A Survey of Primary Health Care, Mental
Health Care and Dental Health Care in
Kitsap County – 2009-2011
By
The League of Women Voters/Kitsap
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Table of Contents
Introduction
Page 3
Primary Health Care Survey Answers
Pages 4-12
Peninsula Community Health Services Update
Pages 13 -15
Kitsap Public Health District Update
Pages 13-15
Kitsap Public Health Strategic Plan 2011-2012
Pages 16-17
Mental Health Care Survey Answers
Pages 18-26
Kitsap Mental Health Services Update
Pages 26-30
Dental Health Care Survey Answers
Pages 31-35
Additional Information:
LWVUS and LWVWA Health Positions
Page 36
Suggested Websites
Pages 36-37
Suggested Reading
Page 38
Glossary of Acronyms
Page 38
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Introduction to the LWVK Health Care Survey Project - 2011
At the annual meeting in May 2009 the League of Women Voters of Kitsap County decided to
do a survey on the adequacy and accessibility of primary health care services in Kitsap County
including mental and dental health. This is a report on that effort. We particularly want to
acknowledge Dr. Scott Linquist, Director of the Health District and his epidemiologists Beth
Lipton and Siri Kushner, and Program Manager, Health Information Resources Chris Craig ;
Barbara Malich, Director of Peninsula Community Health Services and Rochelle Doan, Director
of Development and Community Relations at Kitsap Mental Health services for their help and
guidance. Of the more than 174 contacts made, a total of 120 surveys were returned; 55 primary
health care, 46 mental health care and 19 dental health care. At the beginning of each survey
there is a breakdown of the specific categories of the responders. At the end of the primary health
care and mental health care surveys the Health District, Kitsap Mental Health Services and
Peninsula Community Health Services have provided a short summary of the status of their
services due to the funding cuts over the two year period of collecting information. Additional
information, websites and a suggested reading list is at the end of the report. Anyone wishing
more detailed information on the report may contact the League of Women Voters Kitsap.
Many thanks to those League members who helped in this effort, especially, Ann Smith, Connie
Waddington, Sue Hughes, Ann Rudnicki, Joyce Maddock, Shawn Northrup, Judy FriedbergNerf and Lucy Johnson.
The Health Committee of the League of Women Voters Kitsap
Pam Hamon, Chairman
pchamon@msn.com (360-598-3508)
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Primary Health Care
Introduction
The League of Women Voters Kitsap's health task force distributed the primary health care
survey to 77 individuals including doctors and nurses, administrators of medical services and
government agencies such as the Kitsap Public Health District (KPHD)and Department of Social
and Health Services (DSHS), Harrison Medical Center, Hospice, Planned Parenthood, Urgent
Care facilities, Peninsula Community Health Services (PCHS), Olympic Internal Medicine
Associates, and the Kitsap County Health District (KCHD). We also included representatives
from agencies such as Bainbridge Island and South Kitsap Helpline, Mary and Martha Children
and Adult Services, Holly Ridge Center, North Kitsap Fishline, United Way, fire and law
enforcement departments, school health officials, advocates for the aging, and for the homeless,
pharmacists and some members of the alternative health community. We distributed surveys to
members of the African American, Hispanic and Native American communities as well. From
these sources we received 55 responses; 11 from doctors and nurses, 7 from administrators of
local medical services, 7 from the Health District, 14 from community service agencies, 3 from
pharmacists, 3 from fire and law enforcement, 1 school counselor, and 9 from advocates or users
of the health system. Any opinions or conclusions expressed in this report solely reflect the
responses received to the survey questions, not those of the League of Women Voters.
The surveys were dispersed and collected over an 18 month period. Both Peninsula Community
Health Services and the Kitsap County Health District have experienced drastic cuts in funding
over this time period. A summary of the resulting changes for both providers is at the end of this
section of the report.
LWV Primary Health Care Survey Answers #1
1. What types of gaps, if any, do you see in primary health care for the citizens of
Kitsap County?
It is clear from the majority of responses received that lack of health care for low income
individuals and families including the uninsured and underinsured is the most significant gap in
health care in Kitsap County. Some physicians accept Medicare and Medicaid but limit the
number of these patients due to the low reimbursement rate for services. In addition there is a
shortage of family practice and internal medicine doctors. The number of these primary care
doctors has decreased due to retirement and the difficulty in recruiting replacements.
Specifically, primary care physicians are in short supply due to the low income generated for
their services compared to other specialties. (This is a national problem).Two responders noted
the lack of OB/GYN physicians especially for low income women without insurance. PCHS and
its two satellite clinics in Poulsbo and Port Orchard provide health care services to many
underserved but they are increasingly having to limit the number served due to funding cuts.
Urgent Care clinics are available in many locations in the County but there are upfront fees for
services that prove prohibitive for many. Even the small fee of $25, $15 or $10 is too much for
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some people. As a consequence an increasing number are turning to the Harrison Medical
Center Emergency Room(ER) for primary care. The ER is always available but also the most
expensive way of providing outpatient care.
Three responders particularly specified the age groups lacking access to primary care. These are
the uninsured working young adult, and a growing number of elderly. Most children seem to
have a primary care provider. Other responders addressed the lack of Spanish speaking
providers or qualified interpreters for all non-English speaking groups, the shortage of
prevention care, the need for school based clinics and the lack of access to mental health care,
dental services and vision services. Transportation was also viewed as a problem for persons
living in outlying areas of the County. Finally a few responders felt there was a need for a better
outreach effort to educate the general public on where and how to access services.
LWV Primary Health Care Survey Answers #2
2. Do you feel that all geographic areas of the county have adequate availability of
primary health care services?
Approximately half of the responders found there is sufficient coverage for those with public or
private insurance particularly in view of the current economic climate. For the most part, those
responders that found inadequate availability were responders who are directly involved in the
health care or social services systems. Noted was the lack of transportation in Kingston,
Seabeck, Hansville, Indianola, Suquamish, Port Orchard, Burley, Olalla and North Mason.
PCHS has clinics in Port Orchard and Poulsbo but access to these clinics was still difficult for
those persons living in the far south and far north because of the lack of public transportation.
Compounding the problem is the fact that rural areas are not fiscally viable areas for physicians
to locate a practice. The concentration seems to be in Bremerton and an increasing number are
locating in Silverdale. Kingston does have one full-time internal medicine doctor and another
internist who works there a couple of days a week.
Seven survey participants did not respond to this question or indicated they did not know the
answer. Some responders addressed the gap in services rather than addressing geographic
availability.
LWV Primary Health Care Survey Answers #3
3. Are there any referral specialties lacking in Kitsap County?
Eleven responders indicated that there was a shortage of rheumatology specialists in the County.
Seven participants noted a need for more OB/GYN physicians especially those that accepted
Medicaid beneficiaries. Many women go without care and consequently develop otherwise
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preventable complications. According to one respondent, there are no primary care providers
delivering babies and midwives do not have hospital privileges at Harrison Medical Center.
Five responders stated there is a lack of breast specialists and those who perform female
surgeries such as breast augmentation.
Neurological services are lacking in Kitsap County according to eight responders. Most trauma
cases have to be sent to Harborview Hospital in Seattle. This practice of referring individuals to
Harborview was not necessarily viewed as a negative as Harborview, the designated regional
trauma center, is an excellent.
A need for endocrinology specialists and a need for providers of pediatric sub specialties were
noted by seven responders and six responders respectively. Other referral shortages are
orthopedics including pediatric and spine, pain management, urology and dermatology. One
person found a need for reconstructive surgery for cleft pallet; another stated a need for providers
who treat diabetes, the developmentally disabled and one mentioned the need for services for
Fetal Alcohol Syndrome Disease. The need for inpatient services for children was noted in one
survey response.
Several responders continued to raise the concern that not enough providers accept Medicaid and
that more people need to know about PCHS 211 phone service. Eight survey participants did not
respond to this question and another eight stated they were unaware of the lack of any referral
providers.
Mental health services (psychiatric and psychology services, especially pediatric) were
mentioned by 12 respondents. These responses also included the need for parenting classes for
new mothers, substance abuse treatment for youth and domestic violence treatment specialists.
This matter is more fully discussed in the mental health services portion of this report.
LWV Primary Health Care Survey Answers #4
4. Do you feel that uninsured and underinsured patients in Kitsap County have access
to recommended primary health care prevention services and medically necessary
treatment services?
The clear answer to this question is no. First, physicians who do accept Medicaid and Medicare
must limit their numbers as the reimbursement received for services rendered is insufficient to
cover the doctors’ cost. It was noted that Washington’s Medicaid reimbursement is particularly
low. Second, the low income, uninsured and underinsured have access to PCHS but the clinic is
stretched due to funding cuts and can only accept a certain number of patients. There is also a
patient co-pay for services that many cannot afford and consequently they do not receive these
services. Many eventually end up in the ER at Harrison Medical Center often late in the
development of the problem or for non-emergent care. The need for a universal health care
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system was noted by the Director of the Kitsap Public Health District. The Group Health Home
model was praised by the Juvenile Detention responders for the coordination and provision of
services to those detainees enrolled in Group Health. The Detention Center is even contacted
when detainees need updates on their immunizations.
LWV Primary Health Care Survey Answers #5
5. What prevention approach(es) to improving health of Kitsap County residents
would you suggest and support?
For Children:
Nineteen responders stated that full funding for services at the District Public Health District
would clearly improve health care for children. The services listed as most important were well
child clinics that need to be reinstated and the continued need for low cost/free immunizations.
One respondent felt strongly that parents should not be allowed to refuse immunizations for their
children as this puts others at risk. Other services mentioned were family planning, sexually
transmitted disease testing, clinics for the homeless which provide follow-up care and public
health nurse services including home visits, parenting information and support for new mothers.
One District Health representative said the Apple Health for Kids program needs to be
maintained at current levels. The Apple Health for Kids program is Washington State’s
Children’s Health Insurance Program (S-CHIP). Another District Health employee
recommended that the standards of health plan developed by the Health District in collaboration
with other members of the community needs to be resurrected and moved forward.
The increase in child obesity was a significant concern noted by sixteen responders. Several
indicated that prevention measures such as education and support groups should be available in
weight control, exercise and nutrition. Schools should be encouraged to offer healthy lunches
and physical education programs for all students. Promoting a healthy community was another
suggestion such as having bicycle and hiking paths, safe swimming areas and sidewalks. Eating
disorders prevention was also mentioned as an important issue.
Every child in the County needs to have a primary care physician and full financial coverage for
services. Twelve responders noted the importance of prevention services for children, improving
the payment rates to physicians and better funding for PCHS as steps that would greatly improve
health care for children.
Seven recommended improving access to dental services and six responders said increasing the
availability of mental health care was important. Specifically mentioned were fluoridation of
water supplies and dental clinics in schools. Increased mental health services should include
smoking, drug and depression prevention. One person felt that every child in the County should
be tested for brain development.
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Six responders saw a need for more and better distribution of information on health care issues.
Recommended vehicles for this effort included health fairs that offer wellness checks,
information to Head Start and a list of resources provided to schools and child care centers. One
responder stated that services were available but not used and another found that special needs
children were well served.
Some participants pointed out the need for expanding family support programs including
prenatal care and parenting classes for parents of children of all ages. The need for adequate
housing was brought up by one survey participant. Schools could improve access to needed
services and provide a health care safety net for children with dysfunctional parents. Finally,
other ideas expressed were the need to provide vision care, decrease the exposure to
environmental toxins and screen all infants at birth for Fetal Alcohol Syndrome Disease.
For adults:
The major step which must be taken to improve the health care status of all Kitsap County
residents is increasing access to services. Everyone needs a medical home so they don’t resort to
the hospital ER for non-emergency services. PCHS needs to be fully funded and
Medicare/Medicaid reimbursement rates for primary care services should be increased so that
physicians are more able financially to serve this population. The State’s Basic Health Plan must
be improved and services reinstated and prescription drugs must be more affordable. One doctor
suggested that individuals should take more responsibility for his/her own health care and be
given a greater degree of control over the financing of their health care.
Nine participants noted the huge role played by the Public Health District in preventive care and
emphasizing the importance of sufficient funding to carry on the District’s effort. Basic
prevention services noted were immunizations, family planning, sexually transmitted diseases
testing, and more public health nurses for mother/child services. The District used to have
conveniently located clinics in the County but these clinics no longer exist.
Other prevention services for adults was screening for the low income residents for potential
problems such as colon, prostate and breast cancer, diabetes, hypertension, vision and dental
needs. Additionally, more classes need to be offered on weight control, nutrition, the benefits of
exercise and a healthy life style. Obesity in adults as with children needs to be more strongly
addressed according to eight responders. A suggested activity is to conduct a countywide
campaign to promote a healthy life style through proper nutrition, exercise and weight control.
More bicycle paths and side walks were also mentioned.
Other ideas pertained to improving the environment through decreased exposure to toxins, and
establishing public policies in this regard. Also mentioned were the need for advocacy services
to help people navigate the health care delivery system, increased support services especially at
more convenient hours for the working population, improved transportation and better chronic
disease management.
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Servicing persons with a mental illness in a timely manner was also noted as critical to prevent
the problem from escalating and becoming more severe. Dental care is almost non-existent for
the low income and this lack of care can be a serious barrier to those looking for employment.
The ER only prescribes antibiotics for those suffering with a dental problem. Otherwise
comprehensive dental services are available only for those who can pay or have dental insurance.
(Mental Health and Dental Services are discussed in more detail in subsequent sections of this
report.)
LWV Primary Health Care Survey Answers #6
6. Do you feel that minorities experience equal access to routine recommended
prevention services and medically necessary primary care treatment services in
Kitsap County?
Respondents were equally split on this question. Sixteen responders said that minorities are
treated equally; an additional six said specifically being in a minority group is not the issue,
being poor with no insurance is the issue. Fourteen indicated that there were many barriers which
keep minorities from accessing routine recommended prevention services and medically
necessary primary services. They listed language barriers, lack of transportation, cultural
differences, poor knowledge and education on available resources, materials written only in
English, lack of interpreters and the reluctance of some providers to use them. The Health
District coordinated with DSHS and the YWCA to serve the Hispanic community with a
program called El Centro de la Famillia but that has been discontinued due to lack of funds.
PCHS sees a slightly higher proportion of ethnic minorities compared to the percentage found in
the Kitsap population and minorities are over represented in the foster care system, in the justice
system and on poverty roles. Twelve responded that they either didn’t know or had no answer,
but did indicate in comments the need for universal health care, the need to fully fund the Health
District, and the over use of the ER. Also mentioned is the need to have health promotions
targeting the poor and assistance finding care for those on Tricare, the military health care
insurance.
LWV Primary Health Care Survey Answers #7
7. Do you feel duplication of services is a problem in Kitsap County?
According to the vast majority of participants duplication of services is not a problem. A few
mentioned prescription duplication at multiple pharmacies, too many family practice options on
Bainbridge Island and one questioned the need for two Urgent Care Clinics in Silverdale and
Bremerton. Eighteen indicated that they either did not know if there was a duplication of services
or left the question blank.
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LWV Primary Health Care Survey Answers #8
8. What do you see as the three (3) greatest strengths in Kitsap County health
services?
Kitsap County’s greatest strengths are the competence and dedication of its physicians, the
access to an ever improving Harrison Medical Center, and the work done by PCHS. These
received 16 responses each. Some particular areas of Harrison Medical Center care were
specifically listed: the nationally recognized cardiac program and the improved oncology, the ER
that serves a diverse population well and the expansion of urgent care services throughout the
county.
The Kitsap Public Health District also came up numerous times as one of the greatest strengths
with 11 responses. In addition to the safety net it offers through the clinics and the excellent
vaccine program, it provides data collection and a connection to the Washington State
Department of Health .
At least for the insured resident, the general accessibility to health care services is improving and
expanding according to eleven responders. Clinics, urgent care centers and doctors’ offices seem
to be moving into the underserved areas in the north and south. Other medical facilities were
mentioned for their contributions to a variety of medical service needs. These include KMHS, inpatient HOSPICE care, Group Health , the Naval Hospital, Frances Haddon Morgan Center (The
Center was closed this year, 2011.), the early Head Start Program 0-3, and Holly Ridge for
Children with developmental disabilities. Although reduced in service, the bus system has helped
many. The Salvation Army provides vouchers for co-pays and the Soroptomists have offered free
clinics for mammograms.
Six responders appreciate the good partnerships forged within the medical community which
leads to better access and coordination of care. One felt that there were particularly good
partnerships for children. Another responder noted the benefits of easy access to state of the art
specialty centers in Tacoma and Seattle.
LWV Primary Health Care Survey Answers #9
9. What do you think are the three (3) most important steps that could be taken to
improve health care in general in Kitsap County?
The need for all residents of Kitsap County to have access to affordable health care was the most
important step according to twenty-one respondents. This could be accomplished through free
or sliding fee scales for the low income, better insurance, more public health clinics, and funding
for other needs such as prescriptions and medical equipment. PCHS needs to be fully funded.
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The lack of access for the low income is caused by low reimbursement rates to primary care
physicians. One doctor said we need to make primary care attractive again in order to recruit
medical students to this field. As it is now, every year the paper work burdens instituted by
Medicare, Medicaid and other insurance providers “grows and grows.” Doctors spend less time
seeing patients in order to meet rising overhead costs and complete the required paperwork while
reimbursements remain flat. Kitsap needs more primary care physicians in general, however,
with the poor financial incentives, it has been difficult to recruit primary care providers here. The
county needs more nurses, as well, and one respondent noted that Olympic College should hire
more nursing educators.
Thoughts on policy changes to improve health were brought up sixteen times. At the national
level, the need for a universal health care system and support for the Health Care Reform Act
was specifically mentioned. This would, among other things, decrease the misuse of the ER,
which is the most expensive way to meet health care needs. Our provider base needs to be
broadened so that everyone has a medical home. One responder felt that the community could
work on developing creative approaches to health prevention strategies.
Furthering partnerships and building collaborative links within the health care community was
brought up several times, reducing competition. Stronger alliances would hopefully lead to
standardization of process. One doctor’s office noted the need to continue supporting shared
electronic health records, and mentioned the need for real assistance to implement it. (The
government is now assisting private offices financially for going electronic.) Another
collaborative step would be to develop a community-based chronic care management system.
Two responders specifically noted the need for geriatric care management.
There were ten responses to fully fund the KCHD. One of the District’s most important roles,
providing prevention services, has been severely reduced because of funding cuts.
There were several ideas expressed in addition to recruiting more primary care physicians to our
county. One was to have physicians and Harrison Hospital better integrate and coordinate their
delivery system; increase education given to clients at doctor’s offices; increase pediatric
specialties, and more OB/GYN physicians. Also mid-wives should be given hospital privileges.
There is also a need to promote the value of physician’s assistants and the importance of followup care.
Eleven responders suggested the need to improve outreach and education to the general public on
the health care system and where to go for services. People are often confused as to who takes
which insurance, especially Medicaid or Medicare, and where they can access the care that they
need. They know that the ER is always available. Some need comprehensive case management
to help navigate the system.
One responder felt that Harrison Medical Center needs to create more community awareness of
the variety and quality of services it provides. One wanted improved ER pediatric care at
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Harrison and still another suggested the Center consider development of a free walk-in clinic,
perhaps with medical volunteers, to keep people out of the ER.
Dental services for the low income is sorely lacking and mental health services very limited.
KMHS is the only provider for Medicaid mental health care patients and is not meeting the need.
Both dental and mental health services for the low income should be improved.
Improving medical services within our school systems was mentioned four times. Increase
funding so that school nurses could do periodic screening. School based clinics could serve the
needs in all the high schools and would go a long way to providing prevention services. It is also
critical to have continuing education in schools about the importance of routine health care.
Finally, three responders said that we need to be assured that people can get to their health care
providers by improving our transportation system.
LWV Primary Health Care Survey Answers # 10
10. Do you have other comments or concerns about health care in general in
Kitsap County?
Responders emphasized their concerns in a number of key areas: the lack of funding and
elimination of key primary preventative services to the low income due to budge cuts; the
increasing elderly population not receiving adequate care; the lack of affordable dental health
care; and the costly misuse of the ER. They also emphasized the need for more primary care
doctors, the viability of small group medical practices and the need to expand PCHS.
Education and awareness of resources county-wide was reiterated. For example, a pediatrician on
Bainbridge wanted to know more about the availability of county-wide services, especially for
adults. Besides obtainable health care, people need access to good nutrition, exercise and
personal health care knowledge. They need to be adequately educated in how to take personal
responsibility, knowing how to do basic self-care and knowing when to seek professional care.
One responder suggested increasing naturopathic and midwife services.
For those in Juvenile Detention, the incarcerated youth receive the full range of primary health
care services. The nurse looks at the patient holistically, and does triage, teaching, prevention
and observation. Attempts are made to notify primary care providers if health risks are identified.
They see a lot of diabetes and asthma in the clinic. Medicaid covers the youth that have no
private insurance.
One person noted that while health care has improved in Kitsap, with the current budget cuts and
the Basic Health Plan services reduction, the system is going to deteriorate
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The following is an update of the status of services and funding as provided by
Peninsula Community Health Services and the Kitsap Public Health District
as of November 2011.
PENINSULA COMMUNITY HEALTH SERVICES’ UPDATE ON THE CHANGES TO
PCHS DUE TO REDUCED FUNDING:
Over the past two years, during the timeframe for the assembling of the League Survey on
Health Care Access, the political climate driven by the nation’s economic trials has taken a
toll. At the start of 2009, PCHS was receiving substantial support from the State of Washington
through a direct grant (Community Health Services Grant) to support access for uncompensated
care provided to the uninsured for both medical and dental services. This was the only funding
source intended to off-set losses incurred in providing such care. Other significant losses have
included compensation for interpreter services, adult dental, and about half of PCHS enrollees
losing insurance coverage through the Washington State Basic Health Plan. We have taken cut
after cut in our Medicaid rates, and the state has never complied with federal law regarding how
the Medicaid program is administered for community health centers, in such areas of paying for
behavioral health services provided by PCHS, assuring adequate payment to cover costs, and
supporting the patients we care for with the full range of support the Medicaid program was
intended by federal statute to provide. But PCHS has NOT reduced Access to Care.
What have these cuts (and the even more onerous cuts now projected in 2011-13) meant to
PCHS?
* We shrank our dental program from 5 dentists to 2.5 dentists….but we are still seeing the same
number of patients and even more adults than before through creative changes in our scheduling
practices.
* Our rate of uninsured patients soared to nearly 42% in 2010 of our total 22,554 unduplicated
patients served—representing an increase from 26% in 2009. This is not a sustainable business
model!
* There have been many other “transformations” we have embraced---asking all staff to provide
more care for more people with fewer to share to work. (In total, over these two years we have
reduced our administrative support by 27 positions.)
The PCHS Board of Directors was faced with a dilemma in 2010. PCHS could shrink further to
survive OR to we could invest to grow into the crisis. In 2010—we decided to grow. In January,
2012, we will open another Bremerton Clinic at 2508 Wheaton Way to expand our program by
25%.
Our goals remain the same:
* To provide a patient-centered health care home for all current and future patients;
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* To provide the highest quality health care at affordable prices; and,
* To offer access to care when care is needed for the growing number of people who are having
a difficult time finding such care. We expect to see many more Medicare, TriCareWest, and
Medicaid patients as the evolution of health care continues in Kitsap County and nationwide.
The dialogue in Washington, DC and in Olympia continues to promise dire cuts in health care
funding---we need your advocacy as a caring community for support of our essential role. Please
join us by signing on as an advocate with www.saveourchcs.org; and
www.savehealthcareinwa.org. We need your voice!
PCHS has provided essential healthcare services to Kitsap County 23 years….we hope to be able
to continue for many years to come.
KITSAP PUBLIC HEALTH DISTRICT SUMMARY OF REVENUE
REDUCTIONS AND SERVICE IMPACTS
2007- 2012
Since 2007, Kitsap Public Health District (the District) has reduced staffing by 31%, from 125.9
FTEs to 86.5 FTEs. Twenty positions were eliminated between 2010 and 2011. OF these, three
management positions, the Assistant Director of Environmental Health, the Onsite Sewage
Program Manager and the Parent Child Health Program Manager, were unfilled when the
incumbents retired or left employment.
In 2007, the District made a difficult decision to close their satellite offices on Bainbridge Island,
Port Orchard and Poulsbo. They also discontinued providing health services to inmates at the
county jail--the County now contracts for jail health services with a private entity.
In 2009, the District ended the El Centro de la Famillia Program when grant funding ended and
efforts to obtain additional funds were unsuccessful. This program provided a Spanish speaking
public health nurse to assist the Hispanic speaking community in navigating the health and
social services available, but in many cases unused, because of cultural and language difficulties.
2010 revenue reductions resulted in the following 2011 program changes:
 The District was forced to terminate Access to Baby and Child Dentistry, a program
connecting high risk children to dental care.
 The state terminated Apple Health for Kids, a program that provides affordable health
insurance for low income children. In turn, the District reduced FTEs devoted to referral
and linkage for the program.
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Family Planning Outreach, school-based curriculum aimed at decreasing risky sexual
behavior, unplanned pregnancies and sexually transmitted infections, was reduced by
approximately 50%.
The state terminated Healthy Childcare Washington, a program providing free training to
childcare workers to ensure a healthy childcare environment. The District still provides
training but must charge a fee.
The District placed its Welcome Home Baby program on hold in 2011. The program
provided support through home visits by a public health nurse to new moms and
newborns. The program will be revived In January of 2012, thanks to funding from
Harrison Medical Center.
The North Kitsap High School/Spectrum School-Based Health Clinic ceased operation in
June as the District was unable to continue supplementing its limited grant funding.
The District reduced its clinical services. Immunization services were reduced from five
days to three days weekly; family planning services were reduced from four days to three
days weekly.
The Injury Prevention program was terminated.
The state eliminated most of the Tobacco Settlement Funds that had supported the
District’s tobacco prevention work. These funds were further reduced in early 2011and
are supposed to remain stable for two years at their current levels.
The Breast and Cervical Health program also received funding cuts but effort remains at
historical levels. The program is slated for additional grant reductions in 2012.
The District submitted a balanced 2012 budget to the County earlier this fall. As of this date,
funding remains insecure and dependent upon final decisions made at the Federal, State and
County level.
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Mental Health Care
Introduction
The League sent out 65 mental health care surveys to people who represented the medical,
counseling, mental health and law enforcement communities. We also reached out to the
Hispanic, Black and Native American communities and asked for input from mental health care
advocates and service users. This survey reflects the opinions of 46 responders - 3
physicians/psychologists, 3 administrators of mental health service entities, 13 counselors, 2
school nurses, 2 from juvenile detention, 1 fire district and 13 employees from a variety of
agencies working with or providing referral services for mental health patients. These agencies
include Bainbridge Island Helpline, Kitsap County Health District (KCHD), Kitsap Mental
Health Services (KMHS), Holly Ridge Center, North Kitsap Fishline, Department for Social and
Health Services (DSHS), Martha and Mary Children and Adult Services, Kitsap Community
Resources (KCR), Peninsula Community Health Services (PCHS), Kitsap Sexual Assault Center
(KSAC) and Kitsap County Drug and Alcohol Department. Other responses came from
advocates for mental health and for the homeless (5) as well as from our minority groups (3) and
religious (1) communities. Any opinions or conclusions expressed in this report solely reflect the
responses received to the survey questions, not those of the League of Women Voters.
The surveys were dispersed and collected over an 18 month period. KMHS funds have been
drastically cut over this time period and a summary of the resulting changes is at the end of this
section of the report.
LWV Mental Health Survey Answers #1
1. What type of gaps, if any, do you see in mental health care services for the citizens
of Kitsap County?
Clearly, being uninsured or underinsured is the major reason why local residents find it difficult
to access mental health service in Kitsap County according to half of our responders to this
survey. Without adequate health insurance, there are few options for low income people who
need mental health care. KMHS is the only agency in the county that has a contract with the
state to serve those on Medicaid and, with recent budget cuts, KMHS is so overstretched that
only the most severe cases meet the strict criteria to receive even limited help. Reportedly, 10
people a week have been turned away since January 2011. The KMHS Crisis Clinic is also
overwhelmed and the hospital ER, the place of last resort, provides only limited stabilization
care. The costs of medications are also prohibitive for the low income or uninsured. Kitsap
Sexual Assault Center is the only agency that provides some services for free.
The need for housing for mental health care recipients was another gap mentioned by a number
of our responders. Beds are needed for those requiring urgent care or help with co-occurring
disorders, for the elderly who are suffering from dementia, for those returning from Western
State Hospital, for those needing drug or alcohol treatment and for the chronically mentally
18
ill. They all need the stabilization that residential care provides. One responder noted that there
weren’t enough beds even at Western State Hospital and another bemoaned the fact that there no
longer was a psychiatric ward at Harrison Medical Center.
Further needs noted by our responders were the lack of many kinds of behavioral health
treatment which includes both mental health and substance abuse services in our community. At
the top of the list was the need for simultaneous treatment of both of these co-occurring
disorders. One respondent noted there was the need to reinstate medical detox which used to be
in Pierce County for those with serious addictions. Local opiate replacement therapy would help
clients who must now go out of the county daily for treatment adding greatly to escalating
costs. A South Kitsap school psychologist specified that children under 21 requiring mental
health services were being underserved. Wrap around services for children (community-based
intervention services that emphasize the strengths of the child and family and include the
delivery of coordinated, individualized services to achieve positive outcomes), prevention
services for infants and children with serious emotional behaviors and transitional services for 18
to 20 year olds are all needed in our community. Furthermore, there is a growing need for
treatment for those with autism spectrum disorders.
Lack of adequate and safe transportation for the low income is another gap in service. Most
counseling services are located in Bremerton and late afternoon appointments can leave bus
riders from Bainbridge Island or other rural areas stranded. Women and children who have
experienced domestic violence may feel too vulnerable while waiting at bus stops and need safer
transportation. Lack of child care can also keep family members from accessing mental health
services. It was suggested the KMHS collaborate more with schools to counsel children and
families on site. The Suquamish Tribe has successfully collaborated with North Kitsap School
District providing two therapists twice a week.
Education of the community including primary care physicians on how and where to access help
was mentioned several times. The lack of a well-informed community is a barrier to early
diagnosis and treatment of mental health problems. In addition, children and families would be
better served if trained mental health professionals were available in schools.
Two responders mentioned additional barriers in accessing services. One mentioned the need for
parity in insurance coverage between physical and mental health. Another expressed the
frustration families feel in being legally barred from making mental health decisions for a family
member including young teenagers 14 years of age or older.
Another barrier for the non-English speaking community is the lack of bi-lingual therapists or
interpreters. This is a particular problem for the Spanish speaking community.
At the juvenile detention facility all mental health issues are handed over to KMHS staff who
provide routine counseling and are available 24/7 for children in imminent danger to themselves
or others. Kitsap is one of two counties in the state that offer these services on site.
The long standing stigma of having a mental illness can lead to a person delaying and seeking
treatment. This is particularly true in the higher income population.
19
LWV Mental Health Survey Answers #2
2. Do you feel all parts of the county have adequate coverage for mental health
services?
For this question, 36 respondents answered that there is not adequate coverage for mental health
services for low income individuals throughout much of the county. Ten responders left this
question blank or indicated “unknown”. For those who can pay there seems to be many therapists
available. Those who must rely on KMHS services must also find their way to its Bremerton
clinic because the North Kitsap and South Kitsap satellite offices have been closed due to
funding cuts. KSAC has an office in Bremerton and Port Orchard but not on Bainbridge Island.
Because there is no bus service in Olalla, Seabeck, Hansville or Kingston, low income clients
can only rely on the “Access” bus.
Some suggestions were made to ameliorate the lack of adequate coverage. One was to staff
mental health professionals at police stations to train police personnel in answering questions
and to help answer calls. Second, was to establish school based clinics. A third suggestion was
to make transportation vouchers available so clients could access care.
LWV Mental Health Survey Answers #3
3. Are there any referrals lacking in Kitsap County? If yes, what?
The strongest response to this question is the need for more local psychiatrists, especially child
psychiatrists. Families are having to go to Seattle or Tacoma for treatment and medications
where waiting lists are long. There is a strong need for therapists who are specifically trained in
a variety of specialties and for certain support services. These include:

Providers who do Cognitive Behavior Therapy

Children’s behavioral specialists

Eating disorder treatment

Traumatic brain injury treatment

Autism spectrum treatment

Specialists to treat perpetrators of sexual abuse
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
Domestic violence and anger management therapists

Anxiety disorders and post traumatic stress disorder specialists

Suicide prevention practitioners

Youth in-patient and out-patient chemical dependency and co-occurring disorders

On going support for chronic mental illness and substance abuse

Housing resources for teens

Parenting skill workers

Psychiatric nurses

Police and emergency medical technicians (EMTs) trained in mental health
intervention
Fifteen people either did not respond, didn’t know or were unsure. Two felt there were adequate
referral services.
LWV Mental Health Survey Answers #4
4. Do you feel that low income patients and those without sufficient insurance have
good access to mental health care in Kitsap?
Our respondents believe overwhelmingly that low income patients with no or insufficient
insurance do not have good access to mental health care in Kitsap County. Six of the 46
respondents didn’t know or gave no answer.
The causes of lack of access are varied. Seven responders mentioned the lack of provider
willingness to serve these populations; seven others mentioned KMHS budget cuts forcing it to
focus only on severe cases. Others mentioned the public’s lack of awareness of services
presently available, the lack of transportation alternatives and the lack of early intervention
services.
21
LWV Mental Health Survey Answers #5.
5. What prevention approach(es) to improving the mental health of Kitsap County
residents would you suggest and support for children and for adults?
For children: Our responders suggested that the focus for prevention should be through the
schools and child care centers. There should be more community-based programs in elementary
schools to help children by teaching them social skills and stress reduction. In addition,
prevention services are needed for those children who are living in violent homes or with
caregivers unable to meet the children’s needs. Having KMHS offer services in the school would
make services more accessible, less costly and with less stigma. The KSAC said they have a very
small budget to help prevent sexual abuse and these funds are far from adequate. They would
like to work more with parents and prospective parents. Encouraging physicians and employers
to promote both healthy mental and physical life styles would be of value. Of equal value would
be educating the public and our leaders on the importance of funding mental health services.
There were also many ideas about providing better support services for children. These included
more availability of professional help within the school including drug and alcohol
interventionists and counselors who can reach out to children in distress. There also needs to be
more outside-of-school activities such as latch key programs in every school, tutoring and
mentoring programs, low cost and accessible parenting classes(some in Spanish), and more
resource information at child care centers. One responder suggested that every school be
requested to examine the “Compassionate Schools” model for learning which can be found on
the Washington Office of Superintendent of Public Instruction website. Many schools have
successfully adopted this program for improving communication and learning, especially for at
risk students. One suggested greater access to programs like the Strengthening Families Program
to help dysfunctional families. Increasing access to mental health services was also brought up
on some of our Primary Health Care surveys.
For adults: There were many prevention suggestions for improving mental health for adults.
These included better access to employee assistance programs, more community discussions like
the recent Burned Out Worker Workshop sponsored by KMHS and KCR and more classes in life
skill building, Love and Logic parenting skill classes and stress reduction. Teaching families in a
community setting about sex offender behaviors to prevent sexual abuse was also suggested.
One of these trainings was well-received at the former Westpark (Bremerton Housing
Authority). Another suggestion was offering training and education for families and
professionals about brain disorders and how people can best cope. Additionally, physicians and
employers should be encouraged to promote both healthy mental and physical life styles.
As with children, offering adult support groups, KMHS counseling and walk-in clinics located in
school settings (portables) or in local church facilities would make prevention and counseling
services for adults more easily available. It was also suggested that immediate access to mental
health services and screening at primary health care sites for moderate symptoms would prevent
22
problems from escalating. Usually patients discuss mental health care issues with their health
care provider but then don’t follow-up on mental health off site referrals. Behavioral health
services need to become fully integrated with other medical services. Better access to behavioral
health services which includes drug and alcohol treatment was also mentioned by respondents in
the Primary Health Care surveys.
LWV Mental Health Survey Answers #6
6. Do you feel minorities experience equal access to routine recommended
prevention services and medically necessary treatment services for mental health
care in Kitsap County?
Most felt that services were equal and available to all regardless of race. Poverty was a greater
problem. However, those who work with minorities or were in a minority community felt that
many minorities fail to seek mental health services because of cultural differences, language
barriers and a basic mistrust of a Caucasian dominated system that doesn’t understand their
culture. Bi-lingual therapists or a trusted interpreter are especially needed. Percentage-wise
KMHS serves more minorities than the percentage of the general population and clinics are
heavily populated with ethnic minorities, especially single mothers. Native Americans can access
services through the tribes if they elect to receive services on the reservation.
LWV Mental Health Survey Answers #7
7. Do you feel that duplication of mental health services is a problem in the county?
Of the 38 responses to this question, 26 said there is no duplication in the county. Access is the
problem. Twelve either did not know or did not answer. Other comments included 1) there are
perhaps more therapists than needed for the “unhappy well” but not enough properly trained
therapists in the area dealing with trauma or cognitive therapy, 2) there is a need to connect with
the English as a Second Language groups, and 3) often a person has to go through several
agencies to get resolution. There is a need for behavioral health counselors to be at the primary
care provider site. KMHS stated that ninety per cent of patients seeking mental health care will
do so at the primary care provider’s office where there is less stigma. Sometimes the patient can
get coverage under a physician’s reimbursement billing code that wouldn’t be available under
the mental health care system. There is lower reimbursement for intervention at the mental health
provider level than at the primary care health provider level for diagnosis.
23
LWV Mental Health Survey Answers #8
8. What do you see as the three (3) greatest strengths in Kitsap County mental
health services?
Twelve responders did not answer this question. Of those who did, fifteen recognized KMHS for
its state of the science integrated co-occurring disorder program (especially the Triage Center for
the indigent), for its support groups, its good follow-up, its residential and housing programs, its
locked inpatient program for youth and adults, its day treatment school for youth, and its
specialty team for nursing home out reach. Having therapeutic foster homes locally was also
noted. Many responders praised the quality and dedication of the people in general who work in
the mental health field in our county and stated that for those with insurance there is good access.
The coordination and cooperation among all providers (Harrison Medical Center, KMHS, PCHS,
KCHD, KSAC, etc.) was recognized as unique and appreciated. Other positives included the
county government’s commitment to the chemical dependency inpatient center for the indigent,
the primary care physicians who try to fill the empty spaces due to the absence of psychiatrists,
Bainbridge Youth Services, Kitsap Public Health District, Peninsula Community Health
Services, the call-in Crisis Clinic, the emergency services and the Naval Hospital. For the
Suquamish Tribe, their pro-active outreach program to their members is worthy of investigation
by others as a good model. Two didn’t see any strengths in the current mental health care system,
and twelve did not answer the question or didn’t have an opinion.
LWV Mental Health Survey Answers #9
9. What do you think are the three (3) most important steps that could be taken to
improve mental health care in general in Kitsap County?
There were many and varied ideas on steps that could be taken in our county to improve mental
health care. The strongest and most frequent of ideas was the need for adequate funding to
provide more access to care for all regardless of income, age and geographic location. Providing
services in the school setting, including school based clinics, could certainly make care more
accessible county-wide and probably at less cost. Education was also brought up a number of
times to help legislators and the public understand the importance and cost effectiveness of
funding for not only mental health treatments but also for prevention services.
Systems changes were also suggested such as creating and implementing a comprehensive
strategic plan for improving local mental health involving participation by all stakeholders,
clients and community members. Under this plan, the roles and duties of specific agencies,
police, schools, fire, and mental health providers would then be clarified. Hopefully this would
also result in better coordination among agencies and counties in pursuing grants to obtain more
local funding. Issues like removing the requirement of multiple duplicative audits, allowing
PCHS to be compensated for services provided outside of the RSN (Regional Support Network*)
24
system/contract, reducing the paper work burden and reducing mental health regulation
requirements were thought to be improvements that would not compromise the quality of care.
One respondent wanted to assure that all mental health professionals are adequately trained in
their specialties or, if not, be under the supervision of a professional with at least10 years of
experience in that specialty. Integrating mental health services with other medical services
would also improve quality and efficiency. These suggestions might lead to bundling services so
the whole client could be served by one team with the same treatment plan, preferably at one
location.
Other suggestions included working with employers to provide employee assistance services,
providing more affordable staff supported housing, bringing more psychiatrists, especially
child/adolescent psychiatrists, to the community, providing financial assistance for expensive
medications, publicity to reduce the stigma of having a mental illness and basically more
education and outreach to the public on how and where to access services.
*Medicaid mental health services are provided through a managed care delivery system in
Washington State.
LWV Mental Health Survey Answers #10
10. Do you have other comments or concerns about mental health care in Kitsap
County?
Most did not have any additional comments. However, there were some that wanted to
emphasize or elaborate on their concerns. Several said that we needed to increase funding for
mental health and one suggested in order to do this we need to seriously consider the 1/10th of
1% sales tax that the county can pass to go towards chemical dependency treatment, housing for
the mentally ill and mental illness prevention (such as public health nurses at the Health District.)
This means a 1 cent increase for every $10 purchase. Eighteen counties have passed this tax.
(Senate Bill 5763 authorized counties to pass such a tax in 2005. The 2007 Report stated that
Jefferson, Clallam, Clark, Island, Skagit, Okanogan, Spokane and King Counties passed the tax
initially. King was the only one that put it to a vote. Benton and Franklin put a 2 cent tax to a
vote and both failed. Whatcom, Thurston, Snohomish, San Juan, Wahkiakum passed in 2009,
Grays Harbor pass in 2010, Ferry and Lewis pass in 2011 and Walla Walla in 2012. Mason
recently passed the tax with a 2-1vote by the County Commissioners.
Having behavioral health therapists, psychiatric consultants and case managers available for
primary care providers is probably the most important thing to one respondent. Another said
there is a serious lack of medical/mental health collaboration. PCHS said they need more
therapists.
25
Two noted that we must be more creative, more thoughtful about sharing resources and more
able to put aside artificial barriers in order to overcome the greater burden of need and the
reduction in funding. One felt that presently there are poor linkages between schools and
agencies. To some therapists, the emphasis on the cumbersome process of documentation rather
than on actual treatment of the patient can be discouraging to providers and promote burn out.
Kitsap has one of the most comprehensive approaches to mental health care in the state.
However, the county just doesn’t have the capacity to treat all in need, especially children and
those of different ethnicities. Individuals with severe illness tend to die 15 to 20 years earlier
than the rest of the population. It was suggested that perhaps another agency besides KMHS
could accept Medicaid patients since KMHS is overwhelmed.
KSAC is being encouraged to adopt a treatment model called “Trauma-focused” services. There
is a concern that this model does not really meet the client’s needs because sexual abuse victims
often have other complicating problems which are not addressed in this service model.
Two respondents mentioned that our Juvenile Detention partnered with 19 other facilities in the
state to develop a Juvenile Detention Admissions Tool which has proved to be thorough and
valuable. The detention center works closely with KMHS and Kitsap Adolescent Recovery
Services for those students going through withdrawal and needing treatment.
The stigma of having a mental illness continues and sometimes discourages those in need of help
from seeking it. This is especially true for the growing number of homeless in our community
who find it an issue when looking for a job. The cutbacks in funding for the uninsured and
underinsured and the stresses on hospital emergency rooms as the only back-up, have caused
many to suffer. Even those on Medicaid and Medicare have experienced a reduction in service.
However, Kitsap County seems to be coping as best it can in providing and coordinating mental
health services. Mental health does not have parity with physical health in importance and the
two need to be more closely aligned for a more comprehensive mental and physical health care
system. Hopefully the ideas expressed in this report will be valuable to the community leaders
who are making decisions around mental health care in our community.
The following is an update of the status of services and funding for mental
health as provided by Kitsap Mental Health Services
Services Background: Kitsap Mental Health Services is a 501.c.3 non-profit organization that
serves as the designated community behavioral health service provider for Kitsap County
residents. Services are provided for adults and older adults with acute and/or chronic severe
mental illness and addictions and for youth with serious emotional disorders and their families.
The agency provides adult inpatient and outpatient services, crisis services including that of the
26
designated mental health professionals to conduct evaluations and the Crisis Line, sub-acute and
supported housing, and specialized programs such as the Community Reintegration and
employment program, the Program for Assertive Community Treatment (intensive services for
select persons living in the community), the Nursing Home Liaison program, substance use
disorders and others. Children’s programs include foster care, a day treatment school, inpatient
treatment unit, outpatient child and family services including home-based services and
community based services such as at juvenile detention and Early Head Start. The programs are
designed to provide a full continuum of care options for persons with mental disorders and to
support them in recovery.
Funding Background: Primary funding for many Community Mental Health Centers, including
KMHS comes from Medicaid and State dollars, typically about 80 – 85% of KMHS’ budget in
any given year. Medicaid funds can ONLY be used for clients who are eligible for Medicaid
Services and even some of their services are not covered. Consequently, state allocated funds
have been used to provide services for individuals without insurance who met diagnostic criteria
but who were not Medicaid-eligible. And for those services to Medicaid enrolled individuals
which Medicaid does not cover. A requirement to match federal Medicaid dollars one for one
with state dollars means some state funds must be allocated as “Medicaid-match” in order to
bring in that revenue. Some State funds are tied to specifically contracted programs such as
Multi-dimensional Treatment Foster Care, the Program for Assertive Community Treatment (incommunity supports for high intensity clients “hospital without walls”). Any reductions to either
Medicaid Funds or State Funds thus results in loss of the ability to provide services, and in some
cases, parts of or complete programs. Additionally, KMHS holds contracts to provide services
for older adults through the Area Agency on Aging, with the Children’s Administration and
School districts for children’s services, with local housing authorities to ensure persons with
serious mental illnesses are housed and in decent affordable housing and with the Department of
Developmental Disabilities and for Substance Abuse Treatment Services. The ability for these
organizations and agencies to maintain these contracts and services also are dependent on federal
and state funding.
Number of Clients Served, Staff Equivalents & Revenue & Expense by (July) Fiscal
Year
Year
FY 2007
FY 2008
FY 2009
FY 2010
FY 2011
Total Clients
5,462
5,994
6,125
5,564
5,092
0-17
18-20
1,102
279
1,220
303
1,228
347
1,076
358
1,038
159
21-59
60+
3,322
759
3,641
830
3,728
822
3,436
694
3,175
579
Full Time Staff Equivalents
321.10
308.86
294.26
277.0
261.21
Revenue Sources
Regional Support Network
76.24%
67.24%
76.88%
71.73%
By Age:
NA (pre yearly audit)
27
Intensive Children’s Services
Private Fee/Insurance
Donations
Donated for Capital Bldg
Other Contracts/Misc
Expenses
24-Hour Services (inpt/hsing)
6.86%
4.17%
1.48%
11.25%
6.61%
4.16%
1.23%
15.13%*
5.62%
7.47%
3.73%
1.2 %
5.13%**
5.59%
4.38%
5.51%
.97%
10.18%***
7.22%
NA (pre yearly audit)
32.38%
30.51%
29.88%
30.91%
Adult Services
Child & Family Services
25.57%
21.80%
20.63%
29.57%
30.56%
20.94%
30.22%
19.77%
Medical Services
Emergency Services
Older Adult Services
10.34%
6.57%
3.34%
10.45%
5.48%
3.37%
9.52%
5.47%
3.63%
9.68%
5.79%
3.64%
* Donated Property: Keller House Residential Services Center ** Capital Bldg Fundraising: KH Residential Services Center ***Capital Bldg Fundraising:
Keller House & Burwell Place
1.What KMHS cut to reduce operational and program expense since 2009
(Examples)
a. Closed Clinics:
- North Kitsap and South Kitsap offices (reduced geographic access, increased
transportation issues for clients) in FY 2010
-North Kitsap Health Clinic at Spectrum which had KMHS staff on site for early
intervention of depression, anxiety, suicide risk among youth, closed 2010 due to lack of
state funding.
b. Staff layoffs: primarily through attrition (see graph). RSN State funding reduced by
$817,453 from 7/1/10 – 6/30/11; $158,000 reduction in Kitsap County Local Medicaid
Funding as of 7/1/11.
c. Discharged over 270 clients who were not receiving Medicaid or who were not
Medicaid eligible, with referral to primary care providers following extensive chart
review ( In 2011)
d. Turn away approximately 10 people each week who meet criteria for services but who
are not Medicaid-eligible, beginning January 2011. Community services referrals made
but unknown whether person is able to access other mental health/counseling services.
e. Foster Care Program Cut. Reduction in number of emotionally distressed foster
children served due to loss of $22,000 in Division of Children and Family Services
Multi-dimensional Treatment Foster Care (7/10/10). Fifty percent reduction in the
number of foster children able to be served decreases from 10 families as in previous
years to 5 children and their families.
f. Loss of $17,198 in State 211 funding – locally, cost is absorbed into agency overall
budget – keeping line open in conjunction with Crisis Line Services creates too lean,
overextended staffing and backfilling with scarce agency funds that might otherwise be
used to directly serve clients.
28
Current Issues of Concern:
a. KMHS is monitoring the impact of potential budget cuts at the state and federal level
closely; however it is too soon to know what the impacts will actually be. We anticipate
it is too soon to discern which programs and more importantly, the number of people who
will be impacted by newly forthcoming, possible, budget cuts.
b. The agency budget for 2012 is approximately $21 million dollars. For 2012, about 88%
of KMHS budget is made up of federal and state dollars receivable through the Peninsula
Regional Support Network. Of this, 77% of KMHS’ budget reflects Federal Medicaid
funding, including the state’s match. If the state cuts its financial match of these Federal
Medicaid funds, funds to the agency are doubly reduced. For example, a theoretical 10%
cut in State Match results in an additional loss of the 10% matching Federal funds which
then becomes a 20% cut to KMHS.
c. Still to come – the potential impact of Medicaid Reimbursement Rate Reductions
following completion of a new State actuarial study; and Significant Medicaid Funding
Reductions now under congressional discussion. In additional to lowering the Medicaid
costs and Medicaid rates, the state is looking at raising the clinical threshold for care for
Medicaid enrollees to be eligible for mental health services. In a worst case scenario, if
40% of Medicaid is cut in total, KMHS could be reduced to providing only crisis and
inpatient services which are the most expensive services.
d. The Governor’s Special Session Budget Proposals, which include the possibility of
additional funding cuts for specific mental health programs, and include drastic cuts to
the provision and near elimination of drug and alcohol treatment services. For example,
currently Kitsap Recovery Center, a county facility providing detoxification and intensive
inpatient services for chemical dependency treatment also provides the county’s triage
services and serves 450 low income clients per year. This facility would be closed. State
funds also are used to contract with 7 other community based adult outpatient treatment
providers who provide outpatient treatment services for an average of 2000 low income
clients per year. KMHS provided substance abuse support and case consultation to
approximately 3,500 individuals a year - this service would be eliminated. Over 50% of
adult clients with mental health disorders have a co-occurring drug and/or alcohol
disorder, and KMHS provides a specialized treatment program for over 350 of its current
clients each year who are being treated for co-occurring disorders. This program could
be eliminated or gravely reduced if the budget proposal to reduce drug and alcohol
treatment services stand.
29
e. What KMHS now is able to offer due to all the funding cuts
KMHS will continue to provide services for individuals who meet the diagnostic criteria
set forth by the State of Washington and which are to be provided by designated
community mental health clinics, for individuals who are eligible for Medicaid. KMHS
will also provide services for individuals who fall within the criteria of State funded
programs, and which include the Program for Assertive Community Treatment program,
Intensive Children’s Services Foster Care Program, older adult services and others
specified by the state (even though these programs too may see some reduction in
numbers we will be funded to serve).
f.Other information:
a. Savings on paper are rapidly lost when out-patient mental health services are not
available. Cost-shifting from front-end out-patient services (about $80 /hr) to
more expensive Crisis & Inpatient Services (Inpatient Hospitalization Cost
$800/day for Evaluation & Treatment, $501/day for Western State Hospital ,
average 14 day stay) when maintenance treatment is not available. About 3035% of KMHS budget currently is used to provide Inpatient Hospitalization and
Residential Services. Again, in a worst case budget scenario, if 40% of
Medicaid is cut in total, KMHS could be reduced to providing only these crisis
and inpatient services.
b. Nationally, historical data shows without the provision of out-patient mental
health services, there will be increased use, expense, and burden to a
community’s Law Enforcement, Courts, Jail, Emergency Department, and
inpatient medical and psychiatric hospitalizations. Ultimately, failure to provide
out-patient mental health services simply increases the cost burden to other
community systems of care and community safety net providers.
c. The expectation for the very near future of health care is to integrate mental
health, substance use disorders, and primary care to affect both optimal health
outcomes and reduce the cost burden to individuals and society. This is not the
time to dismantle a portion of the specialized care and case management system
that will support this endeavor.
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Dental Health Care
Introduction
Our task force sent out 32 dental surveys to private dental practitioners, referral agencies,
pharmacists and government agencies who struggle to provide help for those who can’t afford to
pay for dental care. We tried to include those who work with children and the elderly, the
homeless, and local minority residents. We received 19 responses; 3 from dental care providers,
9 from government employees (Peninsula Community Health Services (PCHS), Kitsap Public
Health District (KPHD), Kitsap Community Resources (KCR)) or private agencies (North Kitsap
Fishline, Bainbridge Island Helpline, Smile Partners), 1 from a school district, 2 juvenile
correction personnel and 4 from advocates or parents of children being served by local
government programs. Many responders to the Primary Health Care survey also mentioned
needs in dental care. Any opinions or conclusions expressed in this report solely reflect the
responses received to the survey questions, not those of the League of Women Voters.
LWV Dental Health Survey Answers #1
1. What type of gaps, if any, do you see in dental health care for citizens in Kitsap
County?
Virtually all responders said there are severe gaps in dental services for the low income and those
without insurance who can not afford to pay full fare. Low income adults and many children
have few options for receiving dental care. PCHS in Bremerton provides dental care for
Medicaid children but they are at capacity and can no longer serve adults. Many adults come to
the hospital emergency room (ER) for critical care but no dental services are available, an
ongoing concern for hospital administrators. In a recent American Hospital Association survey
about ER use, dental care came to the top regarding concerns. There are very few pro-bono or
sliding fee scale private dental services. Smile Partners is a group of dental hygienists who
provide preventative dental care at a low or no cost. Project Smart Smiles and Smiles at Schools,
target at risk Head Start and elementary school children by providing dental screening, fluoride
varnish, sealants, education and helping parents in seeking a dentist. Through Smile Partners,
Bainbridge Island has a small preventative program called Smiles for Life for seniors over 60,
but it lacks funding for a dentist. The Mom and Me Cavity Free program for low income
pregnant women no longer is Medicaid funded which is an important loss because poor dental
health can lead to premature births. Volunteer dentists offer a clinic on Saturdays quarterly but
this only reaches a few people. Clearly lack of adequate insurance or ability to pay is the number
one barrier to accessing preventative and emergency dental services.
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LWV Dental Health Survey Answers #2
2. Do you feel that all geographic areas of the county have adequate availability of
dental health care services?
There are a reasonable number of dental service providers in Kitsap County but dental clinics
for the low income are mostly located in urban areas, making it difficult for needy families
without cars to reach services. One person noted that having to depend on the bus system is of
particular concern when one has a late appointment and the buses are no longer running, or
the person is groggy from medications and is unable to get home without a ride. Some
responders said geography is not the problem, lack of insurance is the problem.
LWV Dental Health Survey Answers #3
3. Are there any referral services lacking in Kitsap County?
Fifty per cent of the responses indicated that they did not know if services were lacking. The
other 50 percent mentioned the following: for the low income, extraction is most often offered
instead of crowns or root canals. Pediatric and oral surgery, and periodontics are also lacking
for the low income. One responder summed it up that there are no specialties for the low
income. One oral surgeon used to accept Medicaid but his/her services are no longer covered
by Medicaid.
LWV Dental Health Survey Answers #4
4. Do you feel that the uninsured and underinsured patients in Kitsap have
access to recommended dental health care prevention services and medically
necessary dental treatment services?
All responders said no, there is no quality, affordable dental care for the low income. Because
many patients cannot afford dental fees for preventative care or they fail to recognize the
importance of it, they wait until a dental emergency to seek help. All too often, for example, they
take their dental problem, such as an abscessed tooth, to the ER where there is no attending
dentist. The few dentists who do occasionally take Medicaid patients are appreciated but their
response to requests for service is limited and not continuous because of the low Medicaid
reimbursement. There was some feeling that not enough local dentists concern themselves with
those who cannot pay. However, one dentist created a program called Service with a Smile
where the patient is expected to give community service hours in return for dental care.
However, he finds that he does not have the time needed to connect with the community service
providers adequately and really needs a coordinator to assist him.
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LWV Dental Health Survey Answers #5
5. What prevention approach(s) to improving dental health care of Kitsap County
residents would you suggest and support?
Our respondents agreed that improving dental health in Kitsap County depends on its citizens
having access to preventive exams and education on good oral hygiene and nutrition. Children
and their parents need the information and motivation to practice early dental care and good
eating habits. The teen population is a large group that needs help and education on the
importance of dental hygiene. Some suggested that the schools should play a greater role
while others suggested that the dental community in Kitsap should be more public in
advocating for the prevention of tooth decay and the need for fluoride in all public water
systems. Presently, the Bremerton water system, one of the largest in the county, does not
introduce fluoride into its water system. With recent cut-backs in government health care
services to the poor, access to preventive exams for adults and children is limited. The Health
District has dropped their dental program completely. Some survey responders suggested that
local dentists could help by sharing greater responsibility for providing affordable services to
the needy, perhaps by instituting a sliding fee scale based of patient' ability to pay.
LWV Dental Health Survey Answers #6
6. Do you feel minorities experience equal access to routine recommended
prevention services and medically necessary treatment services for dental health
care?
Most answered this question by saying that discrimination is not the issue, it’s more related to
lack of income. There is a disproportionate number of minorities at PCHS compared to the
general population. One noted that he/she did not know of any Spanish speaking dentist. Another
stated that minorities are more likely to fall into the current system that devalues them making
health success problematic.
LWV Dental Health Survey Answers #7
7. Do you feel that duplication of dental health services is a problem in the county?
Almost all responders did not feel that duplication of dental health services is a problem,
although one noted orthodontics. Some simply did not know of or were unaware of any
duplication. One dentist felt that we put too few resources into non-effective programs such as
school based dental sealants. The reasons for this are several: according to him, the reseal rate of
school based dental sealants is quite high as they are often poorly placed and as a result can trap
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bacteria next to the tooth and can do more harm than good. Parents also get the idea that when
kids are examined in school they do not need to go to a dentist for a complete exam.
LWV Dental Health Survey Answers #8
8. What do you see as the three greatest strengths in Kitsap County’s dental health
services?
Kitsap County is fortunate to have a strong, committed dental health community and a Dental
Society which can offer access to a broad range of excellent dental services, especially for the
insured or those who can pay. For those on limited income, a few dentists have been willing to
provide low or no cost assistance within their practices. An example is Service With a Smile
which provides a limited co-pay and community service option for those unable to pay. The
Salvation Army offers a co-pay system and Smile Partners, mostly made up of dental
hygienists, provides some preventative care for children in schools, seniors over 60 and in
quarterly clinics. Peninsula Community Health Services, a local government funded agency,
is the main provider for the low income but has had to let some dentists go due to lack of
funds. Indian health clinics also provide important dental care and education to children in
their communities.
LWV Dental Health Survey Answers #9
9. What do you think are the three most important steps that could be taken to
improve dental health care in general in Kitsap County? List in order of
importance.
The strongest suggestions for improving dental health in Kitsap County included more affordable
prevention services and increased access for all. Funding needs to be found to re-establish the
Oral Health Project at the Health District, expand the community clinic services, and include
dental health as part of universal health care. There was also strong support for encouraging
more local dentists to provide some volunteer and/or sliding fee scale services, perhaps on a
rotating basis. Tracking children in elementary school and providing education on the
importance of good dental hygiene to children and families was also high on the list. Putting
fluoride in the water and continuing the sealant program was also mentioned more than once.
There was some thought that we need to license dental hygienists to practice independently.
They can provide a lot of critical dental care at a significantly lower cost than dentists. And
finally, we need to encourage our population to take ownership of their own dental health.
Affordable co-payments should be encouraged as free care is all too often taken for granted and
patients who get free care seem to lack commitment to practicing good dental hygiene.
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LWV Dental Health Survey Answers #10
10. Do you have other comments or concerns about dental care in Kitsap County?
There were only a few answers to this question. The Juvenile Detention Center does not provide
dental services. Tooth aches are usually handled in the facility and treated as an infection. This
covers the needs of most youth as a majority of incarcerations are less than 30 days. If there is a
greater need for dental services, the youth is taken either to his own dentist or to PCHS.
Ironically, even the dental condition known as “Meth Mouth” seems to be dropping off while
methamphetamine usage seems to be going up. There were a couple of comments suggesting that
the community might want to look at the dental care problems in the county with new creativity.
Policy makers do not seem to recognize that dental health care is important. When dental health
care is ignored, there is a “snowball” effect which leads to other problems of well being such as
difficulty eating, sleeping, and an ability to get a job. Several responders emphasized that we
need to focus more on prevention services and the Hispanic community indicated the need for
more dental professionals who speak Spanish. The lack of adequate or any dental care in our
community for the low income, uninsured and underinsured was mentioned several times in the
Primary Health Care questionnaire. Terms like “it is a disaster” was used more than once.
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Additional Information:
Health Position of the LWVUS: Promote a health care system for the United States that
provides access to a basic level of quality care for all U.S. residents and controls health care
costs.
Health Position of the LWVWA: Policies as part of comprehensive reform of the existing
health system which:




Ensures universal access for all residents to a comprehensive, uniform, and affordable set
of health services. These services shall be available regardless of one’s health status (i.e.
pre-existing conditions) or financial status.
Provide “seamless” coverage and continuity of care, to the extent possible, regardless of
changes in life circumstances such as change in employment, marital status, financial
status, or health status.
Establish a mechanism to adequately control total system expenditures for health services
while maintaining quality standards of care.
Assure that no one shall be forced into poverty because of medical or long-term needs.
Websites that may be of interest:
Primary Care:
www.kitsapcountyhealth.com – Kitsap Public Health District
www.kitsapchp.com – Kitsap Community Health Priorities, go to “data” for full report
www.harrisonmedical.org – Harrison Medical Center
www.kcmedical.org – Kitsap County Medical Society
www.kcmedical.org/advertising/fall - Communiqué - Newsletter for the Kitsap County Medical
Society
www.internalmedicanenews.com – Newspaper for internists
www.depts.washington.edu/fammed/new - University of Washington Family Practice Newsletter
www.pchsweb.org – Peninsula Community Health Services for the insured and uninsured
www.hollyridge.org – Holly Ridge Center, neurodevelopmental clinic and support for children
and adults with developmental disabilities.
www.med.navy.mil/sites/nhbrem - Navy Hospital, Bremerton
www.ghc.org/locations/medcenters - Group Health in Kitsap County
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www.DSHS.wa.gov – State of Washington Department of Social and Health Services
www.hrsa.dshs.wa.gov/applehealth/ Apple Health for Kids, a health insurance program for low
income children in Washington State
www.cms.gov – Centers for Medicaid and Medicare Services
www.UnnaturalCauses.com – series of 6 CD’s on economic causes of ill health
www.KFF.org – Kaiser Family Foundation
www.landmarkbook.com – book on the Patient Protection and Affordable Health Care Act 2010
www.k12wa.us – Office of Superintendent of Public Instruction
Mental Health:
www.Kitsapmentalhealth.org – Kitsap Mental Health Services – the contracted provider of
mental health services for Kitsap County in the Peninsula Regional Support Network
www.communityrelations@kmhs.org – suicide issues
www.pchsweb.org – Peninsula Community Health Services for the insured and uninsured.
www.kitsapmentalhealth.org/happenings_newsletter.aspx KMHS newsletter
www.nami.org/local - National Alliance for the Mentally Ill, a non-profit, grassroots education,
advocacy and support for families (local chapter located in North Kitsap and on Bainbridge
Island)
www.olympicpeninsulaautismcenter.org – serving children 18 months to 18 years with autism
www.kitsapgov.com/hr/wsolympic/prsn/prsnmain.htm - Peninsula Regional Support Network, a
3 county consortium of Clallam, Jefferson and Kitsap Counties providing planning, contracting
and administration to deliver a comprehensive system of community mental health services.
http://dor.wa.gov/content/findtaxesandrates/SalesAndUseTaxRates/doingBus_LocSaTxChNts.as
px - Website for local taxes
Dental Health:
www.wsda.org/kitsap - Kitsap County Dental Society
www.pchsweb.org – Peninsula Community Health Services for the insured and uninsured.
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Suggested Reading:
Landmark, The Inside Story of America’s New Health Care Law and What it Means for Us All
by the staff of the Washington Post. An explanation of the Patient Protection and Affordable
Care Act - 2010
The Healing On America – A Global Quest for Better Cheaper, and Fairer Health Care by T.R.
Reid – A discussion of how other developed countries provide health care to their population.
Glossary of Acronyms
DSHS
Washington State Department of Social and Health Services
ER
Hospital Emergency Room
KCHD
Kitsap County Health District
KCR
Kitsap Community Resources
KMHS
Kitsap Mental Health Services
KPHD
Kitsap Public Health District (New name for Health District as of January 1, 2012)
KSAC
Kitsap Sexual Assault Center
LWV
League of Women Voters
LWVK
League of Women Voters Kitsap
PCHS
Peninsula Community Health Services
PCHS211
Peninsula Community Health Services information and referral phone services
RSN
Regional Support Network
*****
Those who did not respond to our request to participate in the survey included: Alive/YWCA, Bainbridge
Island Police Dept., Poulsbo Police Dept., Bremerton Police Dept., Kitsap Co. Sheriff’s office, Bainbridge Fire
Dept.(medics), Bainbridge Youth Services, Central Kitsap Urgent Care doctor, VP Harrison Medical Center., some
nurses at Kitsap County Health District(Dir. Community Health and Prenatal Care, one working with AIDS and
another with Drug Free Communities), Bainbridge Island Health and Human Services, DSHS Child Health and
Education tracker, North Kitsap Family Practice and Family Care Center, Suquamish Tribe (The doctor in the clinic
& those in the Human Resources Dept. needed permission from the tribe to participate), Liberty Shores elder care,
Kitsap Commission on Children and Youth, an acupuncturist, a chiropractor, 4 internists, 2 family practice doctors,
2 dentists, 1 urgent care doctor, some members of the general public.
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