care and support services provided to an Adult Family Home resident who DSHS has
identified as requiring personal care and behavioral intervention. SBS services include developing and
implementing negotiated care plans, supports and programming designed to support community living and
crisis prevention.
Expanded Community Services (ECS)
ECS support people with exceptional behavioral support needs residing in adult family homes and assisted
living facilities. ECS may provide direct support and training to the individual and residential staff. Behavioral
management strategies include training and consultative support services for individuals relocating or being
diverted from state or local psychiatric hospitals or who are otherwise at risk for loss of community living
options due to challenging behaviors. Services include behavioral support plan evaluations, medication
management and oversight and peer support services.
Community Stability Supports (CSS)
CSS services provide clients residing in an EARC setting with personal care, medication oversight, and
specialized staffing, including on-site nursing 40 hours per week and 24/7 on-call nursing coverage. CSS
provides additional caregiver staffing and a behavior support clinician on-site 40 hours per week. A client-
specific behavior support plan is developed and implemented by staff. Mental health treatment services are
provided through the client's Medicaid-managed care plan and delivered by a community behavioral health
agency provider.
Finally, we note that HCA-contracted MCOs may fund exceptional care supports for people whose primary
need for additional care is related to a behavioral health diagnosis to help transition individuals from inpatient
settings and maintain people with behavioral health needs in home and community-based LTSS settings.
In-scope DSHS DDA programs
Residential programs
Residential programs serve clients with intellectual or developmental disabilities who require assistance with
activities of daily living. Services may receive facility- or non-facility-based. Clients receiving facility-based
services live in contracted Intermediate Care Facilities, group homes, or adult family home settings where on-
site staff provide support and training. Clients receiving non-facility-based services live in their own homes,
with contracted agencies providing the needed supports.
SOLA
SOLA programs provide supported living services that offer instruction and support to people who live in their
own homes in the community. Supports may vary from a few hours per month to 24 hours per day of one-to-
one support. SOLA programs are operated by DDA and staffed by state employees.
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