10/28/2025 Bridge Coalition Meeting Notes

Meeting Notes: Bridge Coalition Meeting on October 28^th

Opening Comments (Jim): 

• A broad overview of NorthStar Advocates Mission and purpose was discussed,
• Focusing on return to community: safe housing, relationships, and supporting young adults facing unaccompanied homelessness interests and passions.

The Bridge Scope and Vision (Sierra): 

• High rate of return to homelessness for young people exiting inpatient care,
• Cross-system information sharing and training,
• Developing Return To Community Plan,
• Developing opportunities for systems reform.

1929 Housing Provider Updates:

Friends of Youth – BridgePointe Program Presenter: Eric Buley Senior Director of Homeless Youth Services.

Eric provided an update on BridgePointe’s continued progress in serving young adults transitioning from inpatient behavioral health programs. The program currently has four individuals housed, with one additional participant scheduled to move in this week. Friends of Youth is also opening a second building, which will allow them to expand capacity and strengthen community partnerships through deeper relationship-building and collaborative efforts with local service providers.

Blanca shared important insights regarding client challenges. Housing availability remains a significant struggle, and employment barriers—particularly background checks—continue to pose challenges for participants seeking stability. Jim raised the idea of developing a legal advocacy and resource connection to help address these barriers, particularly for individuals navigating housing and employment restrictions related to their records.

The group also discussed whether program staff are CE certified and explored the process for ensuring that Bridge Housing staff can nominate clients for CE referrals directly. Eric confirmed that Friends of Youth has the capacity to make those nominations.

Eric emphasized the importance of a “soft transition” during the first 24–48 hours of program entry, allowing participants to settle in and stabilize before re-engaging in the community. This period helps create safety, trust, and a sense of belonging as young people begin adjusting to life after inpatient care.

Excelsior Wellness – Bridge Housing Program Presenter: Dylan Ramirez Program Manager of TAY Services 

Dylan shared that Excelsior currently has one individual in the Bridge Housing program, with several referrals in process. The team is actively connecting participants to community resources, recovery supports, and local networks, while ensuring that sobriety and structure are central components of daily living.

Common themes among residents include substance use disorder (SUD) as the primary challenge, highlighting the need for more county-wide resources and judicial supports within Spokane County. Excelsior continues outreach to inpatient providers and has met with Oxford House representatives to strengthen connections between treatment and housing.

Many residents express a desire to relocate closer to family, and Excelsior’s team remains responsive to those individual goals.

The program operates with 24/7 staffing, providing both consistency and individualized care. Each morning begins with a structured routine—participants review their Return to Community Plan, set goals for the day, and participate in life skills activities such as cooking, budgeting, and shopping. Residents have their own rooms and access to on-campus walking trails, offering a balance of independence and community.

Dylan emphasized the importance of maintaining structure with flexibility—ensuring that young people have clear expectations and routines while still having choices that empower them. When new residents arrive, the team hosts a welcoming group to foster community and belonging from day one.

Ryther – Mobile Medication-Assisted Treatment (MAT) Team

The Ryther MAT Team—comprising Johnny Ohta (SUDP), Abbie Woods (SUDP & Team Coordinator), Tal Rizzo (Outreach Case Manager), and Dr. Taryn Hansen (MD)—was created in response to the growing opioid epidemic across King County. Funded through King County Public Health and state programs, the team operates under a partnership between Ryther, Kaiser Permanente, and YouthCare, with the shared mission of meeting young people where they are—literally and emotionally—to build trust and provide pathways to recovery.

Serving youth and young adults ages 12 to 25, the team works in drop-in centers, shelters, housing programs, hospitals, schools, detention centers, jails, and encampments, and with foster-care-involved individuals. They are often the first line of support for young people experiencing opioid use disorder (OUD) and related challenges.

Approach and Philosophy

At the heart of Ryther’s philosophy is a simple but profound belief: relationships save lives. Johnny Ohta emphasized that the team’s success is rooted in the trusting, consistent relationships they build with young people who may have lost faith in systems or adults. Engagement begins with compassion—no expectations of readiness for treatment. The team’s goal is to stay connected long enough for change to become possible. Their work embodies the principle of “client in the driver’s seat.” Each young person determines their own goals—whether harm reduction, stabilization, or abstinence—and the team tailors support accordingly. They navigate the maze of health care, housing, legal systems, and education alongside their clients, not for them, modeling empowerment through partnership.

Scope of Services

The Ryther MAT Team provides a full spectrum of wraparound services, including:

• Medication for Opioid Use Disorder (MOUD) — Buprenorphine (Suboxone/Subutex), Sublocade, Brixadi, Naltrexone, and Vivitrol.
• Treatment navigation — Helping clients access any level of care: detox, residential, outpatient, or recovery housing.
• Medical care — Offered through their clinic at YouthCare’s Orion Center, which provides a wide range of medical services free of cost.
• Mobile outreach and transportation — The team travels across all of King County, often transporting youth to treatment or medical appointments throughout the state.
• Intensive case management — Supporting access to housing, education, employment, and mental health care, and assisting with legal needs.
• Harm reduction supplies, crisis response, and same-day outreach to community referrals and encampments.

Their nimble, four-person structure allows for high mobility and rapid response. The team is often in the field all day, carrying supplies and medications, connecting clients to supports, and ensuring that no opportunity for engagement is lost.

Why MOUD Matters

The team’s medical approach is grounded in evidence: MOUD saves lives. Research shows—and Ryther’s field experience confirms—that these medications reduce opioid-related mortality, stabilize individuals, and improve long-term outcomes.

• Death Prevention: MOUD dramatically lowers both opioid-related and all-cause mortality.
• Stabilization: It reduces cravings, supports those seeking to manage their use, and improves treatment retention.
• Social Recovery: Participants show increased success in employment, housing, and community integration, and reduced involvement with the justice system.
• Engagement Tool: Having medication available helps the team reach clients in crisis or withdrawal—critical moments when traditional outreach often fails.

Medication Options and Innovations

Ryther’s team is adept at navigating the full range of MOUD options:

• Buprenorphine (Partial Agonist): Delivered as Suboxone (with naloxone), Subutex (without naloxone), and the long-acting injectables Sublocade and Brixadi. Injectable buprenorphine has revolutionized care—eliminating the traditional 72-hour withdrawal waiting period and providing up to a month of stability per dose.
• Naltrexone / Vivitrol (Antagonist): Blocks opioid receptors, available as a daily pill or a monthly injection. Vivitrol also treats alcohol use disorder but requires seven days opioid-free to avoid withdrawal.
• Methadone (Full Agonist): Not prescribed by Ryther due to long-term dependence concerns, though they coordinate care for clients who use it elsewhere.

The injectable buprenorphine formulations have been particularly transformative. Johnny shared that clients who were overdosing monthly stopped overdosing once stabilized on the injections, with several now engaged in treatment and rebuilding their lives.

System Navigation and Collaboration

Ryther operates within a vast network of systems—medical, legal, housing, and social. Their partnerships with BridgePointe (Friends of Youth), Oxford Housing, and other local providers allow for warm handoffs and shared care planning. The team often advocates in court for clients using MOUD, ensuring medication access is not interrupted by incarceration or probation requirements.

They also prioritize family reunification and long-term relationship building. As Johnny noted, even when young people initially feel isolated, “over time, people show up.” The team helps clients identify who in their lives is safe, supportive, and ready to walk alongside them in recovery.

Barriers and Breakthroughs

The MAT Team continues to navigate challenges such as fluctuating funding and the stigma surrounding medication-based treatment. However, innovations in mobile medication delivery—including direct delivery of oral prescriptions and in-stock injectable supplies—have made care more accessible than ever. Since 2022, the program has rapidly expanded, ensuring same-day initiation and continuity for clients unable to visit pharmacies.

Their guiding philosophy remains steadfast: “If there’s a barrier, we’ll find a way through it.”

Ryther’s work demonstrates how a small, highly skilled team can produce system-level change. Their emphasis on trust, mobility, and flexibility allows them to reach youth other systems often overlook. As Abbie Woods reflected, “Our success starts with connection. Medication keeps people alive—but relationships keep them engaged.”

Through this combination of medical expertise, relentless outreach, and unconditional care, Ryther’s MAT Team continues to redefine what effective substance use intervention looks like for young people in Washington State.

Health Care Authority (HCA) – Supporting Youth & Young Adult Housing Stability Through Partnerships

Presenter: Rachel Baxter, Emerging Adult Behavioral Health Stable Housing Policy Lead

Rachel Baxter of the Health Care Authority (HCA) presented Supporting Youth and Young Adult Housing Stability Through Partnerships, offering an in-depth look at how Washington State’s behavioral health and housing systems can work together to ensure that no young person exits a public system into homelessness. This presentation is part one of a two-part series; the first session focused on behavioral health systems, care coordination, and statewide policy alignment, while the second—scheduled for January—will focus on the specific housing resources and supports available across Washington State.

Youth and Young Adult Homelessness

Rachel began by defining youth and young adult (YYA) homelessness as a broad spectrum that includes literal homelessness, couch surfing, doubling up with friends or relatives, and other forms of unstable housing. She emphasized that most young people experiencing homelessness are exiting systems of care such as:

• DCYF: child welfare, juvenile rehabilitation, reunification, and foster care;
• HCA: behavioral health and substance use treatment systems;
• DSHS: developmental disabilities and other family services; and
• The criminal justice system.

She identified the primary vulnerabilities contributing to youth instability, including unaddressed behavioral health needs, family conflict, poverty, the current housing crisis, and immigration-related challenges. Rachel highlighted that these vulnerabilities often overlap, compounding the barriers young people face when transitioning to independence.

Behavioral Health: A Foundational Concept

Rachel reframed behavioral health as a holistic concept that extends beyond mental illness or substance use—it encompasses the Eight Dimensions of Wellness, each contributing to overall well-being and stability:

• Emotional – Coping effectively with life and creating satisfying relationships.
  • Environmental – Good health by occupying pleasant, stimulating environments that support well-being.
  • Financial – Satisfaction with current and future financial situations.
  • Intellectual – Recognizing creative abilities and finding ways to expand knowledge and skills.
  • Occupational – Personal satisfaction and enrichment derived from one’s work.
  • Physical – Recognizing the need for physical activity, diet, sleep, and nutrition.
  • Social – Developing a sense of connection, belonging, and a well-developed support system.
  • Spiritual – Expanding our sense of purpose and meaning in life.

She emphasized that certain thinking patterns and emotional responses can contribute to unhealthy behaviors, and that recovery is a developmental process focused on improving wellness, self-direction, and quality of life. HCA’s work, she explained, is rooted in behavioral health equity—ensuring that services, supports, and recovery opportunities are accessible across communities and populations.

Core Principles of HCA’s Work

Rachel outlined the foundational principles that guide all HCA initiatives aimed at supporting youth and young adults. These include:

• Developmentally appropriate supports that recognize the distinct needs of each age group;
• Diversity, equity, and inclusion as core drivers of systems design;
• Data-informed decision making that ensures policies are measurable and effective;
• Trauma-informed practices that account for adverse childhood experiences;
• Lived experience as a central voice in planning and service delivery; and
• Poverty impact mitigation through attention to social determinants of health.

These principles are operationalized through broad collaboration among divisions, state agencies, regions, and community partners to ensure children, youth, and families receive coordinated care across systems. The Division of Behavioral Health and Recovery (DBHR) serves as the single state authority for mental health and substance use, managing both federal grants and state priorities that emphasize innovation and population-based approaches.

Care Management and Coordination

Rachel presented HCA’s framework for care management, which serves as an umbrella term for both care coordination and case management.

• Care Coordination (CC) focuses on short-term or intermittent needs and is often delivered by non-clinical or unlicensed staff. It helps young people access social supports, health services, and community resources while improving clinical outcomes and building self-management skills.
• Case Management (CM) provides longer-term engagement (typically three to six months) and is delivered by licensed or clinical staff. It helps youth and families manage complex health conditions, set individualized goals, and integrate care plans that reflect member consent.

Both models are voluntary and centered on client choice, reinforcing the principle that engagement should empower youth rather than direct them.

Medicaid Coordination and Discharge Planning

Rachel discussed House Bill 1860, which establishes requirements for notifying Managed Care Organizations (MCOs) when a member is experiencing housing instability or homelessness. Under this policy, MCOs must be notified at least 24 hours before discharge planning begins, though HCA encourages providers to engage them as early as possible—ideally at the start of the admission process—to ensure the best outcomes.

This proactive approach allows time for Medicaid coverage activation, care coordination, and housing referrals prior to discharge. The intention is to prevent discharges into homelessness by ensuring continuity between behavioral health services, case management, and housing supports.

The Prenatal-to-25 Framework (P-25) and Developmental Lens

Rachel then introduced HCA’s Prenatal-to-25 (P-25) framework, which emphasizes meeting individuals where they are developmentally and ensuring behavioral health services are integrated across the lifespan.

The continuum includes several interconnected stages:

• Early Childhood (Prenatal–5 years): Focused on mental health assessment for young children, the Parent-Child Assistance Program, and services for pregnant and parenting women. These programs support prevention and family stability during the earliest stages of life.
• School-Age Youth (5–18 years): Focused on long-term inpatient treatment (CLIP), Family Initiated Treatment, the System of Care and Healthy Transitions grants, and Wraparound with Intensive Services (WISe). Each initiative aims to strengthen family engagement, continuity of care, and community-based supports.
• Young Adults (16–25 years): Emphasizing stable housing strategies, collegiate recovery supports, and early intervention programs like New Journeys for first-episode psychosis. These programs recognize that emerging adults face unique behavioral health and housing challenges as they transition out of systems of care and into independence.

Across all age ranges, the P-25 model integrates trauma-informed care, early intervention, and recovery-oriented supports to ensure continuity from childhood through adulthood.

Meeting People Where They Are

Rachel emphasized that success in supporting youth and young adults requires meeting people where they are—both physically and emotionally. This involves using diversion conversations to prevent unnecessary system entry, acknowledging trauma and environmental factors, reducing stigma, and strengthening cultural responsiveness. The goal is to create a system where every interaction is person-centered, supportive, and rooted in respect for lived experience.

Connecting P-25 to Housing

Rachel concluded the first half of her presentation by linking the P-25 framework to housing stability. She noted that youth homelessness prevention must start early—beginning with conversations in schools, community organizations, and behavioral health settings—and continue through coordinated discharge planning. The P-25 model positions housing as a key determinant of behavioral health—recognizing that stability in one directly supports success in the other. Because Rachel’s presentation was so comprehensive and includes important statewide resources, I’ve downloaded her PowerPoint as a PDF. To view the entire presentation, [click here]. The second half of this presentation will take place in early 2026.

Community Updates: 

• Eric Buley shared about the upcoming Friends of Youth Ribbon Cutting Ceremony on November 4^th.

Closing Comments:  

• Jim closed the meeting and thanked everyone for their support and active participation in this work. The next meeting is scheduled for November 25^th from 1:00-2:30.