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She was 18, fresh out of foster care, living with a friend. Her high school grades were slipping, her life unraveling. She told the friend she was going to jump to her death from a bridge.

The worried friend drove her to the emergency department at Providence St. Peter Hospital in Olympia, Wash., where members of the in-house crisis services team met with the young woman to let her talk about her troubles and to fully assess her needs. They kept her in a secure room in the emergency department set aside for patients with symptoms of mental illness, including suicidal thoughts, and the effects of substance abuse. Satisfied that after a few hours the young woman's mental state had stabilized, the crisis service counselors recommended follow-up care at a local agency and let her go home.

Since 2005, the team has staffed the emergency department around the clock with two counselors and a nurse. When patients with mental health issues arrive in the emergency department, the crisis staff steps in to assist in care, call in the hospital psychiatric staff when needed and refer appropriate cases to more than a dozen specialized community agencies.

T.J. LaRocque, psychiatric services inpatient manager at the hospital, brought expertise in the idea for mental health crisis services with him when he joined Providence St. Peter Hospital. He'd worked at Harborview Medical Center, the main public hospital in Seattle, 60 miles to the north, which has a behavioral health crisis team in its emergency department. Providence St. Peter Hospital, with 390 beds, is the only one of five hospitals in its five-county area to staff its emergency department in this fashion.

Minding the gap
Sue Beall, regional director of behavioral health for Providence Health & Services, said Providence St. Peter Hospital has become the "go to" hospital for psychiatric emergency care in and around Olympia, a city of 50,000.

The need for emergency care has increased, Beall said, as state and local governments have cut back on mental health services. Washington has two main psychiatric hospitals. LaRocque estimated the state has a shortage of about 800 beds to serve psychiatric patients.

Providence St. Peter Hospital has an 18-bed unit for voluntary behavioral health admissions and can refer patients to Western State Hospital in Lakewood, 30 miles away, or other medical facilities. Beall said one big reason for providing care in the emergency department is to assess patients as they arrive without having them wait for an on-call staff psychiatrist or psychiatric nurse practitioner, or to be referred to services elsewhere.

"Bottom line, it's the best thing for the patient," she said.

Grateful police
Lt. Ray Holmes, supervisor of the patrol division for the Olympia Police Department, calls crisis services "a positive, valuable resource for us." Holmes said his officers often encounter people on the streets who suffer from mental illnesses and addictions. He said the crisis service unit offers the area's most comprehensive emergency care and secure setting for assisting those patients.

"It's where the regional law enforcement agencies go with people who need that help," Holmes said. "It is the only (emergency department) in this area with secure rooms. With its facilities and services, we have been able to develop a strong partnership with the hospital."

The 15-person crisis services department has an annual budget of about $640,000, provided by the hospital. The hospital receives no reimbursements for the crisis team's share of emergency costs. LaRocque, who reports to Beall, said the program is in keeping with the hospital's Catholic mission of serving the poor and marginalized.

Beall said the program originated in 1998, when the hospital put a psychiatric nurse in the emergency department to assist in cases of mental illness or substance abuse. The doctors were glad for the help and wanted more. The crisis services staff now assists an average of 17 patients per day, roughly two of whom will require admission to the hospital's 18-bed inpatient unit.

It operates with three secure rooms and a fourth "quiet" room set aside specifically for arriving mental health patients. The rooms have keypad entry and can be locked from the outside. In-room cameras help staff members monitor patients. They have beds that can be used to restrain patients if necessary. Each work shift consists of a master's level counselor, an assistant with a bachelor's degree in counseling and a registered nurse. They can summon a hospital psychiatrist and psychiatric nurses as needed.

Lara Toney, supervisor of the crisis team, said the most common situations the team responds to involve patients who have expressed serious thoughts of suicide or have harmed themselves. The next largest group is people with mental illness who have abused drugs or alcohol, including chronically homeless patients, many of whom are frequent users of emergency care.

Community partnership
One of crisis service's key partners is Behavioral Health Resources, a mental health and addiction-treatment agency that serves three counties and is managed by a local foundation. Behavioral Health Resources, only two blocks from the hospital, works with most of the patients who need involuntary placement and handles the court process when patients need to be admitted to one of the state mental hospitals. Behavioral Health Resources has its own 15-bed center for involuntary placement.

Ian Harrel, Behavioral Health Resources chief operating officer, said having a dedicated crisis services team at Providence St. Peter allows for quick and comprehensive assessment of behavioral health patients.

"A lot of emergency rooms are overwhelmed with medical cases and auto accidents and don't have a lot of time for psychiatric emergencies," Harrel said. "The crisis services people can step in and provide a timely treatment plan. They are set up to call us in quickly when they need our help.

"They do excellent work over there," he said.