Health officials are amping up for a major overhaul of Hawaii’s fragmented treatment system for people with mental illnesses and addiction.

A new vision for creating a unified, comprehensive mental health system in the islands is laid out in a legislative report prepared by the state Department of Health in collaboration with dozens of health care providers and law enforcement officers.

“What we really want to do is get to a place where people can get the same kind of treatment that we would expect someone to receive who is suffering from a heart attack,” said Eddie Mersereau, deputy director of behavioral health at the state Department of Health. “Because mental health and substance abuse are just as tragic and traumatic, if not more.”

The current system is rigid and siloed, according to the sweeping, year-long review. Systemic gaps and poor coordination of available resources is putting a drain on hospitals, jails and police departments. People with serious mental illness aren’t getting adequate help, often becoming sicker as they recycle through the system.

Fence runs along some of the Hawaii State Hospital's bordering area with the Windward Community College campus. The fence ended on the Kahaluu side along where the road met up with the road that runs thru Windward Community College.
DOH wants an old building at the Hawaii State Hospital to be used for those voluntarily seeking treatment. The rest of the hospital takes patients committed through the criminal justice system. Cory Lum/Civil Beat/2017

“No behavioral health care provider or system is an island unto itself,” Mersereau said. “But more or less we’ve been functioning that way. There are gaps to fill, but what we really need to do is leverage the resources we already have. We don’t have the kind of coordination that has been achieved, to some degree, in the medical profession.”

A key feature of the plan is to redirect people experiencing a mental health crisis out of hospital emergency rooms and into psychiatric or substance abuse treatment specifically tailored to their level of need.

In turn, hospital emergency departments would handle only the most severe and acute mental health patients. Namely, those in which a doctor has determined that the patient poses a danger to himself or others.

Rather than the starting point for treatment, the ER would be a resource reserved for people needing the highest level of care. Patients with less severe symptoms would be matched with more suitable treatment options.

To achieve this goal, the state plans to expand treatment services already in existence, such as outpatient treatment and long- and short-term residential care.

The system, Mersereau said, must be flexible to the ebbs and flows of patients’ conditions.

“In the new behavioral health world that I want us to get to, we would have a system that would support a person in a long-term residential setting,” he said.

“And rather than kicking her out the second that she starts to decompensate, I’d rather pull her up to a higher level of care for a short period of time to help her get stabilized and then bring her right back down to where she was again.

“What happens now is that people get blacklisted. They don’t get second and third chances.”

Getting People Out Of The ER

Plans to expand treatment options with new mental health “stabilization” beds are already underway. Last year the DOH launched a pilot project to offer short-term care in a hospital setting to patients who aren’t so sick that they need to be hospitalized in the ER but are not functioning well enough to return home.

In the current system, these patients are often treated at the ER and then discharged on to the street, only to experience repeated hospitalizations or brushes with law enforcement, sometimes just days after their release.

In many cases, the ER is not well equipped to provide care to people with psychiatric disorders. There are often long wait times for treatment as staff work to cobble together resources to fit the patient’s needs. This in turn increases wait times for patients with physical health emergencies.

The ER is also one of the most expensive venues for treating mental illness.

Queens Emergency Room.
The Queen’s Medical Center treats more emergency psychiatric patients than anywhere else in the state. State mental health officials say more alternative treatment options are needed. Cory Lum/Civil Beat

There are other gaps in the system that need to be filled with new treatment options, Mersereau said. But first, the DOH needs to partner with providers to better coordinate the resources that already exist.

“The idea that we just need more hospital beds — that that’s the silver bullet — is way too simplistic,” Mersereau said. “Say we magically could build a facility with 1,000 beds. If we keep doing things the way we’re doing it now, those 1,000 beds would be gobbled up immediately and we would not have any improvement.”

Stars Are Aligned For Change

Another goal of the health department is the development of a robust tele-psychiatry system in the next two years. This would reduce the numerous barriers to getting psychiatric care from a specialist, including Hawaii’s rural geography, a statewide shortage of psychiatrists and the stigma of mental illness.

Holding all of these efforts together is a big push to centralize and standardize data collection, intake criteria and treatment protocol among behavioral health providers. In the same way that most doctors would offer identical care to a patient whose leg is broken, Mersereau said the goal is to develop a uniform patient response system across the private and public sectors.

“It really feels like the stars have aligned for us to actually implement all the things that we know need to happen for behavioral health,” Mersereau said. “There’s a real groundswell of community will and political will for us to not let this be another report that gets put on the shelf.”

This year, DOH officials are requesting that legislators give them permission to use existing funds in a mental health and substance abuse special fund to pay for the rollout of new stabilization beds that are currently being tested in a pilot program.

Another request has to do with the $161 million Hawaii State Hospital facility, which is on track to open in 2021. The new 144-bed building is expected to relieve long overcrowded and dilapidated facilities.

But rather than shutter the outdated, 90-bed Guensberg building, the DOH plans to ask lawmakers for capital improvements to keep the building open for psychiatric patients who are seeking treatment voluntarily.

The mental health system needs to get to a place “where people can get the same kind of treatment that we would expect someone to receive who is suffering from a heart attack.“ — Eddie Mersereau, Hawaii Department of Health

This calls for a paradigm shift. Virtually all admissions to the hospital involve patients who were committed to the custody of the Hawaii Department of Health by state courts after getting arrested.

The result would be a much higher net gain in psychiatric beds and an opportunity to care for patients other than those who’ve been court-ordered into treatment.

The DOH also wants the Legislature to fund the building of tiny homes on the state hospital grounds as transitional living quarters for patients on the verge of being discharged from the hospital.

“As a department we recognize that we need to do better,” Mersereau said. “We recognize that we need to move the needle. We also recognize that it’s not going to be just us dictating how it’s going to be. We need to make sure that we’re working with other stakeholders to make it happen. Right now there’s a lot of momentum.”

Involuntary Hospitalization Task Force Report Final (Text)

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