In May, a Sound Health employee stepped out of the El Rey, a 60-bed residential facility for people with serious mental illness in Seattle’s Belltown neighborhood, and recognized someone on the sidewalk. 

Feet from the entrance was a woman who had been discharged from the facility earlier in the year, according to the employee. She sat next to a tent covered in a red tarp behind a toppled shopping cart, an empty cup in her hand. 

“Where are you living now?” the employee asked. 

“Out here,” she said. 

The Seattle Times’ Project Homeless is funded by BECU, The Bernier McCaw Foundation, The Bill & Melinda Gates Foundation, Campion Foundation, the Paul G. Allen Family Foundation, Raikes Foundation, Schultz Family Foundation, Seattle Foundation, Starbucks and the University of Washington. The Seattle Times maintains editorial control over Project Homeless content.

For the employee, who asked to remain anonymous for fear of losing work, seeing the former resident homeless affirmed worries that had developed since September 2019, when nonprofit Sound Health merged with Community Psychiatric Clinic, the former owner of the facility. 

This August, the El Rey shut down due to long-running maintenance concerns, according to Sound Health. The closure highlights a gap in the social safety net for people exiting the region’s psychiatric hospitals, many of whom would otherwise be homeless, providers say. With the El Rey gone, so are nearly 13% of the county’s contracted mental health residential treatment beds, a serious blow to an increasingly rare resource.

The beds lost “are probably the most critical beds in our system, frankly,” said Jim Vollendroff, former behavioral health and recovery division director at King County and the current behavioral health service line administrator at Harborview Medical Center. Harborview, like many other local hospitals, refers patients to housing at facilities like the El Rey when possible.  

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There’s already a dearth of beds for people leaving treatment, Vollendroff said. Shuttering the El Rey is a “huge loss,” he added. 

The El Rey building was built in the early 1900s, and when Sound took over the facility, the organization discovered “a lot of what I’ll call deferred maintenance,” said Sound Health chief financial officer Paul Eisenhauer. That included a sewage leak in the basement and plumbing problems throughout the building. 

“When we looked at it, we said we’d have to put several million dollars into this property to bring it up to where it needed to be,” Eisenhauer said. “We considered it for a good number of months.” 

Ultimately, they decided to tear the building down.

Eisenhauer said the hope is to redevelop the property and include a primary care clinic on-site, along with some housing. There is not yet a plan to replace the mental health residential care beds. 

Discharge plans

The way the facility cared for and discharged residents before the closure also raised concerns from some staff caregivers, seven of whom spoke to The Seattle Times on the condition of anonymity for fear of losing their jobs.

Marisa Doelling, the El Rey’s former clinical supervisor, was fired in March, after which she filed a complaint about Sound’s management of the facility with King County, which contracted with the El Rey to provide mental health care. The clients being discharged to other settings weren’t ready to move, she said. She also alleged that Sound’s management had changed her clinical program into something that more closely resembled assisted living without sufficient mental health treatment. 

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“It’s setting them up for failure,” Doelling said of the clients who were being transferred out of the facility. “They may be able to survive for a month or two before their apartment looks like hell and they’re not taking their meds.”

The other employees who spoke to The Times raised concerns about the program and its clients that echoed Doelling’s.

The employees described what they perceived to be a shift away from clinical programming as case managers left or took on more administrative duties like manning the reception desk and reminding clients of meal times. 

“It felt like you were shepherding people in and out, rather than therapeutic interventions, rather than [cognitive behavioral therapy] or life skills,” one employee said.   

Sound strongly disagreed with Doelling’s and the other employees’ allegations.

“I can safely say that any changes made since the acquisition of the facility were made in an effort to improve quality of life for all residents,” Sound spokesperson Steve McLean wrote by email. “Any and all transfers were made carefully and thoughtfully, and the only urgency on our end was to make sure each client was provided a safe environment in which to receive care.”

In reviewing Doelling’s concerns about four clients who had been, in her view, inappropriately discharged, Kelli Nomura, head of the county’s Behavioral Health and Recovery Division, said the county “believe[s] the discharge plans, including where the clients went from the El Rey, [were] appropriate at that time.”

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“[King County] is aware of the four residents’ current status and the ongoing behavioral health services they are receiving,” Nomura said by email.

Sound Health initially told The Seattle Times that no resident had become homeless as the facility was preparing to shutter. But when provided with more details about the client who was found outside the building, McLean said the woman was an El Rey client “who chose to come and go from our facilities on multiple occasions, but always left of her own accord, which is her right.” 

The client was assessed by a Department of Social and Health Services employee who found she “qualified for a much higher level of care than the El Rey can provide,” McLean said. She was allowed to visit the adult family home she was referred to, he added, and decided to move there.

After moving into the adult family home, however, the client ran away twice, McLean said. Police returned her to the home once, but after the second incident “the adult family home decided she wasn’t a good fit due to this dangerous behavior and opted not [to] accept her back.” 

Nomura said in an interview she wasn’t aware of the resident who became homeless after being discharged from the facility. Once a client is placed into an adult family home, that client is no longer tracked by the county, Nomura said.  

Few options for people exiting treatment

For people leaving hospital psychiatric care now, the loss of the El Rey’s 60 beds for the county is a serious one. 

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Two years ago, Gov. Jay Inslee launched a plan to end most civil commitment at state psychiatric hospitals in a turn to community-based care at smaller facilities. As a result, more clients are moving out of Western State Hospital, Nomura said, and “we need those beds more than ever before.” 

There aren’t plans to immediately replace the El Rey’s portion of mental health beds in King County, and Nomura said the county is in talks with Sound Health about whether it makes sense to replace them as part of the rebuilding of the El Rey facility. 

“We want to find a way that it strengthens our presence in Belltown because we think there’s a pretty big need for our services in Belltown, especially with the homeless population,” Eisenhauer, Sound’s CFO, said. “We’re hoping to find a way to do that. I just don’t know what it is at this point.” 

Amy Blondin, spokesperson for Washington state’s Health Care Authority (HCA), said HCA was working with King County to “understand the issue and how to mitigate it to the extent possible.” 

“Obviously, anytime our state loses capacity for much-needed mental health services, we are concerned,” Blondin wrote by email. 

Losing the El Rey’s beds will likely put more pressure on the overall homelessness system, said Daniel Malone, executive director of the Downtown Emergency Service Center, one of the city’s biggest homeless shelter and service organizations.

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“I don’t mean to suggest that some things don’t ever need to be replaced or rehabilitated, but if [the El Rey] is usable in its current form it’s certainly in the community’s interest for it to continue to operate as a place for people to live given how many people don’t have a place to live,” Malone said.

Part of the gap is because of the low Medicaid reimbursement rates set for the beds, Nomura said — something advocates have been trying to change at the state Legislature for years.  

“Eventually all of the providers who run these facilities have to take a hard look at how we maintain this facility at a time when behavioral health rates are not sufficient to cover the cost,” she added. 

In the meantime, the already meager options for people exiting psychiatric treatment at hospitals are at risk of disappearing.

“We currently don’t have enough housing options for people exiting treatment,” Vollendroff, of Harborview, said. “We spend all these resources on stabilizing people and end up discharging them to unstable housing situations, or to shelters, or to homelessness.”