After years of cuts, the state is gradually restoring adult mental health services and looking to streamline operations in an effort to rebuild a safety net that advocates say is failing too many.
The work comes as the population at the Hawaii State Hospital, the only state-run psychiatric facility in the islands, remains well above normal since swelling over the summer.
Police are also reporting more mentally ill people requiring transport to emergency rooms, according to a Department of Health report.
State officials say bolstering key services, including case management hours and crisis intervention, will ensure more people with severe needs are helped — and helped earlier.
But given budget constraints, officials also emphasize they’re restoring services in a measured way. "We want to give people the right amount of resources for the right amount of time, not necessarily a fixed amount," said Mark Fridovich, acting chief of the Adult Mental Health Division.
Lynn Fallin, Department of Health deputy director for behavioral health, added, "We have an opportunity to build back in an informed way, based on experience."
Advocates and mental health division clients are welcoming the state’s pledge to provide a more robust network, saying improvements are overdue.
"It’s kind of obvious that those cuts took a toll," said Louis Erteschik, executive director of the Hawaii Disability Rights Center, which monitors conditions at the Hawaii State Hospital. "There’s a lot of people who used to be served by the system who have been cut out."
Erteschik said of the DOH, "I do feel like they’re moving in a better direction."
The DOH began making big cuts to adult mental health programs in 2009 to meet severe budget reductions. Among services hurt were specialized residential treatment programs, homeless outreach, crisis intervention, case management and respite care. Nearly 60 people were laid off at community mental health centers, the Hawaii State Hospital and the division’s central office, and a hiring freeze meant key positions went unfilled.
The DOH also revised eligibility requirements, no longer covering such ailments as post-traumatic stress disorder.
The division largely serves people who have no insurance or who receive government-funded medical care, so mental health advocates worried that those ineligible for state services would have no other place to go.
The DOH’s figures show the number of people served by the division has declined every year since 2008.
In fiscal year 2012 the division helped some 11,062 people with everything from intensive service needs to brief support during a crisis. That’s down 32 percent — or by 5,108 people — from fiscal year 2008, when the division served 16,170 adults.
"When the cuts happened in 2009, we felt it," said client Robin Hart, 51, of Nuuanu.
Hart, speaking at one of the state’s psychosocial rehabilitation centers (called clubhouses) on a recent weekday, said the reductions meant some people who were on the edge fell off.
"Some of us didn’t make it," she said, adding that she knows of one former client who is now homeless and very bad off.
Several other clients at the Hale o Honolulu Clubhouse nodded as Hart spoke, and agreed the service cuts were jarring and difficult.
Jonathan Inouye, 31, of Waikiki said he was able to muddle through, but a friend wasn’t so lucky. "She’s not doing so well," he said. "She became more isolated. She doesn’t go out."
THE rising population at the Hawaii State Hospital over the summer prompted the state’s urgent look at its delivery of mental health services. A "special action team" that studied the situation issued a report late last year, making a host of recommendations aimed at expanding services and diverting the mentally ill from the streets, the state hospital and jail.
Virtually all the patients at the state hospital in Kaneohe are "forensic admissions," which means they were ordered there by a court.
As of Friday the state hospital’s population was 227: 187 at the hospital and 40 at a private facility contracted by the state. In June 2010 the average daily census was 199:183 at the hospital and 16 at the private facility.
The numbers are expected to lead to an operating deficit for the facility of about $4.8 million this fiscal year.
The team’s report also said police had reported an increase in those with mental illnesses needing emergency help. In fiscal year 2011-12, Honolulu police transported about 1,600 people with mental illnesses to the emergency room at the Queen’s Medical Center, according to the report. That’s about double the total seen in the previous fiscal year.
Department of Health Director Loretta Fuddy, who was appointed in 2011, said in order to address that apparent increase, "we needed to look at how we could improve on our systems internally." But she added that money is still tight, so the restoration of services will be gradual. "It’s not the same environment that we were (in) five years ago, and I guess people need to recognize that," she said.
For now, services are being expanded within the department’s existing budget, thanks to cost savings during the hiring freeze and other efficiencies.
Among services fully or partially restored are case management hours and crisis intervention.
The DOH also is looking at hiring to bolster its suicide and mental health crisis hotline, where staffing issues have meant many calls were diverted to a recording.
More staff also are to be hired at the division’s 10 clubhouses statewide.
Kathleen Rhoads Merriam, statewide clubhouse coordinator, said staff additions will allow the centers to boost workforce development and other programs.
While the number of clients going to clubhouses has remained steady in recent years, the number of program hours at the centers has declined.
"What I’m thankful for is that we still have clubhouses, because a lot of programs have been cut," Merriam said. "But they’re not at the level of care that I would like."
At Hale o Honolulu on a recent morning, about two dozen clients were participating in different activities: cooking, reading, working on computers.
Hart said she came that day for breakfast because her cupboard was bare. Tears filled her eyes as she talked about the program.
"I’ve been a member for 10 years," she said, adding that it has given her an opportunity to make friends and seek employment. "It’s really revolutionary."
WHILE SOME services are being restored now, Fuddy said other changes, such as expanding eligibility for services, will require additional funding.
The DOH is looking to again cover people with post-traumatic stress disorder and substance-induced psychotic disorder. Fallin, of the DOH, said the eligibility changes would likely happen in fiscal year 2014 if a legislative appropriation is approved.
Marya Grambs, executive director of Mental Health America of Hawaii, said she’s heartened by that possibility but is concerned that those who are suicidal and have major depression still will not be helped.
"Especially around suicide, we used to cover it all," Grambs said. "And then it got reduced to only psychosis, which is the most severe end of mental illness. But there are a lot of other mental illnesses in which people can’t function."
The DOH also hopes to better coordinate efforts with primary care providers and is working with the Department of Human Services to seek federal matching Medicaid dollars for adult mental health programs now fully funded by the state.
DHS is also in talks with the DOH to better streamline delivery of services and to cut the bureaucratic maze that many clients —and their case managers — must navigate to secure services.
About one-third of the division’s clients are on Medicaid, though many more probably qualify for the government-funded health insurance program for low-income seniors or those with disabilities.
Pat McManaman, DHS director, said the efforts under way ultimately will provide easier access to care so people don’t end up at the Hawaii State Hospital or on the streets, or cycle through both.
"All of this fits together," she said. "The idea is you provide a comprehensive wraparound of services to stop the revolving door."
