Frank Ford enthusiastically agreed to take Suboxone when he was in jail earlier this year, happy to be on medicine that would help him avoid the opioids he did for the last 15.

Even though he qualified for medication and even though he was under a court order to treat his opioid use, he still needed to be assessed by a specialist before the state would pay for his treatment, whether that’s Suboxone, a prescription used to treat people who are addicted to opioids, or a bed in a treatment facility.

But county rules make it difficult to get that assessment while in jail, according to his lawyer and others who work with the system, and Ford is homeless, which makes the next easiest option — house arrest — difficult as well.

“I’ve been doing drugs for longer than I haven’t been doing drugs,” said Ford, 29. “And I’ve been yelling at them: I don’t need prison, I need help.”

Ford was in the nearly impossible situation many homeless people with drug addiction or severe mental illness — or both — face during the pandemic. Even if they want intensive treatment, the process leaves them stuck, often spiraling further into crisis in public view, according to nurses, patient navigators, care coordinators and doctors interviewed by The Seattle Times.

Navigating the behavioral health system has never been easy — one expert called it “nothing but barriers” — but when COVID-19 hit, treatment facilities slashed capacity and mental health clinics and Harborview Medical Center suspended drop-in hours.

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The Seattle Times’ Project Homeless is funded by BECU, The Bernier McCaw 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.

“The net was already pretty loosely woven,” said Malin Hamblin, a social worker at the county public health clinic downtown. “And I think with COVID, that webbing has even gotten spread further apart. The holes are so much larger.”

So far this year, more than 200 homeless people have called the Washington Recovery Helpline, the state’s addiction call center, which just began tracking who’s homeless. The No. 1 thing callers ask for is inpatient treatment — a room in a facility, round-the-clock care and a place to get a short break from the streets and get sober.

But though the number of calls is on pace to beat last year, the number of low-income people actually getting into inpatient treatment has dropped: According to claims submitted so far for February 2021, nearly 800 fewer people got into state-paid inpatient treatment across the state than February 2020, according to data from the Washington State Healthcare Authority.

“You’re seeing an increase in requests, and there’s fewer beds than what were available,” said Troy Seibert, the helpline’s opioid use disorder manager.

The consequences are dire: a third of all deaths among those the King County medical examiner identified as homeless in the first 12 months of the pandemic were caused by probable overdose or alcohol poisoning; that’s 87 people.

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The treatment system has never been particularly helpful to people grappling with mental illness, addiction and homelessness, but the shift to telemedicine and virtual treatment has laid bare that divide, according to Kim Powers, a referral coordinator at Evergreen Treatment Services’ homeless outreach arm, who has worked in the system for more than 20 years.

“If you’re living homeless, you may have to move. You may have changed your mind. You may decide that treatment isn’t right for you right now,” Powers said. “So to be able to capture them at the moment they want help is not the way the system is set up.”

Inpatient treatment is far from the perfect fix for many people who are addicted, experts say: After someone goes through treatment there’s not enough quality recovery housing or mental health housing available, so people often head back to the streets and back to using, Powers said.

This is an old problem, dating back to the ’70s when state mental health hospitals began shrinking. Federal disinvestment, combined with a movement away from institutional treatment, has created an underfunded “community” behavioral health system where staff are paid so poorly there’s a 32% turnover rate. Last year, at least five treatment or detox facilities around the Puget Sound closed, many saying the state wasn’t reimbursing them enough money per patient.

Then COVID-19 came along and made it worse: Double, triple and sometimes even quadruple rooms at treatment facilities were converted to singles. The county lost more than a 10th of its inpatient beds last October when a Belltown inpatient mental health facility closed, the nonprofit owner hemorrhaging millions of dollars. Behavioral health providers across the system have lost 11% of their full-time staff and can’t find enough replacements, according to a survey by the Washington Council for Behavioral Health.

Capacity in behavioral health facilities in Washington dropped from about 88% to 65% within a year, according to the survey.

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“We have a lot of CEOs who have been in the field for decades and we have been hearing very frequently that this is the worst that they’ve ever seen it,” said Joan Miller, a policy analyst for the Washington Council for Behavioral Health.

Some federal money is being used to help the weakened system: $3.7 million from the CARES Act has gone to treatment centers with an emphasis on those that treat Medicaid and uninsured populations, but that money is not to add beds. It’s for protective equipment, testing supplies and overtime pay for health care workers.

“There’s more stress on a system that’s already stressed,” said Rep. Lauren Davis, D-Shoreline, who is also head of the Washington Recovery Alliance.

The places that haven’t cut their capacity are under pressure to meet the pent-up need. At Harborview, there are 66 beds set aside for people needing urgent psychiatric help, and those are often people who also use drugs and are homeless. Patients initially stopped coming because of fear of contracting the coronavirus, said Allie Franklin, the administrator for behavioral health services.

But now, those numbers are back up, the beds are almost always full, and because many people didn’t come in during the first three months of the pandemic, their conditions have escalated and they are worse off when they do show up.

“Folks come and they have a higher acuity so they’re staying a little bit longer, and then we’re also finding it’s harder to find places to discharge people in our community,” Franklin said. She declined to share an average length of stay.

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Choke points that exist before a person even enters a facility have also contributed to the growing waitlists.

First, the paperwork: Many homeless people don’t have ID, which often takes weeks to rectify, said Dr. Nancy Connolly, a doctor at Harborview who works with homeless populations. Next, they have to figure out how to pay for care, and may need Medicaid, another complicated process.

Then, when a patients schedules an assessment like the kind Ford needed, they must make it to the appointment, which is a struggle for someone who might not have access to reliable transportation.

Connolly has had patients disappear several times during this time-intensive process.

Your window’s pretty short for someone who’s suffering a severe addiction,” Connolly said. “You only have so long to help them before they’re so intoxicated that they’re gone.”

Jessye Sedergren, Frank Ford’s navigator, has been learning how to help patients through the behavioral health system for 17 years. But the pandemic’s restrictions made much of Sedergren’s knowledge of the system useless.

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“It’s way tougher,” Sedergren said. “For a lot of people, [treatment] is not worth pursuing.”

Thankfully, Ford had two things most homeless people don’t have: A father in Lynnwood who agreed to put him up for a week under house arrest, and Sedergren, who managed to get him an assessment during that week.

“Let’s say someone didn’t have a house to go to,” Ford said. “They don’t give you anything. They don’t set you up. It’s insane.”

To further complicate this process, while many chronically homeless people have psychiatric disorders and chemical dependencies, most treatment facilities are focused on one or the other, according to Richard Geiger, chief of inpatient and residential services at Valley Cities, one of King County’s largest low-income behavioral health providers.

Geiger manages Recovery Place Seattle, which is rarely full despite being the only voluntary treatment center in the county licensed for both substance use and psychiatric disorders. Lots of people don’t show because they decided not to go into treatment at the last minute, or were arrested, or some other obstacle. And Geiger said staff often have to deny people who want treatment but also need serious medical care, many of them homeless people.

“If you’re on the streets and you’re really sick on top of detoxing and withdrawing, we’re going to want you to go to the emergency department first,” Geiger said.

Still, Valley Cities is the only provider that Tiffany Turner, operations manager for South Lake Union’s Recovery Cafe — a space for free food, 12-step meetings and resources — can rely on anymore. Turner said she’s seen clients wait more than a month to get into treatment, and in the meantime they are living on the streets, life is unstable and it can be impossible to find them when a bed opens up.

“We’re losing people just with the wait,” Turner said. “They’re on the streets, they’re on the drug. If you were dealing with these situations, you wouldn’t want to live life sober.”