An agitated homeless man barreled down Seaside Avenue in Waikiki on Thursday, hurling obscenities at passers-by.
Lunch-goers in the busy visitor district quickly sidestepped his oncoming, overflowing cart.
Scenes like this have become common for the many tourists, residents and workers in the area.
"Everyone’s complaining," said Waikiki Neighborhood Board member Walter Flood. "No matter what the city and state do, (the homeless) keep coming back. … Some of them are physically and mentally sick. We’ve seen them stay so long that they die on the streets. It’s worse than ever."
Data show an increase in the number of homeless people suffering from mental illness in Hawaii over the past several years, which has also seen a decrease in support services.
According to the Honolulu Emergency Psychological Services and Jail Diversion Program, calls to police psychologists involving homeless adults have risen 300 percent since January 2010, averaging about 60 calls per month. The trend is especially true for Waikiki, which since 2007 has received 472 percent more calls for police psychologists than is expected for an area with its population size, according to the HPD program.
Still, several state and city efforts to tackle the challenge in Waikiki and throughout the state are creating pockets of hope that Hawaii’s mentally ill homeless people will get more help. It is also expected to bring relief for overburdened emergency rooms, courtrooms and jails.
For starters, the state is rolling out its new Community Care Services program today. The program gives the state Department of Human Services oversight of behavioral health services for Medicaid beneficiaries with severe mental illness and serious persistent mental illness.
Since some of the services were once split between DHS and the state Department of Health, both say the streamlining is expected to ease implementation of the Affordable Care Act, produce greater state efficiency, optimize federal funds, increase continuity for health care providers and beneficiaries, and broaden the range of mental illnesses that are eligible for services.
The Assisted Community Treatment Law, which the state Legislature passed last session and takes effect in January, provides a legal way to encourage people to receive treatment if they are unable to consent because of their illness. The new law allows authorities to get a court order urging a mentally ill person to take their medication.
The Health Department also expects to find out this month if it will get funding from the federal Substance Abuse and Mental Health Services Administration. One grant would provide $10 million over four years for screening and brief interventions in community health centers. The other would pay $700,000 a year for three years to provide housing with services for chronic homeless people with substance abuse.
When combined with a commitment from the HPD Psychological Services and Jail Diversion Program to divert more mentally ill people from the criminal justice system into the mental health system, supporters say that these changes could vastly improve life for Hawaii’s mentally ill homeless people.
It could be welcome relief for a population who typically show high levels of arrest and poor access to health care. Consider:
» The 2013 Point in Time Count, which measures the state’s homeless population on a specific day, showed an 11.9 percent year-over-year rise in severely mentally ill homeless and a 126 percent increase in those with chronic substance abuse, which some consider a mental health concern.
» New data from the HPD program show that arrests of homeless people tripled and arrests of homeless people with mental illness quadrupled between 2010 and 2012.
» In 2012, 44 percent of everyone arrested on Oahu suffered from severe mental illness and/or severe substance abuse. In addition, 39 percent of everyone who was arrested was homeless, and 58 percent of this population suffered from severe mental illness and/or severe substance abuse.
"I would bet the vast majority of people who are seriously mentally ill and homeless end up in jail," said Michael Christopher, a police psychologist who coordinates the HPD program. "It’s much cheaper to divert them."
It’s also less costly to make sure that people get medical coverage for the care that they need, said Marya Grambs, executive director of Mental Health America of Hawaii, the state’s oldest mental health education and advocacy organization.
After state cutbacks in 2009, the Hawaii Health Information Corp. noted that the emergency room charges for those with severe mental illness and substance abuse increased 46 percent in a three-year period to nearly $31.7 million. Likewise, inpatient charges for the same population during the same period rose nearly 22.6 percent to nearly $66.7 million.
Grambs said another indicator of the results of the cutback of services is the dramatic increase in the census at Hawaii State Hospital, which accepts only court-ordered patients. Adult Mental Health Division Administrator Mark Fridovich said the state hospital houses about 240 patients, each costing about $250,000 annually and comprising a third of his total budget.
"We want folks to get effective treatment before they get charged with a crime," Fridovich said.
Patti Bazin, DHS’ Health Care Services Branch administrator, said the state plans to expand Community Care Services to include peer specialists, money management services, housing support and job training. The department also hopes to expand behavior health eligibility for Medicaid recipients, she said.
"We still don’t have the funding for substance-induced psychosis and PTSD, but we are working on covering it by Oct. 10," she said. "We are waiting for the Centers for Medicare & Medicaid Services to approve it. Anyone who is a Medicaid beneficiary who has that diagnosis would be able to access those benefits through CCS, MedQuest or through (the Adult Mental Health Division)."
The state’s behavioral health transformation should make it easier for homeless people, especially those with mental illness, to secure the services they need and for providers to respond promptly, said Lori Tsuhako, DHS’ Homeless Programs Office administrator.
"There are a lot of folks on the street homeless with PTSD and many with substance abuse-induced psychosis and many with just substance abuse," she said. "Now, someone who is in need won’t have to talk to 10 places; they can talk to one agency. That’s good because it’s hard to overcome challenges like when a person is paranoid and wants to know why you need their name or Social Security number. Also, when the person is ready to move into housing, we want to be in a position to strike while they say ‘yes,’ before they have a bad day or change their mind."
The state Adult Mental Health Division is bolstering its own support by considering expanding police psychologists to the neighbor islands. It’s also trying to restore its coverage for PTSD, substance-induced psychosis and major depressive disorder without psychotic symptoms.
The division’s eligibility changes are pending an internal review, public hearing and a Hawaii Administrative Rule change; however, Fridovich said he’s optimistic it could happen by the end of 2013.
"Many more people will be covered than were covered or were coverable in 2009," said Fridovich, who estimates about 2,500 of the people in the system have conditions that would benefit from these eligibility changes.
Still, some question whether Community Care Services truly will improve access to health care and delivery for beneficiaries, especially for the harder-to-reach homeless population.
Chad Koyanagi, a community psychiatrist working at Castle Medical Center and the Institute for Human Services, said he’s cautiously optimistic about CCS, but warns that it will need strong leadership from the Department of Human Services and collaboration with the Health Department and homeless outreach and housing providers.
"The mentally ill population has been the throwaway of our health care system over the last 10 years. The system as it is doesn’t focus on preventing people from ending up in that condition," Koyanagi said. "One of the main weaknesses is that once a client gets so impaired that they become homeless, a lot of agencies don’t know what to do with them anymore so they fall out of care."
