Meeting Notes: Bridge Coalition Meeting on March 24th
Opening Comments (Jim):
- Introductions via chat were done
- 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 (Mayauna):
- 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.
Reimagining Care: Harborview Community Heart Failure Program (CHFP)
Presented by Jaimie Pechan, DNP, ARNP and Kate Smith, RN, BSN, Harborview Community Heart Failure Program
The Harborview Community Heart Failure Program is a multidisciplinary team designed to reach individuals who are often unable—or unwilling—to engage in traditional healthcare systems.
Their team includes providers, nurses, a pharmacist, a peer support specialist, and cardiology specialists who collaborate both in the field and through research and innovation.
At its core, CHFP is built on a simple but transformative premise:
care should meet the patient, not the other way around.
A Low-Barrier, High-Access Model
The program focuses on individuals living with heart failure who also face complex barriers such as:
- Substance use disorders
- Severe mental illness
- Chronic homelessness or housing instability
Many of the patients they serve have a history of missed appointments, repeated hospitalizations, and limited engagement with outpatient care systems.
What makes this model different is its intentional design:
- No barriers related to insurance, immigration status, language, or behavioral history
- No requirement for sobriety or perfect adherence
- A trauma-informed and harm reduction approach embedded into every interaction
This creates a space where individuals who have historically been excluded from care can finally access consistent, relationship-based support.
What Care Looks Like in the Field
Rather than expecting patients to come into clinics, CHFP brings full-spectrum cardiac care directly into the community.
Care happens wherever patients feel most comfortable:
- Tiny home villages
- Shelters and supportive housing
- Cars, tents, and street settings
- Community spaces and motels
A typical visit can include:
- Full heart failure assessments
- Cardiac ultrasounds and EKGs
- Lab draws in the field
- Medication management and titration
- Care coordination across systems
- Goal-of-care conversations, including end-of-life planning
The team adapts treatment plans to what is realistic for each individual. This includes creative medication strategies like alarmed mediset systems and flexible dosing approaches that prioritize consistency over perfection.
This is not just medical care—it is relationship-driven, adaptive care.
Consistency, Flexibility, and Scale
The CHFP team operates five days a week, seeing 6–7 patients per day per team. Depending on acuity, patients may be seen multiple times per week or as infrequently as every few months.
Currently, the program:
- Serves over 90 active patients
- Receives approximately 2–5 new referrals per week
- Covers a wide geographic region across the Seattle area
This balance of intensity and flexibility allows the team to stabilize patients while maintaining long-term engagement.
More Than Medicine: Trust, Coordination, and Presence
One of the most critical elements of this model is care coordination.
For individuals without phones, stable housing, or predictable routines, connection requires deep partnerships with:
- Case managers
- Outreach teams
- Housing providers
- Community organizations
The team emphasized that this level of coordination is complex—but essential.
Equally important is their commitment to non-judgmental care. Patients are not required to “earn” services by meeting expectations. Instead, the team shows up consistently, building trust over time.
Lived Experience: Bringing the Model to Life
Following the presentation, Sierra, a Lived Experience Advocate with NorthStar Advocates, shared her personal story of navigating severe health challenges and how this model of care impacted her life.
Her story is shared below in her own words:
“The date was March 10th 2022. At this point I had been to Swedish 9 different times over the last two years and each time I would be diagnosed with having cellulitis of the legs and would be given 3-4 days of IV antibiotics then discharged and told to finish up the week long course of antibiotics. I’d feel better for a short time and then I’d be back to feeling real cruddy. Growing up with a hypochondriac mother who would rush me to the hospital for the slightest thing created a fear in me to admit that I may be sick. This fear has led me to wait until I was near death before I went in to the emergency room. By This time the swelling in my legs was the worse I had experienced. I couldn’t bend my knees. I was struggling to breathe and something just felt wrong. My friend suggested that we try a different hospital. So that’s what we did. We went to Uw Montlake. By the time we managed to get there it was as if my body gave up. Every part of me that was trying to be strong, trying to hold it together just gave up. I was incoherent, had an extremely high fever and was unable to walk. Intially they tried to push antibiotics while saying it was cellulitis. I remember feeling so defeated at first, however when my friend came to visit me the next day she advocated for me and asked the doctors to run some more tests. The tests found that I had pulmonary arterial hypertension which is high blood pressure in the the arteries of my lungs. This high pressure results in a decreased flow of blood and that in turn has caused my heart to overwork resulting in heart failure. I remember getting this diagnosis and being so confused…why me? I remember my friends asking the same thing…they would point out that I didn’t use needles and that I didn’t use opiates so why was I the one that got sick? Getting this diagnosis wasn’t the fix. It was the start. I still continued to use drugs, wasn’t taking the prescribed medications, and wasn’t going to my appointments. I had another 3 or 4 hospital admissions and would get a little better each time only to decline yet again. In November 2023 I was sick yet again. I couldn’t walk 50ft without needing to be placed on oxygen. I had isolated myself and my dog in my rv and had pretty much accepted that I would likely die there and I was okay with it. I had burnt my hands so severely a couple weeks prior and was unable to open my meds. Thankfully a friend came to check on me. She told me that she wasn’t going to let me die there and that I was going to the hospital again. This time I spent two weeks in the hospital. When I got out I was ready for a change. I walked away from the RV and was full time at my tiny house village. At this time I got connected with Kate and Jaimie. They started showing up at my tiny village weekly, they helped me manage my medications, they showed up for me and really gave me the support I needed. They have been such a blessing for me. They have shown up for me even when I haven’t shown up for myself. I think that what they are doing def needs to be replicated and done more places. I’ve said for years that there needs to be more Johnny Ohtahs, but I now believe there needs to be more Jaimie Pechans and more Kate Smiths. I talk about my health conditions often so that others can get the help too. So with that I’ll end this with a huge thank you to Kate and Jaimie and the rest of their team. You guys are absolute legends and I’m so grateful to have you as a part of my care team.”
Looking Ahead: An Emerging Trend We Can’t Ignore
The presentation and Sierra’s story together highlight not only what is working—but also what is changing. A key theme that emerged is a growing and urgent trend:
an increase in young adults developing serious heart conditions, largely associated with heavy stimulant use.
Providers are seeing more individuals—many far younger than what is typical for heart failure—presenting with advanced cardiac issues. These are not isolated cases, but part of a broader shift that is becoming increasingly visible across systems.
For many young adults, stimulant use is intersecting with:
- Housing instability
- Mental health challenges
- Limited access to consistent healthcare
- Disconnection from traditional care settings
This combination is accelerating complex medical conditions that often go undetected until they reach a crisis point.
What makes this especially concerning is that many individuals are not engaging in care until they are already facing severe, life-threatening symptoms—often after multiple hospitalizations.
At the same time, this trend reinforces why models like the Harborview Community Heart Failure Program matter.
They are not only responding to crisis—they are:
- Reaching people earlier
- Providing consistent, community-based medical care
- Building trust through trauma-informed, low-barrier approaches
- Addressing both the medical and social realities individuals are navigating
As systems continue to evolve, this is something everyone—providers, policymakers, and communities—needs to pay close attention to.
The intersection of stimulant use and long-term physical health outcomes, particularly among young adults, is no longer emerging—it is here.
And how we respond now will shape what the system looks like moving forward.
Bridge Housing Updates: Progress Across SHB 1929 Providers
Following the presentation, the coalition heard updates from both SHB 1929 Bridge Housing providers, highlighting continued momentum and meaningful progress across programs.
Friends of Youth (FOY)
Friends of Youth shared that their second Bridge Housing home is opening next Monday, marking an exciting expansion in capacity. The new home includes an ADA-accessible unit, increasing accessibility for young adults with additional needs.
The program continues to demonstrate strong outcomes:
- There is still an active waitlist, reflecting ongoing demand
- All current residents have secured employment
- Each individual has housing plans lined up for their next step
FOY also highlighted a key challenge that continues to surface across the program:
substance use disorder remains the most significant barrier young people are navigating.
Despite this, all individuals in the home are actively working toward recovery and remain committed to their progress—underscoring both the complexity of recovery and the strength of the support model in place.
Excelsior Wellness
Excelsior Wellness shared updates on their continued program development and referral growth.
They have:
- Received referrals from STARS Recovery & Treatment
- Welcomed two new individuals into the program
They are also continuing to focus on increasing referrals across Eastern Washington, working to ensure more young adults in the region are able to access Bridge Housing services.
Legislative Engagement: Strengthening Referral Pathways
The coalition was also joined by Representative Davis, who brought valuable insight and practical recommendations to support the continued growth of SHB 1929 Bridge Housing programs.
A key focus of her input was increasing referral pathways and ensuring stronger connections between Bridge Housing providers and treatment systems across the state.
She specifically recommended leveraging existing statewide resource lists to expand outreach and coordination, including:
- The Washington State Residential and SUD Inpatient Treatment Centers Directory
- The Washington State Detox Services List
These resources provide comprehensive overviews of treatment providers across Washington and present an opportunity to:
- Strengthen referral pipelines from inpatient and detox settings
- Increase awareness of Bridge Housing as a step-down option
- Build more consistent transitions for young adults exiting treatment
Her recommendations reinforced the importance of intentional system connection—ensuring that providers across behavioral health, treatment, and housing are not operating in silos, but instead working as part of a coordinated continuum of care.
Legislative Update:
The meeting concluded with a legislative update from Jim Theofelis, who provided a high-level overview of the outcomes from the recent Washington State legislative session.
A central focus this session was the state budget, including movement toward addressing Washington’s historically regressive tax structure through measures such as the proposed “millionaire tax.”
In terms of key wins relevant to this work, Jim highlighted several important developments:
- Bridge Housing funding was preserved and fully funded for the biennium, ensuring continued support for this critical housing model
- HB 5957 passed, expanding the Office of Homeless Youth Advisory Committee to include additional voices, including individuals with lived experience, disabilities, and broader community representation
- HB 5911 made progress toward protecting Social Security benefits for youth in foster care, beginning to shift away from the long-standing practice of using those funds to cover the cost of care
At the same time, there were also challenges.
The Bridge Coalition was not included in the final budget, despite being included in earlier proposals. However, there is ongoing engagement with the Health Care Authority to identify potential funding pathways to sustain the work moving forward.
In response, NorthStar Advocates shared a strong commitment to continuity:
- The coalition will continue operating, even without immediate funding
- The team will absorb costs in the short term
- There will be an intentional effort to reflect on and strengthen the coalition’s impact
This moment is being approached not just as a funding gap—but as an opportunity.
Jim emphasized the importance of engaging coalition members in shaping what comes next:
- What is working well?
- What should be strengthened or expanded?
- How can the coalition continue to add value across systems?
Community Updates:
- No updates
Closing Comments:
- The next Bridge Coalition will feature Spokane Treatment & Recovery Services as well as the Lived Experience Advocates from NorthStar Advocates who will give their neurodivergence presentations and system recommendations.
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