Snohomish County Mental Health and Chemical … · Mental Health and Chemical Dependency Action Plan August ... Louise Stanton-Maston, ... substance abuse is a factor in three-fourths

MHCD Tax Plan Draft for Stakeholder Review

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Snohomish County

Snohomish County Mental Health and Chemical

Dependency Action Plan

August 2008

Submitted by: Janelle Sgrignoli


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Table of Contents

Sections Page Numbers

Acknowledgements 3

Background 4-5

Overview of Need 6-14

Cost Benefit Analysis 15-16

Summary of Proposed Strategies 17-24

Proposed Spending Plan 25

Oversight Committee Description 26-27

Administrative Structure 28

Evaluation Process 29-30

Next Steps and Recommendations 31

Plan Development Process 32

Complete Strategy Descriptions 33-97

Resources 98-100


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Acknowledgements We wish to gratefully acknowledge the following individuals and organizations for their support and contributions to the completion of this plan. Snohomish County Council John Baker, Blue Ribbon Commission on Criminal Justice Jim Bloss, Blue Ribbon Commission on Criminal Justice and NAMI Teresa Cox, Blue Ribbon Commission on Criminal Justice Seth Dawson, Blue Ribbon Commission on Criminal Justice Gary Weikel, Blue Ribbon Commission on Criminal Justice Renee Ripley, Blue Ribbon Commission on Criminal Justice Kit Wennersten, Blue Ribbon Commission on Criminal Justice Susan Neely, Senior Legislative Analyst Hon. Larry E. McKeeman, Presiding Judge, Superior and Juvenile Courts Bob Terwilliger, Court Administrator, Superior and Juvenile Courts Marilyn Finsen, Assistant Administrator, Superior Court Craig Daly, Assistant Administrator, Juvenile Court Marie Jubie, Snohomish County Mental Health Advisory Board James Mead, NSMHA Advisory Board Steve Ahern, Snohomish County Council on Aging Janice Ellis, Snohomish County Prosecutor Snohomish County Sheriff John Lovick Sally Hintz, Northwest Washington Director, Senator Maria Cantwell Jean Hales, President/CEO, South Snohomish County Chamber of Commerce Louise Stanton-Maston, President/CEO, Everett Chamber of Commerce Human Services Department Corrections Department Snohomish County Executive’s Office North Sound Mental Health Administration Mental Health provider agencies Chemical Dependency provider agencies Senior services provider agencies Housing agencies Community Stakeholders


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Background

The State Legislature recognizes that there are insufficient state and federal funding to adequately meet the mental health and chemical dependency needs of the state of Washington. During the 2005 legislative session, Senator Hargrove championed ESSB 5763.SL creating the omnibus treatment of mental and substance abuse disorders act of 2005 that included a provision allowing counties to impose a 1/10th of 1% sales and use tax to support mental health and chemical dependency treatment. RCW 82.14.460 enables the sales and use tax “solely for the purpose of providing new or expanded chemical dependency or mental health treatment services and for the operation of new or expanded therapeutic court programs. Moneys collected under this section shall not be used to supplant existing funding for these purposes.” Substitute Senate Bill 6791 passed during the 2008 legislative session, clarified the use of these funds “(3) Moneys collected under this section shall be used solely for the purpose of providing for the operation or delivery of new or expanded chemical dependency or mental health treatment programs and services and for the operation or delivery of new or expanded therapeutic court programs and services. For the purpose of this section, ‘programs and services’ includes, but is not limited to, treatment services, case management, and housing that are a component of a coordinated chemical dependency or mental health treatment program or service.” The bill further clarified that “Moneys collected under this section shall not be used to supplant existing funding for these purposes, provided that nothing in this section shall be interpreted to prohibit the use of moneys collected under this section for the replacement of lapsed federal funding previously provided for in the operation or delivery of services and programs as provided in this section.” The Snohomish County Blue Ribbon Commission on Criminal Justice was established in 2007 to advise the Snohomish County Council on priorities to meet the diverse criminal justice and public safety needs of Snohomish County. Through outreach to service providers, recognized experts, and the public, the Commission systematically reviewed and evaluated existing and new proposals and recommendations for meeting the diverse criminal justice needs in our community. The Human Services Department presented an overview of the tax option and several potential new and enhanced services to benefit those with mental illness and chemical dependency. Included in their presentation was an estimate of the impact of imposing this tax on Snohomish County residents. Based upon their research, it is estimated that a low income adult would pay less than $6.00 annually and a family with 2 adults with preschooler/school age children would pay less that $14.00 annually. In general, for every $100 dollars spent on taxable items, an additional 10¢ would be collected by this tax option.


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The final report from the Commission recommended approving the 1/10th of 1% sales and use tax. Council requested a comprehensive plan be written to provide them with sufficient information to determine if imposing a 1/10th of 1% sales and use tax for the purpose of enhancing mental health and chemical dependency treatment and therapeutic court services is appropriate for Snohomish County. This plan is in response to Council’s request.


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Overview of Need According to the 2000 Census, there are approximately 70,000 individuals covered by Medicaid in Snohomish County. Each month almost 3,500 receive mental health services through our publicly funded mental health system. Thousands more without insurance cannot afford to get the help they need. A large number of adults and youth enter the criminal justice system due to mental health and/or chemical dependency. The criminalization of mental illness is recognized as a nationwide problem. Nationally, an estimated 16% of adults and 24% of youth in city and county jails suffer from a mental illness. According to Snohomish County Jail data, more that 20% of all bookings have a history with the mental health system. Once in jail, adults with mental illness are in jail longer than those without a mental illness. Additionally, the daily cost of care while incarcerated is much higher for the mentally ill population due to the need for additional staff to observe and keep safe individuals who are at greater risk of suicide and the extra costs for psychiatric services and medications. The percentage of adults in jail who have a chemical dependency disorder is much higher, with national estimates ranging from 60% to 80%. The 2006 Snohomish County Arrestee Substance Abuse Study found that 3 out of 4 (74.8%) male arrestees tested positive for any illicit substance. Inmates who suffer from mental illness or chemical dependency have a higher rate of recidivison due to a lack of adequate community services, including treatment and housing. A study conducted by the Department of Social and Health Services in July 2004 found that 55% of clients who visited costly hospital emergency rooms in Snohomish County 21 times or more in fiscal year 2002 had a diagnosis of both a mental illness and chemical dependency. Although they are less than 1% of the aged and disabled population, the 66 most frequent emergency room users had over 2,300 emergency room visits in fiscal year 2002. It’s estimated that approximately 13,000 children in Snohomish County are considered indigent but have no Medicaid coverage. Almost 55% of them need services but cannot access them. A study of children’s health in Washington conducted in 2003 by the Department of Social and Health Services found that 8% of Washington’s children needed mental health services, but only 43% of those children actually received services. Only 20% of youth who need chemical dependency treatment are able to receive it. Studies have show that depression is prevalent among older adults, between 8% and 20% in the community and up to 37% in primary care settings. Persons 65 and older have the highest suicide rate of any age group. The American Psychological Association noted in their newsletter that “researchers estimate that almost two-thirds of older adults with a mental disorder do not receive needed services.”


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Courts: E2SSB 5763.SL states that “every county that authorizes the tax provided in section 804 of this act shall, and every county may, establish and operate a therapeutic court component for dependency proceedings designed to be effective for the court’s size, location, and resources. A court with a drug court for criminal cases or with a mental health court may include a therapeutic court for dependency proceedings as a component of its existing program.” Over the years, courts and child welfare agencies have seen a substantial rise in cases of child abuse and neglect. Many factors may account for this statistic including poverty, domestic violence and a more mobile population resulting in the loss of family support systems. However, according to Linking Child welfare and Substance Abuse Treatment: A Guide for Legislators (National Conference of State Legislators, 2000), “a large percentage of parents who abuse, neglect, or abandon their children have drug and alcohol problems…Although national data are incomplete, it is estimated that substance abuse is a factor in three-fourths of all foster care placements.” It requires a coordinated approach of several systems including the courts, child welfare, mental health and chemical dependency treatment providers to adequately address the complex needs of these families. A therapeutic dependency court provides the structure to bring these systems together. Superior Court is currently working on a plan to implement a therapeutic dependency court. However, lack of adequate funding has been a major stumbling block to implementation. Snohomish County Drug Treatment Court is a court that has been specifically designed and staffed to supervise non-violent felony drug-addicted defendants. A judge closely monitors defendants who are referred to a comprehensive program of drug treatment and rehabilitation services. Over 1500 such programs are now in operation or in the planning stages in jurisdictions throughout the nation, including at least 14 in the State of Washington. The Drug Court movement is growing because Drug Courts have proven effective for breaking the cycle of conviction, punishment and re-offense. Drug Courts represent a very non-traditional approach to criminal offenders who are addicted to drugs. Rather than focusing on punishment for the crimes they commit, Drug Court attempts to treat their addiction. Drug Courts are being established across the country because they work exceedingly well for the offenders who choose it as an option to help them change their lives and to be held accountable in treatment. A recent study by the Rand Corporation concluded that treatment programs like Drug Court are ten times more effective in reducing crime on a dollar for dollar basis than traditional criminal justice methods. It is estimated that 6,020 jail days were avoided between January 2000 and March 2003 in Snohomish County which equals a cost savings of around $391,300.


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Mental Health: Mental illnesses rank first among illnesses that cause disability in the United States, Canada and Western Europe (World Health Organization, the World Health Report 2001: Mental Health: New Understanding, New Hope, 2001). The primary funding source for public mental health is Medicaid, and access to services is severely limited for those who are not eligible for Medicaid. Often the only services available to those who are not on Medicaid are the most expensive services – crisis intervention and hospitalization. The Oregon Department of Human Services, Addictions and Mental health Division recently released the results of a seven year study to assess how Oregonians who receive public mental health and chemical dependency treatment compared with the general population in terms of mortality and other factors. The study, “Measuring Premature Mortality among Oregonians”, found that 89% of those treated for both mental health and chemical dependency die before age 50. It reported that mental health and chemical dependency clients have higher risks of death associated with suicide, homicide and unintended injuries as well as being economically disadvantaged. State and federal funding to support the public mental health system in Snohomish County comes to the county through the North Sound Mental Health Administration (NSMHA). NSMHA is a 5 county regional support network of which Snohomish County is a member along with Skagit, Island, and San Juan and Whatcom counties. Most service funding goes directly to provider agencies from the NSMHA. Currently, the NSMHA provides funding for a variety of services including outpatient, adult intensive outpatient programs, program for assertive community treatment, wraparound (children’s high intensity program), children’s hospitalization, children’s hospital alternative program, and fidelity supported employment. However, these services are only available to a small number of those in need. Based upon information provided by NSMHA, over 26% of the adult population in Snohomish County has a diagnosable mental disorder and almost 6% (approximately 28,000) have a serious mental illness. The number of children (0-17) with a serious emotional disturbance is 7% (approximately 12,000). During the period of May 2007 through May 2008, there were an average of 3,316 Medicaid and 95 non-Medicaid individuals with an open outpatient primary episode. There are a large number of children and adults needing mental health services yet unable to access them through the public mental health system. Mental health programs managed by the county include Jail Transition Services, Resource Management, Involuntary Treatment, and planning and community organizing others in the county to identify and address, when possible, unmet needs. Jail Transition Services provides transition services to inmates in jail suffering from severe mental illness. Services include mental health treatment, medications, expedited application for financial benefits, referrals for housing and other social and health services.


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Connecting inmates with treatment and other services prior to release facilitates a smooth re-entry into the community with the outcome of reduced recidivism. While this program is addressing those with severe mental illness, there are certainly many more with less severe mental illness needing assistance but without the financial resources to pay for treatment. Additionally, this program does not provide comprehensive services to optimize re-entry into the community. The 2008 Point in Time Count found that 245 individuals incarcerated on the night of the count would be homeless upon release. Of those, approximately 54 reported dealing with a mental illness. Resource Management staff provides discharge planning and linkages to community placements for adults leaving Western State Hospital and children leaving Children’s Long-term Inpatient Programs for the 5 county region. Staff develops creative community treatment plans that address most or all of an individuals needs, specifically safe and stable housing, not just mental health needs. The State continues to reduce the number of beds available at Western State Hospital and the Proactive Alternative Living System (PALS) program. Many of the people returning to the community from these facilities need an intensive level of services in order to succeed. The 2006 State Legislature increased funding to the State Mental Health Division to implement Programs for Assertive Community Treatment (PACT) in 2007. Snohomish County, via NSMHA, is receiving funding to provide intensive services for up to 100 individuals with severe mental illness, many of whom are homeless and cycle in and out of hospitals and jails. PACT uses a multi-disciplinary team of professionals to provide high-intensity services that are available 24 hours a day, and is a nationally recognized evidence-based program. While the startup has been slow, it is expected that PACT will reduce jail use by some of the more frequent users of the jail. While this program provides for 100 slots, there is still a need for additional permanent supportive housing for individuals with severe mental illness. Include unmet need pact. Chemical Dependency: Chemical dependency is a progressive disease. In most individuals, dependency begins slowing and grows until their life becomes progressively unmanageable. Consequences are often reflected in the individual’s family life, health, social life, school or work relationships and legal matters. Often the only services available to those who are not on Medicaid are the most expensive services – crisis intervention and hospitalization. The County manages the public funded chemical dependency treatment system for adults and youth in Snohomish County. Certified chemical dependency treatment and ancillary services are provided through subcontracts with local agencies. The programs serve indigent and low income alcoholics and addicts. The Department provides system coordination by developing and maintaining collaborative partnerships with Superior Court, Jail,


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Sheriff and Narcotics Task Force. They provide county and state funding to support the Adult Drug Court (CHART). Approximately 150 non-violent drug related felons are enrolled at any one time. It is estimated that 6,020 jail days were avoided between January 2000 and March 2003 which equals a cost savings of around $391,300. Four to five applicants a day are being turned away as C.H.A.R.T. is at capacity. Adjusting for vacancies created through graduation and terminations, but not adjusting upward for population growth or growth in drug related crime or the number of defendants in jail who may be otherwise eligible, needed capacity is close to 750. In 2006, 63% or 4,089 clients in the public funded chemical dependency system were involved in criminal justice activities. The 2006 Snohomish County Arrestee Substance Abuse Study found that 3 out of 4 (74.8%) male arrestees tested positive for any illicit substance, over 11% higher than the previous study conducted in 2003. The study also found that male arrestees that reported heavy substance use were more likely to have been arrested in the past 12 months, reported a greater number of arrests across their lifetime, and reported spending more time in jail that arrestees that did not report heavy substance use. A Female Supplement to this study found that 3 out of 4 (70.8%) female arrestees also tested positive for any illicit substance. Females were not included in the 2003 study. The County has provided funding for chemical dependency treatment and opiate substitution (methadone) treatment in the jail. In the first 4 months of 2007, 71 inmates received treatment and all but 1 continued treatment upon release. Of those completing treatment, there have been no new arrests. The methadone treatment program has resulted in savings of correction staff time previously spent managing behaviors and health risks of inmates detoxing “cold turkey” from methadone. Also, the jail has seen reductions in “send outs” to local emergency rooms for medical care. There is no state or federal funds available to support these programs so they are funded with approximately $300,000 of County Current Expense. Access to Recovery (ATR), a federally funded program, offers treatment and ancillary services for those who traditionally don’t access treatment. Ancillary services may include housing, transportation, mental health, clothing and prescriptions. ATR has served over 3,000 individuals since April 2005. While funding for this program has been extended to June 2009, it has been slated for reduction or elimination in the past. If the funding is not renewed, services will not continue for this population. While the state has increased funding for chemical dependency treatment in the last few years, it is still not nearly adequate to meet the needs of our county. The State requires that 60% of the calculated need be served. “Calculated need” means the percentage of the population under 200% of the federal poverty level in need of chemical dependency services as determined by the 2003 Washington state needs assessment study. There is also a statewide shortage of certified chemical


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dependency specialists. Agencies cannot meet the demand for treatment without certified chemical dependency specialists. Consequently, there is a long wait for treatment, even if the individual can afford to pay. Relapse episodes are prevalent among individuals who must wait for a public pay treatment slot. Housing: There has always been a shortage of safe, stable and affordable housing for persons with mental illness or chemical dependency issues in Snohomish County. In the last several years, the cost of buying or renting a home has risen substantially due to a shortage of housing. The County serves as a HUD entitlement area and oversees federal and state funding for the development of affordable housing, services for the homeless and low to moderate income households and public facility improvements in low to moderate income areas. Approximately 87,000 households earned less than 80% of the county’s median household income ($60,650 of $63,313 in 2006). 60,000 or 69% of those households had existing housing needs (defined as paying more than 30% of total income for housing, sacrificing other necessities such as food or medical care). On January 24, 2008, 2,154 individuals were counted as homeless during the annual “Point in Time Count.” Of those, 301 were identified as chronically homeless (defined as a single adult living with a disabling condition that has been homeless for a year or experienced 4 episodes of homelessness in 3 years). The cost of supporting and unsheltered chronically homeless individual exceeds $100,000 annually in service dollars for shelter, emergency room visits, jail days, etc. Stable housing with supportive services is much less costly and yields more positive results. This was the second year that the jail population was included in the count. 245 individuals were incarcerated on the night of the count and reported they would be homeless upon release. 66% of these individuals were also dealing with substance abuse issues. 22% reported having a mental health disorder. In June 2006, the county released “Everyone At Home Now”, a 10 year plan to end/reduce homelessness. The plan noted that resources to treat, support, and house individuals with chronic mental illness have steadily declined and that many homeless individuals have a mental illness. The plan calls for at least 50 units of safe haven housing be developed for the chronically mentally ill and that funding be increased for services individuals with mental illness need to live independently. The plan also calls for increased permanent housing for persons with chemical addiction; and more treatment resources for those with a dual diagnosis of mental illness and chemical addiction. The NSMHA 2008 Housing Plan noted that the public mental health system faces a number of pressures as it tries to help individuals find and keep permanent housing. Philosophical changes such as community integration, permanent housing and


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“housing first’, has put greater pressure on case managers to find the right type of housing, not just whatever might be available. The public mental health system is trying to be more respectful of individual’s preferences for developing new housing and housing supports. Also, the Supreme Court’s Olmstead decision requires mental health systems to make reasonable accommodations that will offer individuals treatment in their communities rather than in institutions. The majority of Medicaid recipients in the public mental health system receive $654 a month in Supplemental Security Income (SSI). Some also earn wages or receive social security benefits. However, with the current cost of $710 for a one bedroom apartment in Snohomish County, those who qualify for Medicaid services cannot afford the vast majority of apartments or houses. Besides the cost of housing and its lack of availability, landlords can pick and choose their renters and usually choose renters who have good references, good rental histories, are employed and don’t need financial or other support services. While traditional public funding for housing has not grown with need, there are new sources of funding. In recent years, the state legislature has passed bills that allow counties to collect recording fees which can only be used to address low income housing and homelessness. In Snohomish County, these sources bring in approximately $4 million estimated for 2008. Given the lack of affordable housing, these funds are in high demand and the county typically receives many more requests for funding than it can support. Special populations: The “Snohomish County Area Plan on Aging 2008-2001” noted that in 2006, 13.4% (90,138) of the total population (671,800) in Snohomish County were persons age 60 and older. The most recent projections available indicate that, by the year 2020, 22.1% (190,258) of the Snohomish County population will be age 60 and older. Life expectancy in the United States has risen by almost 30 years in the last century. However, this is mainly due to improvements in public health and preventive medicine. Concerns regarding mental health and how it contributes to physical health were largely ignored. Studies have show that depression is prevalent among older adults, between 8% and 20% in the community and up to 37% in primary care settings. Depression has many consequences in later life. Persons 65 and older have the highest suicide rate of any age group. Depression has also been linked to an increase in disease as well. Depression considered chronic (lasting on average 4 years) raises the risk of cancer by 88% in older persons. A study of older adults in Baltimore showed those with depression were at increased risk to subsequent functional impairment, cognitive impairment, psychological distress, and death.


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The County is the Area Agency on Aging and oversees federal and state funding that supports services for the elderly and disabled adults, including mental health. Programs include geriatric depression screening, adult day services for mentally ill, peer support, and stabilized housing for vulnerable seniors. However, less than $200,000 is available to support these programs, which is not sufficient to meet the need of our older residents. A study of children’s health in Washington conducted in 2003 by the Department of Social and Health Services found that 8% of Washington’s children needed mental health services, but only 43% of those children actually received services. Only 20% of youth who need chemical dependency treatment are able to receive it. The “2006 Snohomish County Healthy Youth Survey” noted disturbing trends of substance abuse with our youth. 4% of 6th grade students self reported alcohol use in the last 30 days. This percentage increases up through 12th grade with 44% of the students reporting alcohol use in the last 30 days. Marijuana use shows similar trends with 6% of 6th grade students indicating that marijuana was easy to get, increases to 61% of 12th grade students noting the ease of acquiring marijuana. 38% of 12th grade students also thought that there was little or no risk to using marijuana. However, brain development continues into the early twenties. The growing brain is more vulnerable to long-term impact from alcohol and other drugs. Depression is a feeling of sadness, helplessness and hopelessness that lingers over time. Untreated it can lead to alcohol abuse and even suicide. Suicide is the second leading cause of death for Washington teens 15 to 19 years old. The “Healthy Youth Survey” noted that 25% of 8th grade students surveyed felt so sad or hopeless for 2 weeks or more that they stopped doing their usual activities. 12% considered attempting suicide and 9% made a suicide plan. For 10th grade students, the numbers increase to 30%, 12% and 17%. For 12th grade students, while 29% indicated they felt so sad or hopeless for 2 weeks or more that they stopped doing their usual activities, the percentage who had considered suicide is 5% less than those of 10th grade students. There are approximately 65,000 veterans living in Snohomish County, about 10% of the total population. These are veterans that at any given time, may find themselves in need due to age, physical disability, unemployment, mental illness or chemical dependency. Previously, the largest subset of veterans needing assistance was from the Vietnam era. However, the current conflicts in the Middle East are resulting in a new wave of veterans with complex needs. Men and women are returning to their families with mental and physical needs not seen in previous conflicts. Increases in mental illnesses, including depression and Post Traumatic Stress Disorder, as well as increases in traumatic brain injuries, substance abuse, domestic violence, unemployment and homelessness are stressing an already lacking system of support. Once again, this is a population that potentially impacts our criminal justice system due to the lack of adequate community support.


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While there are state and federal benefits for veterans, they are inadequate and the wait can be months. Counties are required to allocate a portion of property tax collections to provide services for local veterans with emergent needs. In Snohomish County, approximately $500,000 in property tax revenue is allocated for veterans services. A few years ago, a report was produced by Snohomish County Human Services Department that demonstrated gaps in services for our Veterans as well as the increased demand for services. Based on that information, an additional annual amount of $275,000 of County Current Expense funding was awarded from Snohomish County Council that went directly to serving additional veterans and providing some dental care. Historically, funding has been “rationed” throughout the year by the Human Services Department to make sure funding did not run out before the end of the year. The Veterans Services Partnership is a collaborative group of agencies, stakeholders, congressional representatives and county staff working to develop a continuum of care for veterans in our county. Work to date has included an inventory of services currently available and potential unfunded gaps in service such as insufficient mental health and chemical dependency treatment, dental care and housing. However, there is no funding currently available to fill those gaps. Additionally, there is a strong correlation between domestic violence victimization and subsequent mental health issues, substance misuse and abuse, homelessness, incarceration and usage of emergency medical care. A strategy has been proposed that integrates programs that support specialized mental health or chemical dependency counseling, therapy and support groups for victims of domestic violence and children exposed to domestic violence in collaboration with recognized domestic violence service providers. Restrictions and reductions in state and federal funding for treatment as well as a lack of availability of housing options make it impossible to meet the needs of our communities. Human service funding is discretionary funding and at the top of the list for reduction at times of tight budgets. Increases in the cost of providing services and increased demand have exceeded all available funding. Without new sources of revenue, thousands of our residents will continue to struggle with mental health and chemical dependency disorders impacting their lives as well as their family, friends, co-workers, employers, emergency care system, criminal justice system and all of Snohomish County.


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Cost Benefit Analysis There have been a number of studies on the cost benefits to government and tax payers of providing adequate and timely mental health and chemical dependency treatment. The most recent was a study conducted by the Washington State Institute for Public Policy (WSIPP) at the direction of the 2005 Legislature to examine the potential benefits Washington could obtain using an “evidence-based” approach for alcohol, drug and mental health treatment. Their study, “Evidence-Based Treatment of Alcohol, Drug, and Mental Health Disorders: Potential Benefits, Costs, and Fiscal Impacts for Washington State”, found that the average evidence-based treatment can achieve approximately $3.77 in benefits per dollar of treatment cost. The study noted that based upon national prevalence rates, approximately 3.8% of the adult population has a serious mental illness, about 1 in 26 adults. Per the NSMHA, over 26% of adult residents of Snohomish County have a diagnosable mental health disorder and 6% (approximately 28,000) have a serious mental health disorder. The Department of Social and Health Services “Washington State Mental Health Services: Cost Offsets and Client Outcomes Fact Sheet” found that providing mental health treatment to clients in Medicaid or General Assistance-Unemployment (GA-U) reduced medical costs, partially offsetting the cost of outpatient mental health therapy. It further noted that savings were greater when the client received outpatient mental health treatment than providing psychotropic medications alone. Costs per client were reduced by about $105 per member per month (pmpm) in the first follow-up year and $126 pmpm in the second year. Lost productivity is one of the costs of untreated mental health and chemical dependency disorders. According to a fact sheet by the National Mental Health Association, the total annual cost for mental illness (public and private) in the U.S. is $205 billion. Only $92 billion is due to direct treatment costs. The rest is due to lost productivity ($105 billion) and crime and welfare costs ($8 billion). Lost productivity is a loss of resources for employers and potential loss of income for families. It makes good business sense to provide adequate mental health and chemical dependency services to prevent absenteeism and loss of productivity. A separate study by WSIPP, “Evidence-Based Public Policy Options to Reduce Future Prison Construction, Criminal Justice Costs, and Crime Rates”, found that some evidence based programs can reduce crime. And that several of the successful programs produce favorable returns on investment. Those programs include, but are not limited to:

• Cognitive-behavioral therapy in jail or community • Drug treatment in community • Drug treatment in jail • Adult drug courts


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For example, adult drug courts provide on average $4,395 in benefits to victims in reduced crime and $4,705 to taxpayers in reduced crime per participant. Taken against the average cost per participate of $4,333, the overall cost benefit is $4,767 per participant. Snohomish County’s adult drug court, CHART, maintains approximately 150 participates. Using the figures from the study, the cost benefit is over $700,000 annually. Programs for youth in juvenile detention provide even greater return on investment with the added benefit of reducing adult offender costs. Drug treatment in the community shows even a stronger rate of return, with approximate benefits ($5,133 and $5,495) less costs ($574) equaling $10,054 in overall benefits per participant. Currently, 1,446 adults are in treatment in Snohomish County, approximately 60% of the calculated need. Using the figures from the study, this equates to $14,538,084 in cost benefits to the county. In June 2004, DSHS Research and Data Analysis Division published a report, “Methadone Treatment for Opiate Addiction Lowers Health Care Costs and Reduces Arrested and Convictions.” The report noted that cost offsets could be interpreted as cost avoidance for clients already receiving treatment and as potential cost savings that may be realized by treating those not currently being treated. Based on their research, the average net cost offset was $765 per person per month for methadone treatment as compared to the average cost of methadone treatment at $219 per person per month. 80% of the cost offset was due to reduced medical costs. It is not just public agencies that bear the cost of chemical dependency. Citizens and our communities at large are also directly affected. Individuals and households are directly affected by chemical dependency related crime through theft and property destruction. Treating chemical dependency disorders can improve public safety, reduce crime and property damage, reduce the use of public assistance, reduce the use of jails and hospitals, and increase the number of employed citizens in our communities.


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Strategies/Initiatives The following pages include summaries of proposed strategies to address unmet need in Snohomish County. These strategies reflect the work previously done by the Human services Department in their presentation to the Blue Ribbon Commission on Criminal Justice as well as programs from other sources. Programs may be “evidence based”, “research based”, or “promising practice” as defined in the legislation and may also reflect innovative approaches to local problems where there are no applicable models. The proposed strategies address the following overarching goals:

• Reduce the incidence and severity of mental health and/or chemical dependency disorders in adults and youth

• Reduce the number of individuals with mental health and/or chemical dependency disorders using costly interventions such as hospitals, emergency rooms or jails

• Diversion of adults and youth with mental health and/or chemical dependency disorders from initial or further involvement with the criminal justice system

• Support linkages with other County efforts • Provide outreach to underserved populations • Provide culturally appropriate service delivery

Some of these strategies may be ready to implement as soon as funding is available. However, most will need further planning and development by key stakeholders and county staff, or will require the issuance of Requests for Proposals that will delay implementation until service providers are chosen and contracts executed. Currently, county and agency staff does not have the capacity to engage in a number of requests for proposals being processed at the same time. Requests for Proposals will need to be released over time, based upon staff capacity, readiness of the strategy and readiness of service providers to respond to the request for proposals and implement the strategy. Strategies have been categorized but are not prioritized. If there are more proposed strategies than can be supported by the estimated annual revenues, key services including a family drug treatment court and expanded mental health and chemical dependency treatment services will be funded first. The Oversight Committee shall develop a process for soliciting, reviewing and recommending new funding requests with staff support from the Human Services Department.

Full descriptions of each strategy are included in a later section of the report.


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Summaries of Proposed Strategies

Community Based Services Strategy 1-CBS Strategy Title: Increase Access to Outpatient Mental Health Treatment for Individuals not on Medicaid Description of Service: Provide expanded access to outpatient mental health services and other therapeutically indicated services for individuals who do not currently qualify for the public funded mental health system. These services include outpatient, adult intensive outpatient programs, program for assertive community treatment, wraparound (children’s high intensity program), children’s hospitalization, children’s hospital alternative program, and fidelity supported employment. Strategy 2-CBS Strategy Title: Increase Access to Chemical Dependency Treatment Description of Service: Outpatient treatment and opiate substitution programs will be increased to serve low income individuals. Strategy 3-CBS Strategy Title: Older Adults Outreach – Mental Health Description of Service: The County is completing the Geriatric Mental Health Access Project (GMHAP) with the goal of designing and developing a mental health service delivery model for older adults that is built upon coordinated and integrated cross-system partnerships. Potential programs and services include, but are not limited to:

• Provide a geriatric mental health specialist to train adult family home staff, nursing home staff and physicians to deal with older residents experiencing mental health problems

• Expand mental health services for older adults with serious depression

• Improve the referral system so older adults can call the mental health assistance line for services they need

• Increase services that help mentally ill older adult maintain their housing

• Fund medication management consultation with a psychiatrist and/or pharmacist

• Expand day services for older adults experiencing mental health issues Strategy 4-CBS Strategy Title: Employment Services for People with Mental Health and/or Chemical Dependency Disorders Description of Service: Mental health and chemical dependency treatment agencies will provide fidelity-based supported employment services that may include: trial work experiences, job placement, on the job intensive training supports, and job retention services for individuals receiving mental health and/or chemical dependency treatment services.


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Strategy 5-CBS Strategy Title: Expand Detox Capacity Description of Service: The County would expand the number of Detox beds it funds from 15 to 30 by creating a second Detox (perhaps located in another part of the County). Five additional transitional beds would be added to the existing and new Detox at a lower cost to provide transitional care for those discharged from Detox who are waiting for their residential treatment application to be processed and a bed located. Strategy 6-CBS Strategy Title: Inpatient/Residential Chemical Dependency Treatment Description of Service: Inpatient/residential chemical dependency treatment would be provided by a state certified inpatient provider capable of addressing the treatment needs of Snohomish County residents. Additional funding, without the restrictions of state and federal funding, would allow low income youth and adults not financially eligible for state funded inpatient treatment to access that treatment. Strategy 7-CBS Strategy Title: Mental Health Services of Domestic Violence Victims Description of Service: Licensed mental health professionals with expertise in mental health and domestic violence will be employed to provide assessment and mental health treatment to domestic violence survivors who are at risk for ongoing mental health issues. Treatment will include brief therapy and mental health support in group and or individual sessions. Strategy 8-CBS Strategy Title: Transportation Assistance for Individuals in Public Mental Health and/or Chemical Dependency Treatment Systems Description of Service: Individuals currently in the mental health and/or chemical dependency system would be identified by their counselor or case manager as needing transportation assistance to treatment. The counselor or case manager would provide referral information to a Human Services Department Recovery Support Specialist. Assistance would average $50 per month per recipient and be provided in either the form of a bus passes that would provide transportation throughout the county or a gas voucher.


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Programs Addressing Youth

Strategy 1-PAY Strategy Title: Intervention Specialist in Schools Description of Service: This proposal would result in an additional 10 Intervention Specialists within Snohomish County schools whose locations would be based upon greatest need as identified by the most recent Healthy Youth Survey. Services would be subcontracted to local youth treatment providers. Strategy 2-PAY Strategy Title: Transitional Housing for Youth in Public Mental Health and/or Chemical Dependency Treatment Description of Service: This proposal suggests that a facility be build or acquired that would be adequate to provide housing and supportive services to approximately 75 youth a year. Supportive services would include chemical dependency treatment, mental health counseling, life skills classes, and access to healthcare, education assistance, and job training. 1) Acquisition of an 8 bed facility serving 25 youth between 16 and 18 years of age per year in north Snohomish county and, 2) Provide 50 market rate housing vouchers for young adults between 18 and 24 years of age where tenants pay 30% of their monthly income to rent. Strategy 3-PAY Strategy Title: Multi-systemic Therapy (MST) Provider Description of Service: High risk youth and families in Snohomish County are in need of services that address serious behavioral disorders that persist despite current interventions and efforts. MST is a family, in home based treatment designed to change how youth function in school, at home and in their neighborhood. This model promotes positive social behavior while decreasing anti-social behaviors. Strategy 4-PAY Strategy Title: Community Team for Children Description of Service: Community Team is comprised of key administrators of child and youth service organizations, child and youth advocates, parents and businesses. In addition to providing financial resources to clients, members support the development, or preservation, of Child and Family Teams that wrap necessary services and supports around children and families to provide a comprehensive continuum of care.


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Strategy 5-PAY Strategy Title: Youth Center Respite Beds Description of Service: A child and family community resource center is a one-stop facility that houses a variety of social service agencies; including, but not limited to, mental health, substance abuse, child welfare, juvenile justice, and education. Case managers at the Center would assess the child’s psychological, educational, and functional needs, determine appropriate services and placements, make referrals, provide some direct counseling services, and determine how services would be funded. Strategy 6-PAY Strategy Title: Youth Outreach Description of Service: Screening, assessment and referral services for children of parents involved in chemical dependency and/or mental health, domestic violence or criminal justice systems.


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Diversion Options and Therapeutic Courts Strategy 1-DOTC Strategy Title: Family Drug Treatment Court (required by RCW 82.14.460) Description of Service: The Family Treatment Drug Court is designed to provide intensive supervision and therapeutic services and substance abuse treatment to parents who are brought to the attention of the court through dependency actions filed by Child Protective Services in cases involving child abuse/neglect. Strategy 2-DOTC Strategy Title: Adult Drug Treatment Court (C.H.A.R.T.) Expansion Description of Service: Drug treatment court is a special court, which handles cases involving addicted offenders through supervision and treatment instead of prosecution and incarceration. C.H.A.R.T. Court includes frequent drug testing, judicial supervision, drug/alcohol treatment, community medical/education/employment resources and the use of rewards and sanctions. Strategy 3-DOTC Strategy Title: Juvenile Offender Drug Treatment Court Expansion Description of Service: In instances where the Prosecuting Attorney agrees to a temporary stay of proceedings or deferred disposition, the Judge will order the youth to participate in the Juvenile Drug Court. The youth who choose to participate follow the requirements set forth by the Department of Justice research based best practices model. While this system is highly effective, there are several gaps in service delivery that continue to preclude youth from receiving services in the community that will strengthen their success. An identified issue is the youth and her/his family’s financial ability to pay for substance abuse treatment and mental health treatment. Strategy 4-DOTC Strategy Title: At Risk Youth Drug Treatment Court Expansion Description of Service: The At Risk Youth Drug Treatment Court program combines substance abuse treatment and intensive supervision by a Superior Court Judge to eligible drug and alcohol involved At Risk Youth (ARY) and their parents. ARY drug court places youth in appropriate levels of treatment determined by a drug and alcohol evaluation. Strategy 5-DOTC Strategy Title: Mental Health Services in Juvenile Detention Description of Service: This proposal will add one full time mental health professional to provide direct client services. Services would be similar to those provided by the mental health professionals at the Corrections Department.


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Strategy 6-DOTC Strategy Title: Mental Health Court Description of Service: A mental health court must have sufficient judicial, public defender and prosecutor staff to accommodate new court case loads, along with sufficient probation staff to monitor clients in terms of court compliance. Other components could include a mental health professional and a peer support specialist as part of the mental health court team. Strategy 7-DOTC Strategy Title: Crisis Intervention Team (CIT) Training for Snohomish County Sheriff, Municipal Police Officers and other first responder personnel Description of Service: Research has shown crisis response training to be effective in improving response to individuals with mental illness and/or chemical dependency, increasing the use of mental health referrals, reducing the number of individuals with mental illness from going to jail, and reducing injury rates to both responders and individuals with mental illness and/or a chemical dependency issue. Strategy 8-DOTC Strategy Title: Adult Crisis Stabilization Unit/Triage Center Description of Service: Screening, assessment, referral, social Detox and crisis respite services 24 hours a day, 7 days a week, will be offered in this newly created facility. In conjunction with community partners, a facility would be established and staffed to accept temporary residents in distress due to mental illness and/or chemical dependency. Assessment and referral would be completed during their stay in order to connect them to ongoing treatment. This program is designed to mitigate unnecessary costs to the Criminal Justice System and to place troubled adults in the appropriate facility initially, instead of jail. Strategy 9-DOTC Strategy Title: Youth Crisis Stabilization Unit/Triage Center Description of Service: The center would be staffed by personnel capable of professionally evaluating youth and their needs and making appropriate referrals to resources assisting in stabilization of the mental health or other crisis.


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Housing Services Strategy 1-HS Strategy Title: Housing Options for Individuals in the Public Funded Mental Health and/or Chemical Dependency Treatment Systems Description of Service: This proposal would provide ancillary housing support and increase the likelihood of maximum benefit from mental health therapy and/or chemical dependency treatment Strategy 2–HS Strategy Title: Rental Voucher Program for Homeless Individuals and Families with Mental Health and/or Chemical Dependency Disorders Description of Service: Provide rental vouchers to approximately 630 homeless families over the next 8 years. The creation of a rental voucher program for homeless families will provide an immediate reduction in the number of homeless in Snohomish County. Strategy 3-HS Strategy Title: Permanent Affordable Housing for Persons with Mental Health and/or Chemical Dependency Disorders Description of Service: The service to be provided under this strategy is the acquisition and rehabilitation or construction of rental housing that will be reserved for people who have mental health and/or chemical dependency needs.


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Proposed Spending Plan The numbers below are estimates. Several factors, including when tax revenues become available, when strategies are ready to implement and staffing will impact the final figures. Strategy Title Start up

or capital On Going

Annual Budget

1-CBS Increase Outpatient Mental Health Tx. $4,217,400 2-CBS Increase Chemical Dependency Tx. $950,000 3-CBS Older Adults Outreach – Mental Health $500,000 4-CBS Employment Services – MH/CD $1,370,880 5-CBS Expand Detox $1,045,725 6-CBS Inpatient Chemical Dependency Tx. $450,000 7-CBS Mental Health for DV Survivors $200,000 8-CBS Transportation Assistance – MH/CD $120,000

1-PAY Intervention Specialists in Schools $700,000 2-PAY Transitional Housing for Youth $1,000,000 $900,000 3-PAY Multi-systemic Treatment $13,750 $277,595 4-PAY Community Team $280,000 5-PAY Youth Center and Respite Beds $1,160,000 6-PAY Youth Outreach $250,000

1-DOTC Family Drug Treatment Court $257,750 2-DOTC Expanded Adult Drug Court $541,750 3-DOTC Expanded Juvenile Drug Court $427,750 4-DOTC Expanded At Risk Youth Drug Court $285,750 5-DOTC Mental Health in Juvenile Detention $80,000 6-DOTC New Mental Health Court TBD 7-DOTC Crisis Intervention Training $200,000 8-DTOC Crisis Stabilization Unit/Adult Triage $2,000,000 $1,000,000 9-DOTC Crisis Stabilization Unit/Youth Triage $250,000

1-HS Housing Options –MH/CD $840,000 2-HS Rental Vouchers for homeless $1,921,400 3-HS Permanent Affordable Housing $2,000,000

Annual Reserve Hold Back (10%) $1,300,000 Administrative Allowance (5%) $650,000 Totals $3,013,750 $22,176,000 Based on Estimated Annual Revenue of

$13,000,000


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Snohomish County Mental Health Chemical Dependency Tax Oversight Committee

Mission: It is the mission of the Snohomish County Mental Health Chemical Dependency Tax Oversight Committee (“Committee”) to ensure that programs strengthen and enhance mental health and chemical dependency services in Snohomish County and that the implementation and evaluation of the strategies and programs funded by the tax revenue are transparent, accountable, collaborative and effective. The Committee is made up of representatives from the human services and criminal justice communities. The Committee will work to ensure that access to mental health and chemical dependency services is available to those who are most in need throughout the county, regardless of geographic location. ESSB 5763.SL, SSB 6791, and RCW 82.14.460 shall provide guidance to the Committee on allocation priorities. Priority will be given to programs that are evidence-based, promising practices or local solutions that demonstrate success addressing a local need and are collaborative, client centered, fiscally responsible and culturally sensitive. Structure: The Committee shall include representation from the legislative, judicial, and executive branches of Snohomish County Government and include, but be limited to, the following members: Mental Health Advisory Board (2) Alcohol and Other Drugs Advisory Board (2) Council on Aging (1) Snohomish County Corrections (1) Snohomish County Superior/Juvenile Courts (1) Law Enforcement (1) Children’s Commission (1) Members will serve a term of 2 years from the time of appointment. No member shall serve more than 2 consecutive terms. Appointment will be confirmed by County Council. A Chair will be elected annually and will serve in office for 1 year. The Committee will meet as frequently as deemed necessary during implementation and then 2 times annually thereafter.


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The Committee tasks include:

• Review progress on approved programs including outputs and outcomes • Review program performance against stated goals • Review progress on filling service “gaps” • Receive and analyze future funding proposals • Make recommendations on current and future funding to Council during the

County’s budget process or as necessary to ensure that funds are distributed in a timely fashion.

The Human Services Department will provide staff support to the Committee and provide, at a minimum, quarterly updates and annual reports to the Council on progress, successes, concerns and allocation recommendations from the Committee.


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Administrative Structure The Human Services Department will provide oversight and management of programs and all revenues collected under RCW 82.14.460 (3). Administrative costs shall not exceed 5% of annual revenues collected. These funds shall be used only for necessary administrative costs within the Human Services Department that directly support funded strategies and necessary Plan oversight. Unused revenue will be added to the reserve account and allocated by the County Council based upon recommendations of the Oversight Committee. The revenues collected under RCW 82.14.460 shall be accounted for as a special revenue account within the county’s budget and financial records and not part of the general fund. The Human Services Department, based upon the strategies approved, shall develop an infrastructure management plan that will adequately support implementation and ongoing oversight of the funded strategies. The plan shall include adequate staffing to provide accountability and oversight of the plan and the approved strategies. Staffing should include:

• Clerical staff to manage contract documents, copying, filing, etc. • Fiscal staff to ensure adequate internal controls of funds received, monitoring of

provider agencies, financial analysis, etc. • Program staff (Human Services Specialist classification) to develop RFP and

other contract materials, provide oversight to provider agencies, monitor progress, support the Committee, develop reports as required by the Committee and Council, etc.

Office space, equipment and other logistics will need to be addressed by the Human Services Department and the Facilities Department. The Human Services Department will incorporate these revenues and expenditures into the County’s budget process in a manner so that they are transparent to the general public.


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Plan Evaluation Process

This plan suggests a tax increase to fund needed services in the community. It is important to the County Council and the residents of Snohomish County that we evaluate the impact of this plan, its strategies and assess achievement of stated goals. The evaluation process will have two parts. The first part will be an overall evaluation that will provide a general assessment of how the implementation is progressing. It will include a review of:

• start up activities • development and management of requests for proposals and contracts • Leveraging and/or blending of multiple funding sources • Coordination of partnerships • Linkages to other County initiatives

This will show what actually is happening as the plan is implemented and also what is unexpected and how it impacts implementation. Areas identified as needing additional work will be identified in case adjustments are necessary. The evaluation will be conducted in such a fashion as to ensure timely responses to issues that arise. The second part of the evaluation process will look at the individual strategies. It must be noted that short and long term results may not be realized for months or even years, depending upon the strategy. The strategy evaluations will measure performance and assess progress toward meeting program specific goals and outcomes. It will demonstrate whether the expected results are being achieved and whether value is returned on the investment and measure the quality and results of each strategy. For existing programs that are being enhanced or expanded, a base set of data for current clients will be established. Where implementation will take multiple years with long term outcomes, intermediate outcomes will be established to show the strategy is progressing to achieve results. Strategies will be evaluated on the following timeline:

• When services will actually start • For existing programs, when this funding is accessed • When a sufficient number of clients have been served to provide useable data

The evaluation process may be conducted by the Human Services Department and coordinated with administrative actives, including requests for proposals, contract management, etc. Process and outcome data will be incorporated into on going department monitoring functions and timely feedback. An alternative recommendation is to set aside funds to contract with a neutral third party to evaluate the programs supported by this revenue source including efficiency, effectiveness and cost offsets.


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The Human Services Department will provide regular status reports to the County Council on the overall implementation of the plan as well as progress on each strategy. The reports will include, but not be limited to:

• start up activities • development and management of requests for proposals and contracts • Leveraging and/or blending of multiple funding sources • Coordination of partnerships • Linkages to other County initiatives • Existing Program current client base information • Strategy performance measurement statistics (outputs and outcomes) • Program Utilization • Request for proposal/contract updates

Reports will be submitted to the County Council every 6 months during the first 2 years of implementation, then annually thereafter.


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Next steps Based upon the information and recommendations contained in this report, Snohomish County Council has several options to consider. They are:

1. Take no action at this time. Defer a decision on whether to impose a 1/10th of 1% sales and use tax to a later date.

2. Appropriate County Current Expense funds to increase programs for mental

health and chemical dependency using current resources.

3. Implement the 1/10th of 1% sales and use tax option, generating new revenue to meet the existing and future needs of our residents. It is estimated that this tax would have receipted over $13,000,000 in 2008.

Recommendations:

1. Implement Tax. Collect tax for up to 6 months prior to allocation to address cash flow, allow for administrative start up, hiring of staff, letting of contracts, additional planning, etc.

2. Ensure that revenues and expenditures are clearly traceable within the

County’s budget and financial records to provide accountability and transparency to the residents of Snohomish County. Revenues collected shall not be commingled with county current expense funds.

3. Direct the Human Services Department to develop an administrative structure

within that department to include adequate staffing necessary to provide oversight and management of programs and revenues collected per RCW 82.14.460 (3). Funding for administrative costs to support this funding source shall be limited to 5% of the annual revenues collected. The proposed structure will be submitted to the Committee for review, with final approval made by the County Council. This work must be completed within 3 months of implementation of the tax.

4. Hold 10% of annual revenues in reserve (emergent need, loss of other funding

supporting plan program/strategy, capital projects, etc.) Recommendations to allocate reserves will be made by the Committee. The Council will make final allocation decisions.


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Plan Development Process This plan was developed using:

• the work completed to date within the County (i.e., by Human Services, Corrections, Superior Court and the Blue Ribbon Commission),

• the experience of other counties which have either implemented or considered implementation of the sales tax,

• available data regarding the current system, its needs and service gaps at both the adult and juvenile levels,

• access to services, • law enforcement and emergency services, • post-arrest actions, • re-entry from jails, prison and hospitals, and • other “best practices” within the mental health and substance abuse

fields. Meetings were held with various stakeholders, in groups and one on one, to get their perspective on community need and possible strategies. Their feedback was incorporated into the draft plan. The draft was sent to a number of stakeholders and community organizations for review and feedback, as well as posted on the Council’s web site for over 2 weeks. Feedback was reviewed and incorporated into the final plan as appropriate. The final draft was delivered to the County Council on August 15, 2008 for their review and consideration.


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Complete Strategy Descriptions

Community Based Services Strategy 1-CBS Strategy Title: Increase Access to Outpatient Mental Health Treatment for Individuals not on Medicaid Documentation of Need: The public mental health system is predominately supported with Medicaid funding. Medicaid funding can only be used for persons on Medicaid. The regulations and restrictions of Medicaid funding prevent Snohomish County from serving a large population of individuals who need treatment but are not on Medicaid, don’t have private insurance that will cover treatment, and cannot afford to pay for services. Persons with severe mental illness may not qualify for Medicaid due to their inability to provide documentation needed to establish eligibility, citizenship status, their income intermittently exceeds the Medicaid income limit for eligibility, etc. Without outpatient mental health services, they frequently end up in emergency rooms, psychiatric hospitals or jails. Over half of those persons with mental illness admitted to psychiatric hospitals are not eligible for Medicaid services. Description of Service: Provide expanded access to outpatient mental health services and other therapeutically indicated services for individuals who do not currently qualify for the public funded mental health system. These services include outpatient, adult intensive outpatient programs, program for assertive community treatment, wraparound (children’s high intensity program), children’s hospitalization, children’s hospital alternative program, and fidelity supported employment. However, these services are only available to a small number of those in need. Based upon information provided by NSMHA, over 26% of the adult population in Snohomish County has a diagnosable mental disorder and almost 6% of the adult population (approximately 28,000) has a serious mental illness. The number of children (0-17) with a serious emotional disturbance is 7% (approximately 12,000). During the period of May 2007 through May 2008, there were an average of 3,316 Medicaid and 95 non-Medicaid individuals with an open outpatient primary episode. There are a large number of children and adults needing mental health services yet unable to access the public mental health system. Target Population: Children, youth, adults and older adults with a mental illness who do not receive or qualify for Medicaid, who are waiting for acceptance for Medicaid or have lost their Medicaid eligibility, yet meet the income and clinical eligibility standards for public mental health services. Priority will be given to those most in need of services, particularly those exiting the justice system, being discharged from hospitals, court ordered treatment, or those at risk of incarceration, hospitalization or homelessness.


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Program Goals: Increase access to mental health services for individuals who are currently not eligible for Medicaid services and reduce jail and inpatient utilization. Performance Measurements: (outputs, outcomes) Additional 1,065 non-Medicaid clients served per year Additional 31,950 hours of outpatient service Outcomes include reduced use of jails, hospitals, emergency department services and emergency outpatient and inpatient mental health services Service Delivery Information: Current contractors with NSMHA should be able to provide services as soon as funding becomes available and access is opened. The current work force capacity of the mental health contractors will need to be increased to meet the program target. Contractors will need to provide estimate completion dates of necessary recruitment and training efforts. Partnerships: Mental health providers, NSMHA, Snohomish County Human Services Department, Snohomish County Corrections, local hospitals, Western State Hospital Financial Data: Start Up Costs:

Specific Activities Estimated Cost None

Annual Ongoing Costs:

Specific Activities Estimated Cost Expanded Treatment - estimate $4,217,400

Other funding used to support this program: Existing funding has been obligated and is not available to meet the needs of these individuals. Without this revenue source, they will not receive the mental health treatment needed to help them be self-sufficient. Implementation: Project planning and overall implementation timeline Finalize number of clients to be service – potential ramp up over period of time Develop RFP Issue RFP Negotiate and execute contracts Providers recruit and train staff Estimated date for services to clients to begin Strategy Evaluation Process to begin


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Community Based Services Strategy 2-CBS Strategy Title: Increase access to Chemical Dependency Treatment Documentation of Need: The publicly funded chemical dependency treatment system provides treatment based on financial eligibility. There are many individuals waiting for treatment because they do not qualify for public funding and are unable to pay for treatment. The wait for treatment can be up to 2 months in Snohomish County. Additional funding without “state or federal categorical strings” would allow the public chemical dependency treatment system to operate without, or with very short, waiting lists. Description of Service: Outpatient treatment and opiate substitution programs will be increased to serve low income individuals. Target Population: Adult and youth in need of chemical dependency treatment who do not meet the financial eligibility requirements of the public chemical dependency treatment system and financially unable to pay for treatment. Program Goals: Reduced or eliminated waiting lists, increased access to chemical dependency treatment and opiate substitution programs; reduce medical and criminal justice costs. Performance Measurements: (outputs, outcomes) Serve an additional 275 adults and youth annually Outcomes include reducing the severity of chemical dependency; reduced medical and criminal justice costs for those served, reduced reliance on public assistance Service Delivery Information: Services will be provided by current chemical dependency treatment agencies. Agencies will need to increase staffing to handle the increased client workload. The original proposal called for funding 275 additional adult and youth. Based upon additional information provided by the Human Services Department, the service gap is 5,800 for adult and youth. Final planning by all partners needs to be completed to determine actual numbers to be served. If services were expanded to address 10% of the gap, an additional 580 adult and youth could be served. It is not known if the current treatment system has the capacity to expand that rapidly.


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Partnerships: Human Services Department, chemical dependency treatment agencies, Corrections, Snohomish Regional Drug Task Force, other interested stakeholders Financial Data: Financial information is from original proposal by Human Services Department. Start Up Costs:



Specific Activities Estimated Cost Expanded chemical dependency treatment $950,000

Other funding used to support this program: Current funding is obligated and not available to serve these individuals. Without this new revenue source, these individuals will not get the chemical dependency treatment they need to become self-sufficient. Implementation: Project planning and overall implementation timeline Determine final expansion numbers (estimate based on 275) Human Services Department completes program design Contract amendment language completed and sent to chemical dependency agencies Contracts executed with agencies Providers recruit and train staff Estimated date for services to clients to begin Strategy Evaluation Process to begin


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Community Based Services Strategy 3-CBS Strategy Title: Older Adults Outreach – Mental Health Documentation of Need: According to the North Sound Mental Health Administration Strategic Plan 2006-2009, “services to older adults have been declining steadily over the last five years and are significantly below the State average on the State-Wide Performance Indicators.” Snohomish County’s older population is projected to more than double from 2005 to 2020, from 90,000 seniors to 190,000. The Surgeon General estimates that twenty percent (20%) of adults ages 65 and older have a significant mental disorder and/or chemical dependency /substance abuse disorder needing treatment, approximately 18,000 in Snohomish County. Mental health and chemical dependency problems among seniors lead to higher health care costs. Seniors with depression visit the doctor and emergency rooms more often, use more medication, and stay longer in the hospital. They also contact 9-1-1 more frequently and are less likely to accept referrals to services. Adults age 65 and older have the highest suicide rate of any age group. Description of Service: The County is completing the Geriatric Mental Health Access Project (GMHAP) with the goal of designing and developing a mental health service delivery model for older adults that is build upon coordinated and integrated cross-system partnerships. Potential programs and services include, but are not limited to:

• Provide a geriatric mental health specialist to train adult family home staff, nursing home staff and physicians to deal with older residents experiencing mental health problems

• Expand mental health services for older adults with serious depression

• Improve the referral system so older adults can call the mental health assistance line for services they need

• Increase services that help mentally ill older adult maintain their housing

• Fund medication management consultation with a psychiatrist and/or pharmacist

• Expand day services for older adults experiencing mental health issues Target Population: Older adults (age 60 and older) with mental illness. Program Goals: Strengthen outpatient mental health treatment for older adults, especially for those not eligible for Medicaid.


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Performance Measurements: (outputs, outcomes) Additional 200 older adults accessing mental health treatment Outcomes include reduced use of emergency services, reduced suicides, and potential reduction in medical costs Service Delivery Information: Final planning is not complete. The Human Services Department in partnership with GMHAP workgroup, will select a specific program or programs. It is recommended that they also look at chemical dependency among this population. An RFP process will be used to select one or more providers experienced with geriatric mental health issues. Partnerships: Human Services Department, GMHAP workgroup, provider agencies, Council on Aging, other interested parties Financial Data: Details to be determined once a specific program is selected. This number is for planning purposes only. Financial information is from original proposal by Human Services Department. Start Up Costs:

Specific Activities Estimated Cost To be determined


Specific Activities Estimated Cost Original estimate only $500,000

Other funding used to support this program: To be determined in planning process Implementation: Project planning and overall implementation timeline Human Services Department and GMHAP workgroup will select/develop program(s) Request for Proposals developed Request for Proposals issued Provider(s) selected Contracts negotiated and executed Provider(s) recruit and train staff Estimated date for services to clients to begin Strategy Evaluation Process to begin *It is recommended that the Human Services Department also develop chemical dependency treatment programs for this population.


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Community Based Services Strategy 4-CBS Strategy Title: Employment Services for People with Mental Health and/or Chemical Dependency Disorders Documentation of Need: Employment is an essential piece in recovery-based systems of care and moving individuals towards self-sufficiency. Less than 10% of individuals in outpatient mental health treatment services are employed. NSMHA opened 24 slots of Substance Abuse and Mental Health Services Administration (SAMSHA) fidelity-model supported employment and within six moths, the slots were filled for the year. Only 25% of those enrolled in the chemical dependency treatment system statewide are employed. For Snohomish County, those numbers are approximately 8,646 and 1,718 respectively. However, not all individuals with serious mental illness can maintain employment. NSMHA recently funded supported employment in Snohomish County and within 6 months all 25 slots were full. Resources for specialized vocational services are very limited in the mental health system and there are none in the chemical dependency system. By helping individuals obtain and retain employment, they are furthering their recovery and self-sufficiency Description of Service: Mental health and chemical dependency treatment agencies will provide fidelity-based supported employment services that may include: trial work experiences, job placement, on the job intensive training supports, and job retention services for individuals receiving mental health and/or chemical dependency treatment services. Target Population: Individuals currently receiving mental health and/or chemical dependency treatment under the public system who need supported employment services to obtain competitive employment. Program Goals: Persons with mental health and/or chemical dependency disorders have improved success obtaining and retaining employment Performance Measurements: (outputs, outcomes) 120 persons with mental health disorder accessing supported employment services 200 persons with chemical dependency disorder accessing supported employment services Outcomes include reduction in homeless population, increased self-sufficiency and stability, decreased reliance on public assistance


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Service Delivery Information: Final planning needs to be completed by the Human Services Department in partnership with community stakeholders. Partnerships: North Sound Mental Health Administration, Workforce Development Council, Employment Security, mental health and chemical dependency agencies, Human Services Department, other interested stakeholders Financial Data: Final costs will be determined based on the number of clients served and the number and types of services provided. Start Up Costs:

Specific Activities Estimated Cost

To be determined Annual Ongoing Costs:

Specific Activities Estimated Cost Supported Employment-mental health (120) $514,080 Supported Employment-chemical dependency (200) $856,800

Total Annual Costs $1,370,880 Other funding used to support this program: To be determined Implementation: Project planning and overall implementation timeline Final program design Develop RFP Solicit RFPs Negotiate contract with successful agency(s) Agencies recruit and train staff Estimated date for services to clients to begin Strategy Evaluation Process to begin


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Community Based Services

Strategy 5-CBS Strategy Title: Expand Detox Capacity Documentation of Need: Snohomish County’s population has doubled in the 20 years since the County began contracting with Evergreen Manor to provide alcoholism and drug detoxification to the County’s residents. At the same time the level of service has remained at 15 beds and the demand has far outgrown the capacity. With the shifts in drugs of choice from alcohol to opiates, narcotics, and benzodiazepines, the Detox period is longer than when only alcohol and this in turn reduces capacity. Completion of Detox is required for persons preparing to enter residential treatment outside the county (including the Involuntary Commitment facility in Sedro Woolley), and over 1/3 of the beds are reserved just for this purpose. It is also a critical resource for police, who locate intoxicated persons on the street, and the hospital. The hospitals each day identify several persons needing public detoxification and are frustrated that they find the program full. Thus, the hospital’s referrals must be returned to the streets, only to be picked up by the police and continue the revolving door. Each night 4-11 persons are turned away from Detox because of insufficient beds, and these are exclusively Snohomish County residents. Although Detox once provided services to other counties, it is no longer possible, and the waiting lists are only Snohomish County residents. There is always a waiting list of 11 persons, extending out over a week. To be turned away from Detox is both problematic for the community as well as life-threatening to the individual. Other treatment providers are also frustrated when they have an individual in their office ready to pursue treatment but can’t get an opening in Detox to help them start the process. It is inefficient and ultimately adds to the cost to the community far in excess of the $190 a day the Detox would cost.

After detoxification is completed, there is generally a 2-5 week wait for an inpatient bed. Discharging persons with this long wait means that most will begin using drugs and alcohol during the interim, lose their bed, and the cycle continues. The availability of transitional beds has proven effective in reducing recidivism in King County and this proposal would incorporate a similar service into Snohomish County’s continuum. See the attachment of TARGET data on Detox patients accessing treatment within 10, 30, 60 and 90 days after discharge from Detox to see the long delays.


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Description of Service: The County would expand the number of Detox beds it funds from 15 to 30 by creating a second Detox (perhaps located in another part of the County). Five additional transitional beds would be added to the existing and new Detox at a lower cost to provide transitional care for those discharged from Detox who are waiting for their residential treatment application to be processed and a bed located. Detox is a medically managed service lasting 5-6 days for persons coming off of alcohol, opiates, narcotics, and tranquilizers. Withdrawal from these drugs is life-threatening and requires close medical supervision and treatment, which detoxification services provide. The transitional beds would provide a short-term post-withdrawal program for homeless persons who are pursuing residential treatment. Target Population: Indigent and low income Snohomish County adults with later-stage addiction, generally homeless or living with individuals who are using illegal drugs. Program Goals: More closely meet the demand for detoxification and encourage subsequent treatment with transitional beds that are operated at lower cost than Detox but facilitate recovery through treatment. This county’s Detox program is effective and has very low recidivism, with only 14% of Detox patients admitted more than once in a year. The primary function of Detox is to serve as a gateway to further treatment, so even 5 transitional beds should improve connection to treatment. Performance Measurements: An additional 900 Detox admissions annually, relieving police and hospitals as well as assisting families in crisis. The percentage of Detox patients admitted to inpatient treatment within 30 days of discharge from Detox would increase by 30%. Outcomes include reduction in the use of hospitals and jails, increased access to treatment in a timely fashion, and reduced recidivism Service Delivery Information: County Human Services contracts with Evergreen Manor, a non-profit providing detoxification in Snohomish County for the past 20 years. The proposal is for operating funds and the contractor would cover facility expansion cost. Partnerships: Evergreen Manor would invest in providing the facility. Those served by the program include local Hospital Emergency Departments (Providence, Stevens, Cascade), local Police Departments, Mental Health Crisis Responders, county public chemical dependency treatment programs, local 12-step self-help groups that refer to Detox (AA, NA, etc.), families and citizens in crisis.


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Financial Data: Calculation: 15 Detox beds @ $190 a day x 365 days per year = $1,040,250; less $104,025 on Medicaid admissions; Net Tax Funding $936,225 for Detox expansion. Transitional Beds: 5 @ $60 a day x 365 days per year = $109,500. Start Up Costs:



Specific Activities Estimated Cost 15 additional Detox beds $1,040,250 5 Transitional Beds $109,500

Total Annual Costs $1,045,725 Other funding used to support this program: To be determined by planning process. Implementation: Project planning and overall implementation timeline Expand existing contract with Evergreen Manor Estimated date for services to clients to begin Strategy Evaluation Process to begin


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Community Based Services Strategy 6-CBS Strategy Title: Inpatient/Residential Chemical Dependency Treatment Documentation of Need: Inpatient treatment is a critical component of the chemical dependency treatment continuum of care. Unfortunately, the public funded inpatient system is only designed to serve indigent and low income individuals. This program will help meet the inpatient needs of Snohomish County’s drug courts. Description of Service: Inpatient/residential chemical dependency treatment would be provided by a state certified inpatient provider capable of addressing the treatment needs of Snohomish County residents. Additional funding, without the restrictions of state and federal funding, would allow low income youth and adults not financially eligible for state funded inpatient treatment to access that treatment. Target Population: Low income residents, both youth and adults, who are alcoholics and/or drug addicts who have been assessed as needing inpatient treatment services but cannot access inpatient treatment through the public funded system. Program Goals: Increased access to inpatient treatment for individuals with chemical dependency Performance Measurements: (outputs, outcomes) 150 low income youth and adults, including those in drug court programs, to have access to inpatient treatment Outcomes include increased drug court participants completing the program Service Delivery Information: One certified inpatient treatment provider would be selected from an RFP process. Partnerships: Superior and Juvenile Court, service provider agencies, Human Services Department


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Financial Data: Financial information is from original proposal by Human Services Department. Start Up Costs:



Specific Activities Estimated Cost Inpatient Treatment costs $450,000

Other funding used to support this program: To be determined Implementation: Project planning and overall implementation timeline Human Services Department develop request for proposals Solicit request for proposals Select successful provider(s) Negotiate and execute contracts Provider recruits and trains if necessary Estimated date for services to clients to begin Strategy Evaluation Process to begin *It is recommended that further discussions among stakeholders explore dual diagnosis inpatient treatment options.


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Community Based Services Strategy 7-CBS Strategy Title: Mental Health Services of Domestic Violence Victims Documentation of Need: Victims of domestic violence are at increase risk for developing depression, post-traumatic stress disorder, and other mental health problems. Studies across multiple settings serving battered women indicated that averages of 48% of women were experiencing depression and 64% were experiencing post-traumatic stress disorder. There are many barriers to victims who have a mental illness. They may be experiencing ongoing staking, threats, and physical violence by their abuse partners that may make it difficult or dangerous to seek services from agencies that are not in confidential areas. Recent reports recommend that mental health and chemical dependency professionals and domestic violence programs: a) collaborate on cross training in order to increase their ability to provide the appropriate range of services to survivors of domestic violence who are suicidal or have other mental health issues, and b) coordinate services and ensure systemic changes to agency polices, procedures and practices. Description of Service: Licensed mental health professionals with expertise in mental health and domestic violence will be employed to provide assessment and mental health treatment to domestic violence survivors who are at risk for ongoing mental health issues. Treatment will include brief therapy and mental health support in group and or individual sessions. Mental Health Professionals will provide referrals to community mental health and chemical dependency agencies for those survivors with severe mental health issues who need more intensive services. Mental health professionals will offer consultation to domestic violence advocacy staff and staff of community mental health or chemical dependency agencies. A System Coordinator may be funded at the county level to coordinate ongoing cross training, policy development, and consultation on domestic violence and related issues between mental health, chemical dependency and domestic violence agencies throughout the county. Target Population: Domestic violence survivors experiencing mental health concerns and providers a mental health, chemical dependency and domestic violence agencies Program Goals: Provide mental health assessment, brief therapy and support in community based domestic violence agencies Improve screening, referral, coordination and collaboration between mental health, chemical dependency and domestic violence service providers


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Performance Measurements: (outputs, outcomes) Number of clients served per year – to be determined Number of counselors and advocates trained per year- to be determined Outcomes include increased access to early intervention and prevention services to domestic violence survivors, decreased mental health concerns among domestic violence survivors served, and increased resiliency and coping skills among domestic violence survivors served Service Delivery Information: One or more mental health professionals will provide services at community based agencies providing advocacy, emergency shelter and transitional housing to domestic violence survivors and their children. The mental health professional(s) could be employed by Snohomish County or provided by a mental health treatment provider under contract with the County. The Human Services Department may employ a System Coordinator position (estimate .5 FTE) to coordinate ongoing cross training, policy development, and consultation on domestic violence and related issues between mental health, chemical dependency and domestic violence agencies throughout the county. Partnerships: Domestic violence, mental health and chemical dependency agencies, Human Services Department Financial Data: Funding will depend on the type of program selected and staffing needs. A rough estimate has been included for planning purposes only. Start Up Costs:



Specific Activities Estimated Cost Mental Health Professional(s) $200,000

Other funding used to support this program: To be determined Implementation: Project planning and overall implementation timeline Work with DV agencies to determine numbers to be served and funding needs Develop policies and procedures Amend existing contracts with community based providers County and/or providers hire and train staff Estimated date for services to clients to begin Strategy Evaluation Process to begin


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Community Based Services Strategy 8-CBS Strategy Title: Transportation Assistance for Individuals in Public Mental Health and/or Chemical Dependency Treatment Systems Documentation of Need: Adults and youth without transportation have great difficulty engaging in mental health treatment and/or chemical dependency treatment. Transportation will allow these individuals to reliably participate in mental health and/or chemical dependency treatment and related support activities. While actual numbers are not available, anecdotally we know that adult and youth currently need assistance with transportation to and from treatment. With the high cost of gasoline, these numbers will continue to rise. Description of Service: Individuals currently in the mental health and/or chemical dependency system would be identified by their counselor or case manager. The counselor or case manager would provide referral information to a Human Services Department Recovery Support Specialist. Assistance would average $50 per month per recipient and be provided in either the form of a bus passes that would provide transportation throughout the county or a gas voucher. A provision for volunteer transportation reimbursement will also be considered. Target Population: Adult and youth currently participating in mental health and/or chemical dependency treatment programs without reliable transportation to allow them to access these services. Program Goals: Increased access to and participation in treatment programs Performance Measurements: (outputs, outcomes) 200 individuals able to access treatment programs due to transportation assistance Outcomes include improved rate of treatment attendance and completion Service Delivery Information: This service could be provided within the Human Services Department by existing staff. Staff will need to work with gas stations to ensure their participation and willingness to accept vouchers. It is recommended that Project Self-Sufficiency be used as a model for service delivery. Partnerships: Human Services Department, gas stations, transit agencies, treatment providers, other community stakeholders


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Specific Activities Estimated Cost Client transportation support only – estimate $120,000

Other funding used to support this program: To be determined Implementation: Project planning and overall implementation timeline Program policies and procedures developed Human Services Department, using the Project Self-Sufficiency model, establishes participation agreements with gas stations within the county Human Services Department secure bus passes Staff trained Estimated date for services to clients to begin Strategy Evaluation Process to begin


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Programs Addressing Youth Strategy 1-PAY Strategy Title: Intervention Specialist in Schools Documentation of Need: Though progress is being seen in the Healthy Youth Surveys, alcohol and drug use among youth in Snohomish County must continue to be addressed. While the need for intervention services to assist youth in accessing chemical dependency assessment and treatment remains high, state and federal funding for these services continue to diminish. It is estimated by the Federal Community Based Substance Abuse Treatment (CSAT) office that 8.2% of youth abuse or are addicted to alcohol or other drugs. Given the approximate population of 56,417 high school, middle school and alternative school students in Snohomish County, 8.2% equals 4,626 students that county benefit from intervention services. According to a 2002 report by the Substance Abuse and Mental Health Services Administration (SAMHSA), substance abuse can be linked to untreated mental illness as 43% of children how use mental health services also have a substance abuse disorder. Youth who fail at school are much more likely to end up on public assistance and involved in the criminal justice system. Description of Service: This proposal would result in the addition of 10 Intervention Specialists within Snohomish County schools whose locations would be based upon greatest need as identified by the most recent Healthy Youth Survey. Services would be subcontracted to local youth treatment providers. School districts would provide confidential space for intervention and treatment services, as well as assisting in identifying and referring youth thought to be abusing or addicted to alcohol and other drugs and/or with a mental or emotional disorder. This linkage would result in moving youth treatment services into outlying areas of the county, providing greater access for youth. Target Population: This program would serve youth in the 36 middle schools, 16 high schools and 28 alternative schools in Snohomish County. Program Goals: Increased access for youth to mental health and/or chemical dependency intervention and treatment Performance Measurements: (outputs, outcomes) Serve 4,626 annually throughout Snohomish County Outcomes include reduced risk of youth developing mental and emotional illnesses and substance abuse, potential increase in youth graduating


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Service Delivery Information: An RFP would solicit a youth treatment provider who would recruit 10 Intervention Specialists. Intervention Specialists would be placed at schools throughout the County. Partnerships: Service provider agencies, school districts, Human Services Department, YMCA, Boys and Girls Clubs, Community Mobilization Financial Data: Financial information is from original proposal by Human Services Department. Start Up Costs:



Specific Activities Estimated Cost Intervention Specialists only $700,000

Other funding used to support this program: To be determined Implementation: Project planning and overall implementation timeline Human Services Department staff meets with school districts to solicit participation Develop and execute memorandums of understanding with school districts Develop request for proposals Solicit requests for proposals Select provider(s) Negotiate and execute contracts Provider recruits and trains staff Estimated date for services to clients to begin Strategy Evaluation Process to begin *It is recommended that stakeholders explore potential programs to address similar needs of out of school youth.


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Programs Addressing Youth Strategy 2-PAY Strategy Title: Transitional Housing for Youth in Public Mental Health and/or Chemical Dependency Treatment Documentation of Need: The 2007 Point in Time count identified 65 youth as homeless. Of those surveyed, 98% identified having a disabling condition which could include substance abuse, developmental or physical disabilities or any combination of the three. Description of Service: This proposal suggests that a facility be build or acquired that would be adequate to provide housing and supportive services to approximately 75 youth a year. Supportive services would include chemical dependency treatment, mental health counseling, life skills classes, and access to healthcare, education assistance, and job training. 1) Acquisition of an 8 bed facility serving 25 youth between 16 and 18 years of age per year in north Snohomish county and, 2) Provide 50 market rate housing vouchers for young adults between 18 and 24 years of age where tenants pay 30% of their monthly income to rent. The original proposal did address the requirements of RCW 82.14.460. The proposal will need to be revised to address those requirements. Target Population: Homeless youth between 16 and 24 in mental health and/or chemical dependency treatment Program Goals: Stabilized housing for youth in public mental health and/or chemical dependency treatment programs Performance Measurements: (outputs, outcomes) 75 youth with mental health and/or chemical dependency disorders accessing housing Outcomes include reduction of homeless youth, increased completion of treatment programs, and improved access to other community based services Service Delivery Information: The Human Services Department will solicit agencies to operate this program using a request for proposals. An agency will be selected to address the capital acquisition as well as operate the facility and voucher program. Other agencies may be contracted with to provide supportive services. Partnerships: Human Services Department, housing authorities, housing agencies, mental health and chemical dependency treatment agencies, Workforce Development Council, youth providers


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Specific Activities Estimated Cost Estimated Capital for 8 bed facility in North county $1,000,000


Specific Activities Estimated Cost Housing Vouchers $300,000 Support Services $600,000 Operating Costs – if any To be determined

Total Annual Costs $900,000 Plus operating Other funding used to support this program: There are a number of federal, state and local funding options for housing vouchers, including Everyone at Home recording fee revenues specifically targeting homelessness. Implementation: Project planning and overall implementation timeline This proposal is in process and needs to be completed prior to implementation. There was no cost proposal for operating an 8 bed facility included in the original proposal. Other revenue sources also need to be explored that are specifically for addressing the needs of homeless youth. This funding cannot supplant other funding. Capital: Find and acquire site Address licensing and health issues Build or remodel Furnish Operations: Contract with agency to operate facility and manage voucher and support services Estimated date for services to clients to begin Strategy Evaluation Process to begin


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Programs Addressing Youth Strategy 3-PAY Strategy Title: Multi-systemic Therapy (MST) Provider Documentation of Need: There is a need for Evidence Based Programs (EBP’s) that are intended to serve at-risk youth and families in Snohomish County. MST targets chronic, violent or substance-abusing juvenile offenders at risk of out of home placement and further criminal behaviors. According to the Washington State Institute for Public Policy (WSIPP), there are a number of these best practice programs that have been deemed cost effective and a) reduce the future need for prison beds, b) save money for state and local taxpayers, and c) contribute to lower crime rates. Snohomish County currently offers several research based interventions approved by WSIPP including: Functional Family Therapy (FFT), Aggression Replacement Training (ART) and Coordination of Services (COS). These programs have also been very cost effective at reducing recidivism. However, the current interventions do not necessarily serve the requirements of the most high risk youth in our community. MST is an addition EBP that has been considered to be a cost effective intervention for youth that are at high risk to be criminally involved (see research related MST issues at www.mstservcies.com). The report based on results queried form the Assessments. Com showed that 242 youth in Snohomish County were eligible for the MST during 2007. Description of Service: The high risk youth and families in Snohomish County are in need of services that address serious behavioral disorders that persist despite current interventions and efforts. MST is a family, in home based treatment designed to change how youth function in school, at home and in their neighborhood. This model promotes positive social behavior while decreasing anti-social behaviors. The MST home-based model of service delivery requires therapists to carry small caseloads (4-6 families). The therapists are available 24hours per day, 7 days a week. The in home service makes the program convenient for the family. The average length of treatment is up to 60 hours of contact provided over a four month period. MST therapists team up with the parents and develop a support system by using identified strengths. The treatment team consists of three MST-trained counselors who receive clinical supervision from an experienced MST-trained mental health professional. MST would offer the very real prospect of reducing criminal conduct when put into practice by a qualified contracted provider.


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Target Population: MST targets chronic, violent or substance-abusing juvenile offenders at risk of out of home placement and further criminal behaviors. These youth are ages 10 to 18 years of age and would have at least four months of community supervisor imposed by a Snohomish County Superior Court Judge. Snohomish County Juvenile Court involved youth would be deemed appropriate for MST services after scoring out as “high risk” with a score for 8 or above in current living situation on the Assessments.com full risk assessment. Youth that score out could be referred from Snohomish County Juvenile Court’s Recovery Services, Supervision Services or the Juvenile Drug Court programs. Program Goals: Provide interventions that address the needs of the most high risk youth in Snohomish County Performance Measurements: (outputs, outcomes) Serve 15 families a year per full time therapist Outcomes include reduced involvement in the criminal justice system, increased positive social behaviors, increased school participation, prevention of out of home placements Service Delivery Information: The MST provider will deliver services to 15 families each year for each full time therapist. They will work with Snohomish County Juvenile Court, MST services and the local contracted systems provider to maintain the highest quality assurance possible. Partnerships: Snohomish County Juvenile Court, youth mental health treatment providers, Human Services Department, other interested parties Financial Data: As indicated in the WSIPP October 2006 report, program effectiveness is dependent on fidelity to the MST model. Competent training and program support is crucial to the implementation of the MST program, adding to the start up cost. However, after the first year, cost per youth in the program drops significantly. Additionally, increasing the number of youth served with a three person team reduces cost per youth substantially. It is likely that these costs would be further reduced with supplemental funding through Medicaid for some youth. Start up Costs: Based on 2 MST therapists (30 youth)

Specific Activities Estimated Cost MST training $13,750


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Annual Ongoing Costs: Specific Activities Estimated Cost

Program Support $26,000 MST Data collection services $5,000 MST services provided $233,375 Admin Overhead (limited to 5%) $13,220

Total Annual Costs $277,595 Start up Costs: Based on 3 MST therapists (42 youth)

Specific Activities Estimated Cost MST training $15,250


Specific Activities Estimated Cost Program Support $26,000 MST Data collection services $5,000 MST services provided $283,375 Admin Overhead (limited to 5%) $15,720

Total Annual Costs $330,095 Other funding used to support this program: To be determined by planning process. Implementation: Project planning and overall implementation timeline The MST provider would hire and send MST therapists to a five day orientation training through the University of Washington School of Medicine or MST Services of Charleston, South Caroline. Quarterly booster sessions and weekly telephone consultation are also required to maintain program fidelity. Typical start up of MST can range form 3 to 6 months. By addressing multiple systems, the intervention can make longer lasting changes for youth and their families. Strategy Evaluation Process to begin


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Programs Addressing Youth Strategy 4-PAY Strategy Title: Community Team for Children Documentation of Need: There are children whose needs are not being met through existing systems or funding mechanisms. These children are referred to as “falling through the cracks” and are at risk for livelong dysfunction, chronic illness, poverty and failure if intervention is not provided. The Community Team for Children is currently without funding and unable to serve these children and their families. It is estimated that up to 100 children and their families could be served annually. Description of Service: Community Team is comprised of key administrators of child and youth service organizations, child and youth advocates, parents and businesses. In addition to providing financial resources to clients, members support the development, or preservation, of Child and Family Teams that wrap necessary services and supports around children and families to provide a comprehensive continuum of care. Target Population: High risk children and youth and their families Program Goals: Increase the number of high risk children who are able to remain in or return home to a non-restrictive family setting, provide family support and services to help stabilize families with high risk children, identify and address system barriers, and assist families in finding natural supports and alternative funding sources for services when traditional sources are not available. Performance Measurements: (outputs, outcomes) 100 high risk children and their families served Outcomes include increased family stability and self-sufficiency, building self-esteem and success in the most vulnerable of youth, and providing access to services and resources for the most acute cases in Snohomish County. Service Delivery Information: Program coordination will be provided by staff within the Human Services Department. Partnerships: Human Services Department, Department of Social and Health Services, Division of Children and Family Services, juvenile justice system, children and youth service provider agencies, law enforcement


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Specific Activities Estimated Cost Recruitment of 1.0 FTE To be determined


Specific Activities Estimated Cost Staffing $83,400 Client Support $200,000

Total Annual Costs $283,400 Other funding used to support this program: To be determined Implementation: Project planning and overall implementation timeline Recruit and train staff Estimated date for services to clients to begin Strategy Evaluation Process to begin


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Programs Addressing Youth Strategy 5-PAY Strategy Title: Youth Center Including Respite Beds Documentation of Need: Families who need to access multiple support systems are often expected to participate in a variety of services necessitating multiple appointments each week. Lack of transportation, limited benefits, limited organizational skills, and time constraints can negatively impact a family’s ability to effectively manage all these expectations. Children and families can benefit from having a single point of contact with many agencies in one place, and appropriate referrals can be facilitated between and among programs on site. The aim of the program would be to provide an array of services working together to prevent the need for juvenile justice or childe welfare custody, or residential or other out of home placements with the goal of keeping the child at home with the child’s own family, when possible. Description of Service: A child and family community resource center is a one-stop facility that houses a variety of social service agencies; including, but not limited to, mental health, substance abuse, child welfare, juvenile justice, and education. Case managers at the Center would assess the child’s psychological, educational, and functional needs, determine appropriate services and placements, make referrals, provide some direct counseling services, and determine how services would be funded. With a respite bed component, costs would depend upon the number of beds that would be available. Six respite beds at $250/day = $550,000. An additional $250,000 would be needed for 2 FTE Mental Health Professionals to provide assessments, evaluations and administrative support. These staff could be within the Human Services Department or with a local mental health treatment provider. Rent/lease of property for approximately 20,000 square feet at $18/sq ft (market rate value) = $360,000. Target Population: This strategy would service children, youth and families in crisis, or who are in need of assistance in identifying and accessing services available to them, or who are in need of multiple system services to address complex needs. They could either self-refer to the program or be referred from various social service agencies, including mental health, substance abuse, child welfare, juvenile justice and education. Program Goals: Increase access to services, programs and resources for youth and their families, especially those dealing with mental health and/or chemical dependency issues


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Performance Measurements: (outputs, outcomes) Number of youth and families accessing mental health and/or chemical dependency services – to be determined Outcomes include youth and families accessing appropriate services in a timely manner, reduction in youth mental and emotional health issues and substance abuse. Service Delivery Information: This program will need further refining prior to implementation to determine the feasibility of the original plan and ensure it’s allowability under the law. It is recommended this strategy be developed with the Youth Crisis Stabilization Unit/Triage Center as a component of this proposal. It is also recommended that stakeholders explore the possibility of housing it with Dawson’s Place and potentially have a transportation component for youth. Partnerships: Human Services Department, Juvenile Court, mental health providers, chemical dependency providers, Division of Child and Family Services, Facilities Department, Dawson’s Place, other community stakeholders Financial Data: Further planning is necessary to determine the feasibility of this strategy. A cost estimate is for planning purposes only. Financial information is from original proposal by Human Services Department. Start Up Costs:



Specific Activities Estimated Cost Respite Beds $550,000 Mental Health Professionals $250,000 Rental/Lease of space $360,000

Total Annual Cost $1,160,000 Other funding used to support this program: To be determined Implementation: Project planning and overall implementation timeline Bring stakeholders together to conduct a feasibility study including allowability under RCW 82.14.460, linkages to other systems, integration with Youth Crisis Stabilization Unit/Triage Center (9-DOTC), Youth Outreach (6-PAY) and Dawson’s Place.


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Programs Addressing Youth Strategy 6-PAY Strategy Title: Youth Outreach Documentation of Need: Research shows that children in families with issues related to chemical dependency, mental illness, domestic violence or incarceration may experience trauma in ways similar to child abuse and neglect. These Adverse Childhood Experiences result in multiple problems as children grow into adolescence and adulthood, but no services focus on this population in any consistent way. Description of Service: Screening, assessment and referral services for children of parents involved in chemical dependency and/or mental health, domestic violence or criminal justice systems. Target Population: Children of families in crisis Program Goals: Timely screening, assessment and referral to treatment for children in families with chemical dependency, mental illness, domestic violence or incarceration Performance Measurements: (outputs, outcomes) 1,000 children and their families annually Outcomes include early assessment, improved access to services Service Delivery Information: This service could be supplied by a service provider or staff of the Human Services Department may conduct the screening. An RFP process will be used to award funding if the work is to be done by a service provider. Partnerships: Human Services Department, Department of Social and Health Services, Division of Children and Family Services, local service provider agencies, Financial Data: Financial information is form original proposal by Human Services Department. Start Up Costs:

Specific Activities Estimated Cost


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Annual Ongoing Costs: Specific Activities Estimated Cost

Staffing Costs $250,000

Other funding used to support this program: To be determined Implementation: Project planning and overall implementation timeline Determine final program design including whether work will be done by County staff or contracted through a local youth agency Develop request for proposals Solicit RFPs Select successful proposer Negotiate and execute contract(s) Agencies recruit and train staff Estimated date for services to clients to begin Strategy Evaluation Process to begin Or Human Services Department recruits and train staff Estimated date for services to clients to begin Strategy Evaluation Process to begin


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Diversion Options and Therapeutic Courts Strategy 1-DOTC Strategy Title: Family Drug Treatment Court Documentation of Need: In 2007 there were 513 new dependency filings. It is estimated by DCFS that 90% of these filings are substance abuse related. The current structure does not address the complicating factors of mental health and/or chemical dependency disorders. Description of Service: The Family Treatment Drug Court is designed to provide intensive supervision and therapeutic services and substance abuse treatment to parents who are brought to the attention of the court through dependency actions filed by Child Protective Services in cases involving child abuse/neglect. The Family Drug Treatment Court is designed to target and treat parents who present deficiencies primarily attributable to substance abuse. The goal of FTDC is to promote and facilitate re-unification of parents and children in clean, stable, drug-free, nurturing homes where children will receive the stability and parental guidance and support they deserve, if such can be achieved. This court program institutes a combination of increased court supervision, competent substance abuse treatment, frequent monitoring, urinalysis testing and reporting, and timely provision of services. Currently, the court has approved a pilot project that is in mid-stream following the national model for drug court dependency programs. A team of professionals have attended the National Drug Court Family Drug Court Planning Program. From that point a design concept was agreed upon and we have 12 families enrolled with a target of 20. As this is a pilot project currently there is no funding given to the court for the position of program coordinator, outpatient treatment, inpatient treatment, program incentives, program support, and specialized urinalysis testing (ETG’s Tramadol etc.). At this preliminary stage we believe that the level of need for this program in the next couple of years could support a total of 50 families. There will be the need to address all staffing, program support and space issues. Target Population: The population targeted is individuals who have dependency petition status alleging abuse and neglect incapable parenting with substance abuse identified as a primary issue. Dependency petitions are entered prior to the entrance of a case into Family Drug Treatment Court. The client must be 16 years of age or older and diagnosed as needing substance abuse treatment. Program Goals: The goal of FTDC is to promote and facilitate re-unification of parents and children in clean, stable, drug-free, nurturing homes where children will receive the stability and parental guidance and support they deserve, if such can be achieved. Further goals are as follows:


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• Overcome the detrimental effects upon families resulting from substance abuse in order to expeditiously reach a plan for permanence and stability for the child

• Break the cycle of substance abuse, domestic violence and unemployment to reduce the future social and financial impacts on the families and our community

• Accelerate access to services for the child and family • Have sufficient statistics to measure success and failure • Strengthen families sobriety and recovery efforts • Be cost effective • Improve the accountability of all players in neglect/abuse cases • Reduce families reliance and reoccurrence on public assistance • Increase the awareness of parenting deficiencies and increase their skills

thereby increasing surrenders and reducing TPR trials • Reduce jail recidivism and crime in the community

Performance Measurements: (outputs, outcomes) 20 families annually, the number of participants accessing treatment will be determined on the family unit which could be a single parent, two parents and extended family depending on the case 70% of participants will earn a high school equivalency prior to graduation from the program 70% of program participates will become employed while in the program Outcomes include increased access to treatment services, improved parenting skills, and increases in substance abuse treatment completion Service Delivery Information: This program is a pilot and the Court has not had the time or resources at this time to complete a thorough assessment regarding the number of cases that could be served. Conservatively we believe that 50 slots should be planned for Family Drug Court as we find within the pilot there appears to be plenty of referrals. This will require the formalization of funding and additional resources as well as space. The staff needed would start with a Judge and court staff, enhancement of administrative staff, Drug Court Coordinator, VGAL Program Coordinator, Housing/Employment liaison. Further impacts would be for the AG, DCFS Social Worker and the revenue to support expanded treatment services at the state level. As to timelines we believe that within 6 months of receiving the funding we could be fully functional though program and court space will be an issue and needs to be addressed. As space for additional program services and courtroom availability is a longer term issue, it is recommended that this program begin with 20 slots. Any additional space needs should be addressed through the County’s Justice Center process.


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Partnerships: Snohomish County Superior Court, Attorney General, Department of Children and Family Services, Evergreen Manor Inc., Community Providers, Families, Human Services Department Financial Data: Start Up Costs:

Specific Activities Estimated Cost Space rental To be determined Equipment To be determined

Data base for outcome tracking To be determined

Total start up costs To be determined Annual Ongoing Costs:

Specific Activities Estimated Cost Drug Court Coordinator (pilot funding ends October 2008)

$65,000

Drug Court Manager (split between 4 programs) $21,250 Program Analyst (split between 4 programs) $19,000 Judicial Coordinator (split between 4 programs) $12,500 Chemical Dependency Treatment $50,000 Urinalysis $25,000 Incentives $15,000 Housing Stipend (in partnership with community providers)

$50,000

Total Annual Costs $257,750

Other funding used to support this program: There are several state, federal and local revenues that are combined to support existing drug court programs. Additionally, a grant was secured to pilot the Family Drug Court. However, this funding will soon expire.

The Court has provided the following resources: judicial time, court reporter, law clerk and administrative time, and resources in developing this pilot. DCFS has provided the program finances for the Drug Court Coordinator for 9 months of this project. The Court is working to secure the last 3 months of funding to complete the pilot. Human Services contracts the treatment resources for this program. Implementation: The family drug treatment court is the newest court program. Already we have identified major funding gaps that need to be addressed to make the program solvent. First and foremost are the coordinator positions, urinalysis testing, outpatient and inpatient treatment, housing and parenting training and support.


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It is recommended that the FDTC is initially funded for 20 slots with increased court participation, chemical dependency treatment and intensive case management in order to reunite with their children. If the parent is unable to engage in services or maintain sobriety, the court will find the best solution for the children. Once the program is up and running, further planning can be completed to determine the best way to add other services such as inpatient treatment, housing and parenting training and support. These most likely would be included in existing contracts with community based agencies. Space needs to be addressed through the County’s Justice Center initiative. Estimated date for services to clients to begin Strategy Evaluation Process to begin


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Diversion Options and Therapeutic Courts Strategy 2-DOTC Strategy Title: Adult Drug Treatment Court (C.H.A.R.T.) Expansion Documentation of Need: Criminal case filings within Snohomish County Superior Court continue to climb at the rate of 14% between 2006 and 2007. Woven within the social complexities of criminal filings is the far too common thread of drug use and addiction. Key findings of the “Arrestee Substance Abuse Study” found that use of illicit substances (including marijuana, crack or power, cocaine, opiates including heroin, and methamphetamine) remains quite high for Snohomish County arrestees. Three out of four tested positive for illicit substances, over 11% higher than in the previous study conducted in 2002-2003. Methamphetamine use is 5% higher than previously documented with one out of four arrestees testing positive. Cocaine rates were also one in four testing positive, an increase of 9% over the previously report. Noteworthy is that almost 75% of Snohomish County arrestees tested positive for illicit substances. Nearly 60% reported using illicit substances in the past 30 days. Nearly one out of three tested positive for multiple illicit substances, and almost 25% of Snohomish County arrestees reported using multiple illicit substances in the past 30 days. (See The Snohomish County Arrestee Substance Abuse (SCASA) Study Characteristics of Drug Use Among Arrestees Booked Into Snohomish County Corrections Including Comparisons to Booked Arrestees in King and Spokane Counties by Michael Gilson, Ph. D and Joe Kabel, PH. D. Looking Glass Analytics, Olympia, WA). Snohomish County is responding to this epidemic with a program that follows the research based best practices model for drug courts. Our program has been in existence since 1999 (2000). It began with a client base of 25 and has grown to 150 active clients in the program. In 2007 we reviewed our recidivism rate within those who have graduated and only 17 of 256 total C.H.A.R.T graduates had committed a new felony for a 6% recidivism rate. Given the success, growth and wide support for C.H.A.R.T. Court it has been expanded beyond the staffing capabilities of the two Drug Court Coordinators and a Program Supervisor, who oversees four drug court programs including the Family Drug Court pilot project. In recognizing the value and resource needs of drug court programs the Court has put forth budget proposals the past two years to request the resources needed for these programs. This year with the addition of the Family Drug Court pilot project administratively we are realizing a need for a different administrative structure to meet the challenges of these new therapeutic programs within our judicial court system. With additional funding we plan to designate a full-time manager dedicated to the development and operation of therapeutic courts. We believe with


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this position it will allow the court to look at the calendaring, resources and community partnerships necessary to build on each program success within a large court system. While the prosecutor acts as the gatekeeper, pursuant to defined eligibility criteria, the program is currently limited to offenders who are out of custody and voluntarily choose to enter C.H.A.R.T. Court. It would be desirable to screen otherwise eligible offenders who are in jail pending trial or disposition and transition those offenders into drug court. An inmate with a month of sobriety and a desire to overcome a history of addiction may be a better risk and/or more deserving than a first time offender who is still actively using controlled substances. Without expanding the program to consider those who are being held in jail, we are currently turning away 4 out of 5 applicants for lack of room. Adjusting for vacancies created through graduation and terminations, but not adjusting upward for population growth or growth in drug related crime or the number of defendants in jail who may be otherwise eligible, to the current “demand”, the capacity of C.H.A.R.T. Court program could expand to 750 participants. Description of Service: Drug treatment court is a special court, which handles cases involving addicted offenders through supervision and treatment instead of prosecution and incarceration. C.H.A.R.T. Court includes frequent drug testing, judicial supervision, drug/alcohol treatment, community medical/education/employment resources and the use of rewards and sanctions. The Judge has much more involvement in supervising drug court offenders than just placing an individual in a probationary or diversionary program for drug treatment. Offenders can be terminated from the program for noncompliance or given intermediate sanctions designed to gain compliance and behavioral change. Target Population: Adult offenders charged in Snohomish County with drug related felonies meeting criteria agreed upon by the C.H.A.R.T. treatment team. Program Goals: To provide intervention and treatment for offenders accepted into the C.H.A.R.T. Court who wants to make positive life changes and break their cycle of addiction. Performance Measurements: (outputs, outcomes) 75 additional participants annually 90% of participants will become gainfully employed prior to graduation from program 90% of participants will obtain their GED or high school equivalence prior to graduation from the program Outcomes include reduced recidivism, reduction in reliance on public assistance, completion of treatment program, and decreased substance abuse


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Service Delivery Information: The adult drug court service delivery is provided by a variety of community providers and partnerships. The treatment providers (Catholic Community Service and Evergreen Manor are contracted through Snohomish County Human Services. There is legal representation from the Prosecutors office and Public Defenders Association. The Court provides the Judge, courtroom staff and two Drug Court Coordinators as well as the administrative support to maintain a large drug court. As to the resource development with timelines there are many variables that must be considered given the courthouse is above capacity and there is little capacity within the court to prepare a full-fledged plan. Timelines cannot be established as there would need to be agreement as to the funding level to determine how quickly the program could be expanded. Partnerships: Snohomish County Superior Court, Snohomish County Prosecutors Officer, Office of Public Defense, Snohomish County Human Services, Snohomish Regional Narcotics Task Force, Snohomish County Sheriffs Office, local police agencies, Evergreen Manor and Catholic Community Services. Financial Data: Start Up Costs:



Specific Activities Estimated Cost Program Lead $55,000 Drug Court Manager (split between 4 programs) $21,250 Program Analyst (split between 4 programs) $19,000 Judicial Coordinator (split between 4 programs) $12,500 Chemical Dependency Treatment $100,000 Urinalysis $234,000 Mental Health consultation and treatment $100,000

Total Annual Costs $541,750 Other funding used to support this program: This program is funded with County Current Expense funding within the budgets of the Human Services Department and Superior Court. There may be federal grants that could be more obtainable with the right data tracking and administrative support.


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Implementation: Given the enormous capacity this program has to benefit Snohomish County this proposal will need to be discussed in many venues. Superior Court has very limited space capacity and as this initiative notes there will need to be consideration given to building in adequate facilities to provide these services. There is no way at this time to produce a timeline given the complexity of the issues involved. We more than welcome a discussion with stakeholders within Snohomish County to further the mission of this program. Space needs to be addressed through the County’s Justice Center initiative. Estimated date for services to clients to begin Strategy Evaluation Process to begin


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Diversion Options and Therapeutic Courts Strategy 3-DOTC

Strategy Title: Juvenile Offender Drug Treatment Court Expansion Documentation of Need: Snohomish County has a population of 671,800 that is 87.2 percent White, 1.9 percent Black, 1.5 percent Native American/Alaskan Native, 6.7 percent Asian, and 2.7 percent representing two or more races. Slightly more than 5 percent were Hispanic. Residents are spread across the county which ranges from the Puget Sound in the west to the Cascade Mountains in the east and covers an area the size of the State of Delaware. According to Washington State’s Administrative Office of the Courts data obtained from the Data Warehouse in September 2007, in 2006 Snohomish County received 5,114 law enforcement referrals for youth between the ages of 12 and 17 of which 769 (15 percent) were for drug and alcohol crimes. Criminal juvenile offender case filings within Snohomish County Superior Court continue to climb from 1,391 in 2006 to 1,774 in 2007. Of these drug and alcohol offenders, 77 percent were male and 23 percent were female with 85.0 percent being White, 4.4 percent being Black, 2.0 percent being Native American/Alaskan Native, 4.6 percent being Asian, and 4.0 being of unknown race. Local data collected from the Chemical Dependency Disposition Alternative assessments indicates that marijuana, methamphetamine, opiates and alcohol are the most commonly abused substances. This data represents the diversity of our county population and the level of need that exists within our communities for youth and family drug court services. Description of Service: According to data from the Washington State Juvenile Court Administrators Case Management Assessment Process (CMAP), approximately 50 percent of all crimes committed by juveniles involve drugs and alcohol as a contributing factor. The data further reveal the impact of drug abuse is evidenced in multiple domains of a youth’s life including school suspensions and expulsions, criminal conduct and the resulting costs of crime, increased family conflict and domestic violence, aggression, and increased strains on the juvenile justice system. The youth served under the Snohomish County Juvenile Court drug court model enter the system at different points but receive similar services regardless of the point of entry. All youth entering the juvenile criminal justice system as a result of an arrest and are evaluated utilizing the CMAP which measures the risk of re-offending based on 12 domains of a youth’s life. Through this process, a given youth is determined to be at low, moderate, or high risk and her/his level of supervision are determined based upon this assessment. All youth entering the juvenile justice system are screened for potential substance abuse issues utilizing CMAP and are then referred for a Chemical


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Dependency Disposition Alternative (CDDA) Program evaluation if appropriate. Any youth for whom treatment is indicated is considered eligible for the CDDA Program. Should the presiding Judge consider the program an appropriate alternative, the youth will sign an order to participate. The level and type of supervision and treatment services are determined using the risk levels identified through the CMAP assessment process. In instances where the Prosecuting Attorney agrees to a temporary stay of proceedings or deferred disposition, the Judge will order the youth to participate in the program’s most structured component, Juvenile Drug Court. The youth who choose to participate follow the requirements set forth by the Department of Justice research based best practices model. While this system is highly effective, there are several gaps in service delivery that continue to preclude youth from receiving services in the community that will strengthen their success. An identified issue is the youth and her/his family’s financial ability to pay for substance abuse treatment and mental health treatment. We are proposing to strengthen our current system and address these identified issues through a collaborative committed to helping youth Reenter, Reengage, and Reclaim (R3) a place in our community. Central to a case plan for many youth is the ability to become employed as a productive, taxpaying citizen of Snohomish County. It is beneficial to this population to have a comprehensive evaluation and for the court to begin the employment of the GAIN comprehensive youth global assessment. The youth in drug court would benefit from paid work experiences via the Workforce Development Council via partnerships with the Center for Career Alternatives and Sunrise Services aka Center for Trades and Careers. It is estimated that the juvenile offender drug court could serve up to 25 additional youth at any one time to total a program census of 75. Target Population: Substance abusing Juvenile Offenders ranging in age from 13-19 years of age charged with misdemeanor or felony crimes. The youth undergo an intensive drug treatment regime and must participate in the program at a minimum of one year. At the end of the year long program, the charges are dismissed. Program Goals: Goal 1: Address the needs of young offenders in Snohomish County. Method: Research evidenced based individualized case plans and treatment practices and train key staff Method: Identify further gaps in the delivery of services to young offenders Method: Research employing the Global Appraisal of Individual Needs (GAIN) Goal 2: Enhance and sustain the current infrastructure to reintegrate young offenders in communities throughout Snohomish County using the R3 process. Method: Research and employ research based assessment tools and identify primary issues confronting young offenders


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Method: Research publications to further expand the practices employed by juvenile court staff, treatment professionals, employment specialists and other partners in the R3 process. Method: Receive coaching to identify gaps in service delivery or the continuum of services provided for young offenders. Performance Measurements: (outputs, outcomes) 25 additional youth served upon review of judicial resources and Bench approval Outcomes include reduction in recidivism, decreased involvement in criminal justice system, improvement in family functioning, increase in school achievement, improved behavior, increase in positive attitudes and beliefs, increase in substance abuse treatment completion Service Delivery Information: The Court would begin hiring for the positions immediately and would expect to be fully staffed within 90 days given the recruitment and hiring process. The staff would be trained with the GAIN tool and screening would begin. Through this more thorough assessment process we believe that mental health issues will be addressed more effectively, the youths education level and deficits will be determined and the staff will have the information needed to work with parents to address underlying issues to promote the child’s’ success. Partnerships: Snohomish County Superior Court, Snohomish County Prosecutors Officer, Community Public Defenders, Regional Law Enforcement Representatives, Human Services Department, and:

• Lakeside Milam Recovery Center, a community based organization (CBO) providing alcohol and other drug treatment which includes inpatient and outpatient services;

• Catholic Community Services, a community and faith-based organization providing alcohol and other drug abuse counseling and mental health counseling;

• Compass Health, a CBO providing comprehensive mental health assessment and services and, through its wholly owned subsidiary, Cocoon House, emergency and transitional housing for youth;

• Snohomish County AmeriCorps Program, operated under the auspices of Workforce Development Council Snohomish County and providing community service and service learning opportunities;

• Everett Community College, a public educational institution providing alternative secondary education and postsecondary education;

• the Center for Career Alternatives, a CBO serving out-of-school youth through workforce investment and alternative secondary education; and

• Sunrise Services dba Community Trades and Careers, a private for profit organization which provides workforce investment and other services to adults throughout Snohomish County, specializing in services to individuals who are chemically dependent and/or disabled.


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Financial Data: Start Up Costs:



Specific Activities Estimated Cost Drug Court Manager (split between 4 programs) $21,250 Program Analyst (split between 4 programs) $19,000 Judicial Coordinator (split between 4 programs) $12,500 Chemical Dependency Treatment $200,000 Urinalysis $75,000 Mental Health consultation and treatment $100,000

Total Annual Costs $427,750 Other funding used to support this program: Other funding used to support this program includes County Current Expense within the Superior Court budget, CDDA dollars from the state and CTED grant funds. There may be federal grants that could be more obtainable with the right data tracking and administrative support. Implementation: Juvenile Offender Drug Court has a history of partnerships that are well established and the community providers are eager to join in this effort. Over the years there have been many hours spent trying to develop a funding mechanism that would provide these services. However given the current budgetary climate, these projects remain unfunded. The Court would begin the hiring process immediately for the staff and would expect program services to be implemented before 6 months. Any space issues to be addressed as part of the County’s Justice Center initiative. Amend contracts with existing agencies Estimated date for services to clients to begin Strategy Evaluation Process to begin


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Diversion Options and Therapeutic Courts Strategy 4-DOTC Strategy Title: At Risk Youth Drug Treatment Court Expansion Documentation of Need: In 2007 there were 343 At Risk Youth Petition filings and 28 Chins petition filings. It is estimated that 75 % of these cases have drug and alcohol involvement. Description of Service: The At Risk Youth Drug Treatment Court program combines substance abuse treatment and intensive supervision by a Superior Court Judge to eligible drug and alcohol involved At Risk Youth (ARY) and their parents. ARY drug court places youth in appropriate levels of treatment determined by a drug and alcohol evaluation. This treatment may consist of inpatient followed by outpatient services, individual and family mental health counseling. A parent education group addresses the special challenges this population experiences and is facilitated by a mental health specialist. This group is held every Friday and parents are required to attend. Youth are expected to attend treatment and school during the week and treatment provides weekly treatment reports and recommendations to the entire drug court team. The youth are expected to call a random UA line daily to see if they need to provide a UA at their treatment facility. The school/employment liaison (shared by the offender juvenile drug court) gathers school records, helps youth enroll in appropriate programs and prepare resumes and apply for jobs. The treatment, school and employment reports are reviewed weekly and sanctions and/or incentives are distributed to increase accountability and promote positive behavior. The goals of the program are to reduce substance abuse, strengthen family and community relationships, enhance educational and employment skills and increase public safety. Target Population: Youth must have an active At Risk Youth Petition filed by his/her parents as defined in RCW 13.22A.031 that the child has been: a) absent from the home for more than 72 consecutive hours without parental consent; b) is beyond parental control such that the child’s behavior endangers the health, safety and welfare of the child or another person; or c) has a substance abuse problem and there are no pending criminal charges related to the substance abuse. The program can accommodate 25 youth and their families and the ages range from 13 to 17 years old. Currently there is a waiting list for families needing this program. The drug court would serve the community in an efficacious manner by increasing the capacity from 25 to 50 youth and their families. Program Goals: Enhanced public safety, strengthened community and family relationships, reduce substance abuse, strengthen the mental, emotional and social wellbeing of substance abusing youth and their families, and provide youth and their families with incentives, encouragement, support and treatment to promote positive changes in their lives.


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Performance Measurements: (outputs, outcomes) 25 more youth served annually based upon judicial resources and Bench approval Percentage of parents participating in Parenting Group – to be determined Outcomes include increased family functioning, reduction in criminal behaviors, increase in school functioning, decrease in substance abuse among participants, increased access to mental health services, increased access to chemical dependency treatment services. Service Delivery Information: ARY drug court currently contracts with two local treatment providers: Catholic Community Services, and Lakeside Milam Recovery Centers. Currently, one Juvenile Probation Counselor is dedicated full time, one School/Employment Liaison is dedicated ½ time, a Senior Probation Counselor dedicated ¼ time and the supervisor dedicated ¼ time. The capacity of the ARY drug court is 25. Our timeline would be to hire program staff within 90 days of funding and begin processing youth into services immediately. Partnerships: Snohomish County Superior Court, Lakeside Milam Recovery Centers, Catholic Community Services, Everett Community College U3, Community Schools, Center for Career Alternatives, Mill Creek Family Services, parents and youth. Financial Data: The ARY Drug Court capacity is 25 youth at this time and this proposal will provide the additional staffing and resources that are needed to serve the number of youth needing these services. Start Up Costs:



Specific Activities Estimated Cost Drug Court Manager (split between 4 programs) $21,250 Program Analyst (split between 4 programs) $19,000 Judicial Coordinator (split between 4 programs) $12,500 Chemical Dependency Treatment $50,000 Parent/Family Consultation $35,000 Urinalysis $50,000 Mental Health consultation and treatment $100,000

Total Annual Costs $285,750


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Other funding used to support this program: Other funding used to support this program includes County Current Expense funds within the Superior Court budget and Juvenile Accountability Block Grant funds. Implementation: The ARY drug court population is noted for high risk behaviors and high needs assessments. Prevalent to this population is dual diagnosis to include Oppositional Defiant Disorder, Bipolar, Attention Deficit Disorder, Depression, Intermittent Explosive Disorder and other conditions that prevent youth from being successful in standard treatment inclusive of inpatient and outpatient. While some inpatient is funded, the ARY drug court population needs inpatient funding for dual diagnosis treatment facilities. ARY drug court youth often do not do well in non dual-diagnosis treatment facilities and completion from these standard inpatient programs is minimal. It is estimated that 20 beds per year are needed for dual diagnosis treatment at the cost of $11,000 per hospitalization. There is a high demand for this program and currently a waiting list for families in Snohomish County to access these services. It is not unusual for youth to be in the program 2 years. There is not a high turnover so when a slot becomes available, it is immediately filled. The program would like to add a full time JPC to handle an additional caseload of 25 youth and families and a School/Employment Liaison dedicated at full time status. The census would thereby be at 50 instead of 25. The program is also limited in outpatient funding. Currently, there is only $5,000 per year available to fund outpatient treatment for families that are above poverty and classify as the working poor with no health insurance benefits. An increase to $125,000 for outpatient funding and unfunded urinalysis testing is being requested. There is another proposed strategy to increase outpatient mental health funding that could address this issue. At this point with Juvenile ARY Drug Court all the partners are established and the community providers are eager to join in providing the unfunded services and strengthening the success of this program. It would take the court a minimum of 6 months so that contracts can be developed and negotiated. There is no shortage of youth that can benefit from these services and this program is a unique model working with a population of youth not normally served within a drug court program. Space needs to be addressed through the County’s Justice Center initiative. Complete planning process Estimated date for services to clients to begin Strategy Evaluation Process to begin


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Diversion Options and Therapeutic Courts Strategy 5-DOTC Strategy Title: Mental Health Services in Juvenile Detention Documentation of Need: Many youth detained in the secure detention facility report behaviors and experiences that indicates a need for mental health treatment. In some cases, youth exhibit poor coping skills; in others the environment exacerbates an already diagnosed mental heath condition. Detained youth are administered a self-reporting Mental Health Juvenile Detention Admission Tool (DAT). Many decisions pertaining to safety and security of the youth and detention staff are based upon a youth’s response to the screening tool. In 2006, 850 juveniles were admitted into secure detention; for a total of 2,781 admissions. Youth admitted that year, ranges from 11 to 18 years of age at the time of admission, 65% were male and 35% female. Of the DATs recorded, 45% reported having spoken to someone about a mental health concern, 15% had reported having stayed overnight in a hospital for emotional or behavioral problems, and 14% had admitted to having attempted to kill themselves at least once in eh past. In 2006, a total of 1,091 mental health diagnose were reported including but no limited to: Post Traumatic Stress Disorder; Drug/Alcohol Abuse; Dependency or Overdoes; Depression; Bipolar Disorder; Psychosis; and Schizophrenia. Description of Service: This proposal will add one full time mental health professional to provide direct client services. Services would be similar to those provided by the mental health professionals at the Corrections Department. Youth whose DAT responses indicate a concern, or whose behavior is of a concern, will be referred to this individual for additional mental health screening. Where indicated, the MHP will provide one on one mental health counseling with the detainee in the facility and assist the family and Juvenile Probation Counselor in securing community resources for the youth after their release. Target Population: The project will serve all youth in detention who are identified by their DAT responses as having a mental health diagnosis or a high prevalence of destructive coping skills; as well as any youth in detention who is having difficulty coping with their environment. Program Goals: Provide adequate services to youth in detention with mental health and/or emotional disorders


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Performance Measurements: Provide appropriate mental health services for 250 youth annually Outcomes include increased access to mental health services, potential increase in safety for others in facility, potential decreased involvement in criminal justice system Service Delivery Information: This is an enhancement to existing services and could be implemented quickly using the current service provider. Partnerships: Juvenile Court, Human Services Department, mental health treatment providers, other interested parties Financial Data: Start Up Costs:



Specific Activities Estimated Cost Staffing $80,000

Other funding used to support this program: There is no other funding available to support this program at this time. Implementation: Project planning and overall implementation timeline Courts amend contract with current provider Services to begin as soon as contract is executed and funds are released Estimated date for services to clients to begin Strategy Evaluation Process to begin


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Diversion Options and Therapeutic Courts Strategy 6-DOTC Strategy Title: Mental Health Court Documentation of Need: The prevalence of individuals with mental health disorders in the criminal justice system is a nationwide problem. On any given day, an estimated 11% of inmates have a serious mental illness in our jail. Once in jail, these inmates stay longer than inmates with similar charges who are not mentally ill. Mental health court is an effective tool for engaging and keeping individuals with mental illness in community based treatment. At the current time, Snohomish County does not have a mental health court. Several other counties across the state, including King and Skagit operate successful mental health courts. Description of Service: A mental health court must have sufficient judicial, public defender and prosecutor staff to accommodate new court case loads, along with sufficient probation staff to monitor clients in terms of court compliance. Other components could include a mental health professional and a peer support specialist as part of the mental health court team. Target Population: Adult misdemeanants with serious mental illness who volunteer to participate in a mental health court program through an “opt-in” process. Program Goals: To provide intervention and treatment for offenders with mental health disorders who wants to make positive life changes. Performance Measurements: (outputs, outcomes) Estimated number of persons served to be determined by final planning process Outcomes include decreased future criminal justice involvement, increased client stability and coping strategies. Service Delivery Information: A lot of work has been done in recent years to determine if a mental health court, located in district court, would be appropriate for Snohomish County. Community stakeholders requested the county look at forming a mental health court as a future consideration of this funding source. Partnerships: Corrections, Human Services Department, District Court, Prosecuting Attorney’s Office, Office of Public Defense, mental health treatment agencies


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Financial Data: There is no current financial data available. Costs would be determined by the number of participants. Start Up Costs:




Other funding used to support this program: Other funding to be determined Implementation: Project planning and overall implementation timeline It is recommended that the identified partners and other interested stakeholders meet to explore the feasibility of a mental health court in Snohomish County, either as a stand alone court or a component of an existing court such as drug court.


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Diversion Options and Therapeutic Courts Strategy 7-DOTC Strategy Title: Crisis Intervention Team (CIT) Training for Snohomish County Sheriff, Municipal Police Officers and other first responder personnel Documentation of Need: Responding to a situation where the individuals’ behaviors are a result of mental illness and/or chemical dependency is a major challenge for deputies, police officers and other first responders. Crisis Intervention Team training equips deputies and other first responders with the training needed to enable them to respond most effectively to individuals in crisis and to help these individuals access the most appropriate and least restrictive services while preserving public safety. Description of Service: Research has shown crisis response training to be effective in improving response to individuals with mental illness and/or chemical dependency, increasing the use of mental health referrals, reducing the number of individuals with mental illness from going to jail, and reducing injury rates to both responders and individuals with mental illness and/or a chemical dependency issue. The Seattle Police Department has a successful, nationally recognized program that could be replicated in Snohomish County. Clark and Yakima Counties also have successful programs. The current Marysville Police Chief established a successful CIT program in his former jurisdiction and would be a likely source for help and advice in pulling together such a program in Snohomish County. For a more in-depth look at the possibilities of such a program, a review of the Memphis, TN. Police Dept. website would be useful. Target Population: Law enforcement, emergency medical, first responders, and jail staff. Future participants could include the entire range of law & justice and human services individuals who are periodically involved in crisis situations involving mentally ill and/or chemically dependent individuals and who would benefit from the training. Program Goals: To increase the knowledge and skills of law enforcement and other emergency workers in responding to calls involving individuals who may be affected by mental illness and/or chemical dependency. Performance Measurements: (outputs, outcomes) The County should set as an overarching goal to provide Crisis Intervention Team training for every first responder in Snohomish County; training first for those first responders already on-board and then to set up such training for each new/replacement individual as they enter service in the County. Each 40 hour class should attempt to optimize student performance by limiting class sizes to no less than 15 and no more than 25 participants. Training will result in increased safety for first responders as well as individuals in crisis. Outcomes will include first trained first


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responders with increased knowledge and skills to successfully manage situations with persons in crisis. Service Delivery Information: It is recommended that the Sheriff and the Human Services Department jointly explore successful programs in other jurisdictions and develop a plan to replicate them in Snohomish County. It is anticipated that a single agency could provide the training. The National Alliance on Mental Illness (NAMI) of Snohomish County would be a good resource for information on this program as NAMI has been involved with CIT Training nationally and with state and local programs all over the U.S., including often taking the lead in assisting law enforcement jurisdictions in establishing such programs. Partnerships: Snohomish County Sheriff’s Office, Snohomish Regional Drug Task Force, Snohomish County Human Services, municipal police departments, mental health and chemical dependency service providers, corrections personnel, county designated mental health professionals, all first responder agencies and non-profit organizations such as the National Alliance on Mental Illness, consumer groups and area family members who may play important parts in helping to pull the training together and also may actively participate in the training itself. It is strongly recommended that the whole effort be coordinated by a member of the law enforcement community; a lesson learned from other programs is that there tends to be better participation and cooperation if the CIT training coordinator is from the law enforcement community. Financial Data: Funding will depend on the type of program selected, staffing needs and the number of individuals trained annually. Training estimates based upon experience in other Washington State programs of costs associated with a 40 hour program for about 15-25 people – an average of $300 per person. It does not include the cost of back-fill/backup cost of providing work coverage for attendees at the training. Start Up Costs:



Specific Activities Estimated Cost Annual Training Activities – estimate only $100,000 Program Coordinator costs- estimate only $100,000 Backfill Overtime costs – unknown at this time To be determined

Total Annual Costs $200,000 Other funding used to support this program: To be determined


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Implementation: Project planning and overall implementation timeline Project planning and overall implementation timelines, procurement of providers, class trainers, service start dates, etc., are all part of the process of developing this training program. The Snohomish County Sheriff’s Office and Snohomish County Human Services Department, aided by others knowledgeable in CIT training (such as the Marysville Police Chief and NAMI Snohomish County) will explore successful programs in other jurisdictions in pulling Snohomish County’s program(s) together. There is a national crisis intervention training conference in November 2008 that would help with the planning process. Links include www.cit.memphis.edu/2008conf.html and www.namiga.org. Potential benchmarks: Determine other first responders interested in training, including city police, fire departments, etc. Appropriate program selected Determine internal staff needs Recruit and Train Develop Request for Proposals Solicit Request for Proposals Select successful proposal Negotiate and execute contract Estimated date for services to clients to begin Strategy Evaluation Process to begin


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Diversion Options and Therapeutic Courts Strategy 8-DOTC Strategy Title: Adult Crisis Stabilization Unit/Triage Center Documentation of Need: Hospital emergency rooms are overcrowded with individuals waiting for mental health and/or chemical dependency assessments and placement dispositions. Many times, individuals who have been assessed as needing involuntary commitment have had to stay in emergency rooms waiting for admission to an involuntary inpatient unit. First responders spend an inordinate amount of time waiting in emergency rooms, a situation that may lead them to find quicker alternatives, including jail. On average, an estimated 11% of inmates in jail have a serious mental illness and 74% have chemical dependency issues. Diverting individuals from the jail, when appropriate based on the nature of the criminal offence and potential public safety risk, not only reduces costs for hospitals and jails, but also provides more appropriate and humane care. The creation of a crisis stabilization unit/adult triage would give law enforcement options for diverting individuals who are in crisis due to mental illness and/or chemical dependency issues from jails and hospitals. Based upon 2007 bookings in the County jail, 47 bookings per month may be eligible to be diverted. Description of Service: Screening, assessment, referral, social Detox and crisis respite services 24 hours a day, 7 days a week, will be offered in this newly created facility. In conjunction with community partners, a facility would be established and staffed to accept temporary residents in distress due to mental illness and/or chemical dependency. Assessment and referral would be completed during their stay in order to connect them to ongoing treatment. This program is designed to mitigate unnecessary costs to the Criminal Justice System and to place troubled adults in the appropriate facility initially, instead of jail. The exact criteria will be established by a planning process lead by the Corrections Department and including the Human Services Department, community agencies, and law enforcement and justice stakeholders. It is recommended to model this strategy on the work done by Yakima County. Target Population: Adults in crisis from mental illness and/or chemical dependency, particularly those contacted by law enforcement that might otherwise be arrested for minor crimes and taken to a hospital emergency room or to jail Program Goals: Reduced admissions to hospitals and jails and increased likelihood of provision of needed mental health and/or chemical dependency treatment and services.


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Performance Measurements: (outputs, outcomes) Estimated number of admissions – to be determined Outcomes include linkage of individuals admitted to needed treatment and services, reduced admissions to hospital emergency rooms and jails Service Delivery Information: Final planning has not been completed at this time. However, Snohomish County Corrections has done extensive work on this issue including a visit to the triage center in Yakima. It is recommended that Snohomish County Corrections take a leadership role for this strategy. Partnerships: Snohomish County Corrections, Snohomish County Sheriff’s Office, hospital emergency rooms, city police officers, Human Services Department, Facilities Department, EMT, 9-1-1 dispatchers, Prosecuting Attorney’s Office, District and Superior Courts Financial Data: Funding will depend on the type of program selected, staffing needs and facility costs. Financial information is from original proposal by Human Services Department and is provided as a rough estimate only. It is anticipated that actual costs will be higher. Start Up Costs:

Specific Activities Estimated Cost Lease/build $2,000,000


Specific Activities Estimated Cost Operating Costs $1,000,000

Other funding used to support this program: To be determined by the planning process. Implementation: Project planning and overall implementation timeline Building on the work by Snohomish County Corrections: Identification of stakeholders Initial planning meeting of stakeholders to outline planning process Monthly planning meeting of stakeholders Review and assessment of established, successful triage units in other jurisdictions Facility Planning – location, building, etc. Development of policies and procedures Determine crisis teams Develop and issue requests for proposals


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Phase in: facility lease or purchase, remodel or build Selection of contractor Recruitment of staff Staff training Estimated date for services to clients to begin Strategy Evaluation Process to begin


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Diversion Options and Therapeutic Courts Strategy 9-DOTC Strategy Title: Youth Crisis Stabilization Unit/Triage Center Documentation of Need: Law enforcement personnel frequently encounter youth in crisis but are unsure of the nature of presenting issues and appropriate placement options. If the youth has an apparent mental health issue, officers often transport them to a local hospital, and may need to wait until a social worker and/or Designated Crisis Responder is able to see the youth, which could take 2 to 6 hours. If the youth is acting out, he or she might be placed in local juvenile detention facilities for lack of more appropriate options, but the behavior could be related to unidentified mental health issues rather than “criminal conduct.” Mental Health and/or chemical dependency screenings and/or assessments must be conducted in safe environment to determine the best services indicated for the youth. Currently, Snohomish County has no “youth crisis drop in” facility where such assessments can be made in timely fashion. Description of Service: The center would be staffed by personnel capable of professionally evaluation youth and their needs and making appropriate referrals to resources assisting in stabilization of the mental health or other crisis. Final planning needs to be completed with all partners prior to implementation. A crisis stabilization unit could be co-located with the Youth Center and/or Dawson’s Place, depending on who is willing to partner on this effort. The Human Services Department provided two suggestions:

• Combine with the youth center strategy. It would have a separate entrance and internal facility, would be staffed 24 hours a day with technicians or aides and would draw from site providers for professional services and evaluations

• Partner with Denney and be located next to or connected to the secure CRC. There would be a sharing of resources, accessing currently unused space and enabling youth to be brought to the facility and “housed” in the crisis center instead of the secure CRC – helping g the county be in increased compliance with federal regulations of detaining youth while also providing a safe and centrally located resource.

Target Population: Youth in crisis, particularly those contacted by law enforcement Program Goals: Law enforcement will be able to link youth to appropriate services; diversion of youth with mental health and/or chemical dependency issues from initial or further law enforcement involvement


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Performance Measurements: (outputs, outcomes) Estimated number of youth admissions – to be determined in planning process Outcomes include reduced admissions to juvenile detention or hospitals Service Delivery Information: Final criteria, including community providers, suitable location, 24/7 capacity and staffing, needs to be determined by stakeholders. Partnerships: Human Services Department, Juvenile Court, mental health providers, chemical dependency providers, Division of Child and Family Services, Facilities Department, other community stakeholders Financial Data: Funding will depend on the type of program selected and staffing needs. Financial information is from original proposal by Human Services Department and only includes operating costs. Start Up Costs:



Specific Activities Estimated Cost Operating costs only $250,000

Other funding used to support this program: To be determined by planning process. Implementation: Project planning and overall implementation timeline Establish planning team to include all identified partners and stakeholders Develop program design including location, providers, etc. Develop policies and procedures Develop and issue requests for proposals Facility planning – lease, buy, remodel, build, co-locate, etc. Recruit and train staff Estimated date for services to clients to begin Strategy Evaluation Process to begin ** It is recommended that this strategy be reviewed in conjunction with strategies 5-PAY and 6-PAY to determine if they can be combined into one strategy.


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Housing Services Strategy 1-HS Strategy Title: Housing Options for Individuals in the Public Funded Mental Health and/or Chemical Dependency Treatment Systems Documentation of Need: On January 26, 2007, 2,666 individuals were counted as homeless during the annual “Point in Time Count.” Of those, 377 identified as having a chemical dependency disorder and 240 had a mental health disorder. Additionally, 250 were identified as chronically homeless (defined as a single adult living with a disabling condition that has been homeless for a year or experienced 4 episodes of homelessness in 3 years). Of those, 92 had a mental health disorder and 153 had a chemical dependency disorder. Individuals with access to clean and safe housing are more likely to be successful in mental health treatment and/or chemical dependency treatment, and communities realize a reduction in costs incurred by incarceration, emergency care and overall health care. It is estimated that up to 200 individuals currently in mental health and/or chemical dependency could be identified by their case managers as needing safe and clean housing. Description of Service: This proposal would provide ancillary housing support and increase the likelihood of maximum benefit from mental health therapy and/or chemical dependency treatment. Individuals currently in the mental health and/or chemical dependency system would be identified by their counselor or case manager. The counselor or case manager would provide referral information to a Human Services Department Recovery Support Specialist. The Recovery Support Specialist will assist in locating suitable clean and safe housing options, issue vouchers to cover housing costs for a limited period of time and provide accountability for the voucher system. Target Population: Adults and youth without clean and safe housing who are participating in the public funded mental health and/or chemical dependency treatment systems, including those leaving Detox, drug court participants, TANF referents and CPS involved treatment clients. Program Goals: Provide clean and safe housing for treatment participants Increase likelihood of maintaining stability and completing treatment. Provide linkage to other county initiatives. Performance Measurements: (outputs, outcomes) Approximately 200 individuals in the mental health and/or chemical dependency system


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Outcomes include increased completion of treatment rates, increased drug court compliance Service Delivery Information: Services will be provided by County staff. It will need to be determined if there is capacity with existing staff or if additional Recovery Support Specialists need to be hired. It is recommended that Project Self-Sufficiency be used as a model for service delivery. Partnerships: Human Services, mental health and chemical dependency providers, landlords, other community stakeholders Financial Data: Financial information is from original proposal by Human Services Department. Start Up Costs:



Specific Activities Estimated Cost Housing Options only $840,000 Additional staffing if necessary To be determined Other funding used to support this program: There is other federal, state and local funding that may be used to support this program. All funding options should be thoroughly explored prior to implementation. Implementation: Project planning and overall implementation timeline Develop program policies and procedures Determine if additional staffing is necessary If so, recruit and train Solicit participation from landlords Develop and execute participation agreements if necessary Add referral language to existing treatment provider contracts Estimated date for services to clients to begin Strategy Evaluation Process to begin


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Housing Services Strategy 2–HS Strategy Title: Rental Voucher Program for Homeless Individuals and Families with Mental Health and/or Chemical Dependency Disorders Documentation of Need: The 2007 Point in Time count identified 2,666 persons as homeless. Snohomish County’s Ten Year Plan to End Homelessness, Everyone at Home NOW provides specific recommendations for housing single adults and families with children. Of those surveyed during the county, 98% identified as having a disabling condition which could include substance abuse, developmental or physical disabilities or any combination of the three. Evidence shows that the cost of housing these vulnerable individuals far outweighs the cost of supporting their needs while living on the streets. Description of Service: Provide rental vouchers to approximately 630 homeless families over the next 8 years. The creation of a rental voucher program for homeless families will provide an immediate reduction in the number of homeless in Snohomish County. Target Population: Homeless single adults and families with children with mental health and/or chemical dependency disorders Program Goals: Provide safe and clean housing for homeless persons with mental health and/or chemical dependency disorders Performance Measurements: (outputs, outcomes) 79 rental vouchers provided annually Outcomes include reduction in homeless population Service Delivery Information: This program will be managed by a local agency. The Housing Authority of Snohomish County (HASCO) has expressed interest in managing the program and has the necessary expertise. Partnerships: Human Services Department, HASCO, homeless shelters, mental health and chemical dependency treatment agencies Financial Data: Financial information is from original proposal by Human Services Department. No information on start up or ongoing operating costs were provided.


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Start Up Costs: Specific Activities Estimated Cost

To be determined


Specific Activities Estimated Cost Rental Vouchers $1,400,000 Supportive Services $521,400

Total Annual Costs $1,921,400 Other funding used to support this program: There are recording fees such as 2163/1359 that are available for this program and noted as funding a rental voucher program in the 2008 Annual Action Plan. It has been determined that this proposal is an enhancement to the rental voucher program in the 2008 Annual Action Plan and will target persons with mental health and/or chemical dependency disorders. Implementation: Project planning and overall implementation timeline Final planning including total funding package and start up costs. Develop contract language Solicit contractor Negotiate and execute contract Agency recruits and trains staff, if necessary Estimated date for services to clients to begin Strategy Evaluation Process to begin


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Housing Services Strategy 3-HS Strategy Title: Permanent Affordable Housing for Persons with Mental Health and/or Chemical Dependency Disorders Documentation of Need: The connections between housing stability, and mental health and chemical dependency treatment are well documented. Affordable housing with support services is seen as a national and regional best practice for serving the needs of homeless people with disabilities, and is a central component of Snohomish County’s ten-year plan to end homelessness, Everyone at Home Now. That plan called for dramatic increases in the availability of permanent supportive housing for people with mental illness and chemical dependency. In 2006, the National Association of State Mental health Program Directors and the National Council of State Housing Agencies jointly signed a Memorandum of Understanding (MOU) to express their common commitment to promoting and supporting permanent supportive housing for low-income persons with mental illness.1 The MOU recognized that “affordable housing is a critical element of mental health recovery and treatment,” and “mental health treatment and recovery are critical to housing stability.” There is a large unmet need across the county for affordable, permanent housing connected to services for people with mental illness and chemical dependency. According to the 2008 statewide Mental Health Housing Action Plan, developed for the Mental Health Division, 949 mental health consumers in the North Sound RSN reported homelessness during 2005. North Sound Mental Health Administration released a 2008 Housing Plan in March 2008. It documents that at least 338 of current consumers of mental health services in Snohomish County are homeless. An additional 97 are living in an institution or corrections facility, and the residential status of 1,500 consumers is unknown. Local data suggest that the most vulnerable among the homeless, for example the chronically homeless and those incarcerated, are those most likely to have substance abuse and mental health issues. The 2007 Point in Time (PIT) Count of homeless individuals in Snohomish County found 2,666 homeless people. During the PIT Count, 192 people identified mental health issues and 359 people identified drug or alcohol use as a cause of their homelessness. 54% of the jail population, identified as homeless in the PIT Count, reported they were dealing with substance abuse issues. 55% of homeless women with children had a mental illness.

1 Available online: http://documents.csh.org/documents/communications/NCSHA-NASMHPD-MOU.pdf


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The 2008 PIT Count uncovered similar circumstances. Of the people identified as chronically homeless in the County, 136 (73%) listed substance abuse as an issue and 48 (26%) listed mental illness as an issue. Those in jail, and identified as homeless, were much more likely to have substance abuse and mental illness concerns, than the homeless who were not in jail. The 2000 Census revealed 54,000 households in Snohomish County who are housing cost-burdened. They earn less than 80% of the area median income and they pay more than 30% of their income for housing. This number has increased since 2000, due to a steep increase in housing costs and wages that have not kept pace with the increased costs. Although not all of these households have mental health and/or substance abuse issues, anecdotal information from affordable housing providers in Snohomish County points to the conclusion that a significant portion of them do. An example is the Sky Valley Chronic Homeless Housing Project, operational since July 1, 2007, which reports that 11 of the 12 households served during the first year were living with both mental illness and chemical dependency, and that stable housing has been key to addressing these issues in combination with stabilizing housing. Description of Service: A home that is safe, stable and affordable is the foundation every person needs to be a part of a community, to gain and hold stable employment or training, and to care for themselves and those entrusted in their care. People who struggle with mental health and chemical dependency issues need a stable home to be able to engage in treatment that will allow them to create economic and emotional stability for themselves and their families. The service to be provided under this strategy is the acquisition and rehabilitation or construction of rental housing that will be reserved for people who have mental health and/or chemical dependency needs. The housing will be owned and operated by non-profit organizations or housing authorities who will maintain the rent at an affordable level (no more than 30% of the household income). Mental health, chemical dependency, job training and other services will be provided for the tenants who live in the housing units. Target Population: The target population for this strategy is primarily adults with mental illness and/or chemical dependency treatment needs and their dependent children. Program Goals: The goal of this program is to provide a safe, stable and affordable home for everyone in Snohomish County who is affected by mental illness and chemical dependency treatment needs, which will enable them to successfully access treatment and other appropriate services to improve their quality of life.


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Performance Measurements: Success will be measured by the creation of new housing units dedicated for people with mental illness and/or chemical dependency needs, and the success of these tenants in maintaining their housing, accessing services and treatment, and improving their life outcomes. Specific measurable outcomes include:

• The number of new housing units created in Snohomish County that are affordable and targeted for consumers of mental health and chemical dependency services;

• The percentage of participants maintaining their housing one, two, and five years after program entry;

• The percentage of participants that voluntarily exit subsidized units for other permanent housing opportunities;

• Increased access to and utilization of needed treatment and services by participants;

• Decreased involvement in the criminal justice system; and • Increased income for tenants, through disability benefits and/or earned income,

depending on the participant’s situation. Service Delivery Information: The housing will be developed, owned and operated by non-profit organizations and/ or housing authorities that have experience in affordable housing development. Collaborations will be developed by the housing agencies with local organizations that have a history of providing successful mental health and substance abuse treatment services. An RFP process will be used to award funding. Partnerships: Many partners will be required to successfully implement this strategy. They include:

• Local non-profit housing developers • Local mental health/substance abuse services providers • Snohomish County Human Services Department • Washington State Dept. of Community, Trade and Economic Development

(CTED) • Washington State Housing Finance Commission (WSHFC)

Financial Data: There is a shortage of affordable housing in Snohomish County. The median rent countywide is $854, far too expensive for a person receiving disability income or with no income at all. Snohomish County Tomorrow recently reported that “virtually no market-rate housing [in Snohomish County] is affordable to those making 30 percent of the county’s median household income or less [about $17,100 for a single person or $24,420 for a family of four].” People with serious mental illnesses may earn far less than even that level or income. According to recent data from local providers and the Snohomish County Office of Housing, Homelessness and Community Development (OHHCD), the current average cost of developing affordable rental housing is:


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• $119,000 per unit for acquisition and rehabilitation of existing units • $262,000 per unit for new construction

The development of affordable housing requires providers to leverage substantial funds from state, federal, and private sources with relatively modest local funding. Housing Within Reach, a plan recently produced by the Housing Consortium of Everett and Snohomish County, projects that $2,000,000 per year of funding from the proposed sales tax increase will leverage over $100 million in funding for affordable housing development, and produce a total of 680 units of affordable housing for people with mental illness and/or chemical dependency over the next ten years. Start Up Costs:

Specific Activities Estimated Cost To be determined Annual Ongoing Costs:

Specific Activities Estimated Cost Housing Development $2,000,000

Other funding: Funding from the proposed sales tax increase would leverage substantial private and public funding from:

• Private investors of Low Income Housing Tax Credits and tax-exempt housing bond financing, which are administered by the Washington State Housing Finance Commission;

• Federal funding for housing for people with special needs, from the U.S. Department of Housing and Urban Development;

• State funding from the Housing Trust Fund, administered by CTED; and • Locally available housing funds, administered by OHHCD.

Implementation: The implementation of this program requires selecting nonprofit and/or housing authority partners to assemble the complete funding packages and develop housing properties that are high-quality and meet the needs of mental health and chemical dependency clients. This process requires a long time-line from initiation to actual rental of the housing units, which varies depending on funding applications, regulatory and zoning issues and construction timelines. After development is completed, these properties will remain dedicated as affordable housing for at least 40 years, as required by the funding sources. In order to ensure tenants receive appropriate and thorough mental health and chemical dependency services, housing agencies will partner with mental health providers. Housing operations staff will work with case managers and service professionals to help tenants succeed in their housing and treatment plans.


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Resources These resources were provided to the County Council and were reviewed as part of the research and development of this plan.

• RCW 82.14.460, as amended • ESSB 5763.SL • Washington State Institute of Public Policy – Criminal Justice Involvement

Among Clients Receiving Mental Health Services • Snohomish County Area Plan on Aging – 2008-2011 • Blue Ribbon Commission on Criminal Justice Final Report 2008 • Snohomish County Human Services Department Report to Blue Ribbon

Commission on Tax Initiative (including follow up responses) • 2008 North Sound Mental Health Administration Housing Plan • North Sound Mental Health Administration Strategic Plan 2006-2009 • Snohomish County Everyone At Home Now • Snohomish County 2007 Point in Time Report • Snohomish County Urban County Consortium 2008 Annual Action Plan, May

2008 • Snohomish County 2006 Community Mental Health Jail Transition Services

Report • “Mental Health Services and Needs”, League of Women’s Voters, 2004 • Whatcom County Strategic Plan for Substance Abuse 2007 • Snohomish County Strategic Plan for Substance Abuse 2007 • Snohomish County Arrestee Substance Abuse Study 2003 • Snohomish County Arrestee Substance Abuse Study 2006 • Snohomish County Arrestee Substance Abuse Study 2006-Female Supplement • Substance Abuse and Mental Health Services Administration News

January/February 2007 – Treatment for Older Adults: What Works Best • National Association for the Mentally Ill Fact Sheet, October 2007 • Department of Social and Health Services Risk and Protection Profile for

Substance Abuse Prevention in Snohomish County, December 2007 • Executive Summary Final Report – Implementing E2SSB5763 In Washington

State Counties, March 2008 • Snohomish County Geriatric Mental Health Action Plan Executive Summary

2007 • Clark County Innovative Programs • Skagit County 0.1% Sales and Use Tax for Substance Abuse and Mental

Health Utilization Report Implementation to Date, November 2007 • Island County Mental Health Initiative, 2007 • King County Mental Illness and Drug Dependency Action Plan, 2007 • Jefferson County Draft Expanded Mental Health and Substance Abuse

Treatment and Therapeutic Courts Funds, 2006


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• Department of Social and Health Services, Research and Data Analysis Division, Medical Cost Offsets Associated with Mental Health Care: A Brief Review

• Department of Social and Health Services, Research and Data Analysis Division, Frequent Emergency Room Visitors in Snohomish County Have High Rates of Alcohol or Drug Disorders and Mental Illness

• Children’s Mental Health, Washington State University, Child and Family Research Unit

• Co-Occurring Mental Health and Substance Abuse Disorders, Washington State University, The Washington Institute for Mental Illness Research and Training

• Geriatric, The Washington Institute for Mental Illness Research and Training and the University of Washington

• Oregon Department of Human Services, Addition and Mental Health Division, “Measuring Premature Mortality among Oregonians” June 2008

• North Sound Mental Health Administration, Combined NSMHA Data Reports for Counties #CR0005 (covering 2007)

• U.S. Department of Justice, Office of Justice Program, Bureau of Justice Assistance: Family Dependency Treatment Courts: Addressing Child Abuse and Neglect Cases Using the Drug Court Model, December 2007

• Addiction Professional: The Changing Face of Older-Adult Addiction, March-April 2008

• Department of Social and Health Services, Research and Data Analysis Division, Washington State Mental Health Services: Cost Offsets and Client Outcomes Fact Sheet, December 2003

• Department of Social and Health Services, Research and Data Analysis Division, Chemical Dependency Treatment Reduces Crime in Washington State, April 2004

• Department of Social and Health Services, Research and Data Analysis Division, Methadone Treatment for Opiate Addiction Lowers Health Care Costs and Reduces Arrests and Convictions, updated June 2004

• Department of Social and Health Services, Research and Data Analysis Division, Chemical Dependency Treatment Reduces Emergency Room Costs and Visits, July 2004

• National Criminal Justice Reference Services: Evaluation of the Outcomes in Three Therapeutic Courts, April 2005

• University of Washington, Division of Public Behavior Health and Justice Policy: King County Family Treatment Court Outcomes Evaluation Design, Cost Benefit Evaluation Design, August 2006

• Washington State Institute for Public Policy: Evidence-Based Treatment of Alcohol, Drug, and Mental Health Disorders: Potential Benefits, Costs, and Fiscal Impacts for Washington State, June 2006

• Washington State Institute for Public Policy: Evidence-Based Policy Options to Reduce Future Prison Construction, Criminal Justice Costs, and Crime Rates, October 2006


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• National Mental Health Association: Mental Health: Pay for Services or Pay a Greater Price

• National Alliance on Mental Illness – New York City Metro: Equal Mental Health Benefits Good for Families – AND – Good for Businesses Fact Sheet

• National Drug Court Institute: Drug Court Benefits • Washington State Screening, Brief Intervention, Referral and Treatment Project,

July 2008 Report • Snohomish County 2008 PIT Report • Whatcom County Comprehensive Behavioral Health Plan • San Juan County Staff Report on 0.1% Sales and Use Tax for Mental Health

and Chemical Dependency and Establish a Therapeutic Court, 2007 • Department of Social and Health Services News Release, April 2008 – Study

shows that paying for chemical dependency treatment improves health outcomes and saves taxpayers dollars too

• Snohomish County 2008 Budget documents

Documents

Snohomish County Mental Health and Chemical … · Mental Health and Chemical Dependency Action Plan August ... Louise Stanton-Maston, ... substance abuse is a factor in three-fourths