At Hawaii’s first summit meeting on community mental health responses, Hawaii Chief Justice Mark Recktenwald had a request for officials from state agencies.

“Imagine individuals receiving more appropriate treatment in a more timely manner,” he said. “Imagine a safer community.”

Judges, law enforcement officials and health agency representatives filled a room on Wednesday at the Hawaii State Supreme Court for the inaugural Hawaii Summit on Improving the Governmental Response to Community Mental Illness.

Their discussion focused on how Hawaii government agencies can guide people with mental illness to proper health care services before they repeatedly cycle through jails, hospitals and courts.

“This is groundbreaking and something we’ve been waiting on for at least 25 years, at least from my capacity at the hospital,” said Run Heidelberg, the Hawaii State Hospital administrator.

“To be able to bring all these different agencies together for one mission gives me chills just thinking about it. You have law enforcement, the judiciary, prosecutors and judges talking about the same subject — mental illness, and the trifecta of mental illness, homelessness and substance abuse.”

The long wait for mental health treatment for those who find themselves in jail after they commit misdemeanors is inefficient, Recktenwald said.

During 2017 and 2018, the Hawaii Department of Public Safety held 275 pretrial detainees in that category. The detainees with mental illness spent a cumulative 12,000 days occupying bed space at DPS before they were transferred to the Hawaii State Hospital, according to Recktenwald.

The chief justice said he hoped to see a reduction in the number of “704” acquittal filings to ease the strain on the judicial system. In the first 10 months of 2019 alone, there were 440 of those filings from people who cited health issues that made them incapable of standing trial.

“The amount of time that people are spending while these determinations are made … it seems like a very inefficient way to use resources,” Recktenwald told Civil Beat. “There are options that are important for us to consider so that people who don’t pose a danger can get the kind of treatment they need.”

The all-day conference was hosted by the State Justice Institute, National Center for State Courts, Conference of Chief Justices and the Conference of State Court Administrators.

It was an opportunity to look at pre-arrest and pre-court diversion routes for people experiencing mental illness that have been tried and tested in other states.

Lessons From The Mainland

Guest speakers from Florida and California shared lessons learned from their jurisdictions.

Almost 20 years ago, Miami-Dade County officials in Florida held a similar state agency summit, said Florida Associate Administrative Judge Steve Leifman.

“We literally mapped out how our community mental health system intersected with our criminal justice system and what we found out is that it just did not,” he said. “We were frankly embarrassingly dysfunctional. After mapping it out on paper and on boards, it was very vivid for everybody and we started to look at how to fill those holes.”

Miami-Dade County implemented two pre-adjudicatory diversion systems: one program for pre-arrest, the other for post-arrest.

New criteria identified which misdemeanor detainees could be voluntarily transferred to a “crisis stabilization unit” within three days. Any detainee who entered the program would receive a criminal hold, so the Florida law that forbids a holding time of more than 72 hours no longer applied.

In Hawaii, by contrast, patients who are mentally ill or in crisis may not be involuntarily held by doctors more than 48 hours.

Ultimately, Miami-Dade County was able to close one of its three jails and reduce recidivism among program participants from 72% to less than 20%. It’s been a two-decade-long collaborative effort, and the next step is to open a 181,000-square-foot diversion facility that offers an array of services under one roof.

“We don’t believe you should have to take a plea to get services,” Leifman said. “It’s like having cancer or heart disease — should you take a plea to get access to care? It’s ridiculous so we avoided that. We monitor the person. It’s not a one shoe fits all.”

Los Angeles County District Attorney Jackie Lacey said she took note of what was happening in Florida.

In 2015, the Los Angeles County Board of Supervisors created an Office of Diversion and Reentry in its health services department.

The county also increased the number of crisis response teams, and the district attorney’s office began to offer de-escalation training for police officers and dispatchers. Legislation also made it possible for judges to divert detainees without a guilty plea, excluding those who committed sex crimes or faced murder charges.

This January, Lacey launched the first Mental Health Division at the district attorney’s office to assist attorneys as they implement California’s new pretrial mental health diversion law.

Lacey said the results have been encouraging, considering Los Angeles County is home to 10 million people and under the purview of many agencies.

“If it can happen in that mess, it certainly can happen in Hawaii,” she said.

A Diversion Model For Hawaii?

Margie Balfour, the chief of quality and clinical innovation at Connections Health Solutions in Arizona, said the physician-owned clinic’s diversion model has made strides in reducing the use of jails, emergency departments and hospitals.

There’s a new crisis hotline, mobile crisis teams, and a physical crisis response center. Like Florida, it’s been a two decade effort, but the easy access for law enforcement officials to drop off patients within minutes has made a tremendous difference, she said.

“We have a facility that can take everybody,” she said.

In May, Hawaii lawmakers updated a state law in an effort to make it easier to assist people with serious mental illness into treatment. Many of those people do not have permanent housing and live on the street. About one-third of people experiencing homelessness in Hawaii have a mental illness.

Earlier this year, the Honolulu Police Department initiated crisis intervention and mental health first aid training. It is still waiting on funding to launch a mobile unit to assist people with mental illness.

And Honolulu’s new Law Enforcement Assisted Diversion Program, or LEAD program, has assisted about three dozen people whose criminal activity is due to behavioral health issues. Low-level offenders are referred to case management at the Hawaii Health and Harm Reduction Center, rather than immediate arrest.

In response to some of the suggestions posed by panelists, Rep. Joy San Buenaventura, chair of the House Human Services Committee, said Hawaii lacks qualified personnel.

“I was a criminal defense attorney before I became a legislator, so I know how we treat 704s,” she said. “We need mental health social workers. That is the biggest problem we have because no amount of theory about how to divert will work if there are no mental health social workers out there who will help treat and stabilize.”

Recktenwald said solutions such as opening a crisis center could be a possibility for Hawaii.

“To make that happen we need to work with the Department of Health and providers in the community to make sure those resources are in place,” Recktenwald said. “You can’t have a meaningful diversion system unless you actually have appropriate resources and a place you can take people to get treatment or care.”