Across Oahu every day, outreach workers from ‘Ohana Health Plan work with nearly 90 “Level 5” chronically homeless clients such as Jeffrey Chipman, who sees people who do not exist and hears voices telling him to kill himself.

Chipman struggled the other day to remember how old he is — he’s 52 — outside of Chinatown’s Mental Health Kokua offices, which he visits every day to get daily medications, including an antipsychotic injection.

Chipman has been housed before, but got evicted because of his drinking and because he invited in homeless friends who trashed his place.

So a special team of ‘Ohana Health Plan workers work specifically with the most complex Level 5 candidates on Oahu such as Chipman. They include five Oahu case managers, a Level 5 housing coordinator, a psychiatrist and a psychiatric nurse, a certified substance abuse counselor and two mental health supervisors.

‘Ohana Health Plan is the only organization in Hawaii contracted through a Med-Quest program that serves Medicaid adults who qualify with a diagnosis of a serious and persistent mental illness, according to Theresa “Reese” Lyons, director of ‘Ohana Health Plan’s behavioral health community care services.

Kelly Whipple, ‘Ohana Health Plan’s behavioral health supervisor, defined Level 5 clients as “actively psychotic, with multiple suicide attempts who are frequently at the hospitals. They may have physical conditions, substance abuse issues and often are difficult to engage with and haven’t been able to be successfully treated in the past.

“A lot of the Level 5s were sent to us because nobody else really knew what to do with them,” Whipple said. “We don’t give up on people even if they‘re not ready for housing, even if they’re not ready to take medications. A good portion of our folks don’t even want to see a psychiatrist, and so we try to meet our members where they’re at. … We walk beside them through their problems and through their issues. Not judging them. Meeting them where they’re at.”

Across the islands, ‘Ohana Health Plan works with 125 Level 5 clients, but the overwhelming majority — 88 as of last week — were on Oahu.

The job requires patience, consistency and collaboration with a wide range of partners including organizations, such as the Honolulu Police Department and The Queen’s Medical Center, that are also working to reduce homelessness, especially for people with mental health and substance abuse issues.

“‘Ohana has stepped up,” said Carla Houser, executive director of Kailua’s RYSE (Residential Youth Services and Empowerment), which helps young adults ages 18 to 24 who would otherwise be homeless.

Out of 30 beds at RYSE, six or seven are regularly occupied by Level 5 clients being helped by ‘Ohana Health Plan’s so-called “wrap-around services.”

One of them, who is diagnosed with autism spectrum disorder, had been at Castle Medical Center for a year because of “self-harming behavior” until she arrived at RYSE in May.

Working with ‘Ohana Health Plan is “especially crucial for young people that are still trying to figure out Adulthood 101,” Houser said. “A really skilled medical provider team is really essential.”

In Kalihi, ‘Ohana Health Plan is working with Justin Ka‘alekahi, 37, who now is thinking of getting an apartment of his own after years of chronic homelessness and substance abuse.

He had been sleeping around the Institute for Human Services in Iwilei and St. Elizabeth’s Episcopal Church in Kalihi until he moved in with his grandmother eight months ago.

But they have a rocky relationship, and Ka‘alekahi believes his best chance at staying sober is to find his own place outside of Kalihi.

At the same time that he’s working on his sobriety, Ka‘alekahi also needs to manage his Type 2 diabetes and is classified as a “super user” at Queen’s for diabetes-related treatment, along with “major depression.”

Since he started working with ‘Ohana Health Plan’s outreach workers and getting treatment, “I don’t walk around talking to myself anymore,” Ka‘alekahi said. “They hooked me up with resources. I’m not sabotaging myself all the time. I’ve just got to keep it real.”

Ka‘alekahi said the people at ‘Ohana Health Plan “did their job. They helped me realize there are choices.”

Chipman also realizes the importance of consistency and routine.

But he’s not even thinking of getting housed. Chipman just wants the voices in his head to stop.

Chipman lives on the street around University Avenue and King Street. He recently lost his bus pass.

So to make his daily appointment in Chinatown, Chipman woke up at 4 a.m. the other day and walked 3-1/2 hours to get to Mental Health Kokua, which manages his medications and metes out his Social Security disability payments so he doesn’t spend them all at once.

Whipple first met Chipman three years ago, when he would cut his wrists in front of her.

He’s survived several other suicide attempts, which included a self- inflicted gunshot to the head with a .38-caliber handgun that left him with seizures; a jump out of a second-story window; and a leap in front of a bus.

“He hasn’t been going to the hospital as much and hasn’t cut himself for three months,” Whipple said. “That’s huge. He used to cut himself every single day.”

As Chipman spoke to the Honolulu Star-Advertiser, he kept snapping green rubber wrist bands provided by ‘Ohana Health Plan to remind himself not to cut himself on either his wrists or his throat, which he’s also done.

“At Queen’s I get frequent- flyer miles,” Chipman said. “That’s what the charge nurse told me.”

Asked why he ever wanted to kill himself, Chipman said, “’Cuz they told me to.”

Asked to explain, Chipman said he sees people that only he can see and hears voices that only he can hear.

“They say, ‘Die and hurry up. Don’t listen to nobody but us.’”

If he ignores the voices, Chipman said, “Then they get really mad.”

But when he follows his routine and stays on his medications, Chipman said the voices “calm down a little bit.”

He could not remember many details of his life, such as his age, how long he’s been homeless or where he’s from.

But Chipman said he does understand the link between treating his mental illness and the help he gets from ‘Ohana Health Plan.

”I don’t want to mess up,” he said.