For more than four decades, the process of deinstitutionalizing the mentally ill has been underway, with the idea that the isolation of long-term commitment to a psychiatric hospital was the wrong approach for most patients: usually dehumanizing, often ineffective and always expensive.
The idea of community treatment is a good one, on balance. People can live in a home setting, enabled by the advent of improved medications that can be self-administered, with outpatient treatment or shorter hospital stays as necessary.
That’s the ideal. However, the challenge faced by case managers is seeing that patients stick to their protocol, and that requires a lot more intensive oversight, often beyond the capacity of government agencies that help the ill, especially those of limited income.
The cutbacks in social safety-net programs in the wake of the recession compounded the problems.
Hawaii has not come to grips with this issue, not by a long shot. But there’s hope to be gleaned from the launch of the Community Care Services program.
Under this initiative, which is being rolled out this week, oversight of behavioral health services for Medicaid beneficiaries dealing with significant mental illness problems is being largely consolidated under the state Department of Human Services.
Previously, many of the duties were split between DHS and the state Department of Health. This streamlining should be a help in preventing some of the cases from slipping through the bureaucratic cracks. The goal is to improve delivery of health services, especially for the homeless beneficiaries of Medicaid.
Further, the passage of a law authorizing "assisted community treatment" also promises to yield improvement in outreach to the mentally ill who often live on the margins of society.
That legislation, which takes effect in January, will allow authorities to get a court order enabling them to intervene when a mentally ill person has fallen out of treatment, encouraging them to take their prescribed medication.
Without this intervention, some patients, who are often homeless, will commit crimes and end up in jail. They get released due to their illness, and the cycle begins again. The numbers caught in this downward spiral may only involve relatively few people, but they generate a lot of costs with repeated calls to police and other service providers.
Of course, holes in the safety net remain. Not all mental illnesses are covered, and not everyone is Medicaid-eligible. The Hawaii State Hospital principally serves those referred by the criminal justice system, and those who don’t have access to that often can’t afford other private care that’s available.
The reform of mental health services in this state is a long-term project, and it will be some time before all the pieces — including changes enabled by the Affordable Care Act — are in place. Still, short-range efforts to close some of the gaps must proceed promptly.
For example, federal authorities should approve a`proposal for Medicaid to cover post-traumatic stress disorder and substance-induced psychosis.
Lori Tsuhako, administrator of the DHS Homeless Programs Office, said this will help many of the homeless to gain services through a single stop.
Secondly, the Adult Mental Health Division of the DOH should restore coverage for those same conditions, as well as major depressive disorders that lack psychotic symptoms, as it resolves to do. This will help another sector of the community that’s marginalized.
Finally, the Legislature should take a hard look at budgets provided to these agencies to ensure that there is sufficient funding for programs aiding the mentally ill.
There has been a tendency to slash funds in recent years, and although this was driven by economic necessity, all that’s done is to put off problems that are now resurfacing in the form of an extremely vulnerable homeless population.
And this ultimately has cost Hawaii even more — in financial as well as human terms.
