Because of a sharp increase in the number of patients at the Hawaii State Hospital, the state is restoring some mental health services that were cut in 2009 and is working to keep severely mentally ill patients off arrest logs.
Overcrowding at the Kaneohe facility, the only state-run psychiatric hospital in the islands, grew so acute during the summer that the governor convened a task force to deal with the problem.
Virtually all of the patients at the hospital are "forensic admissions," which means they were ordered there by the courts after an arrest.
Last week, the hospital had 188 patients, 20 more than its budgeted capacity. Another 40 patients were being cared for at a private facility at public expense. The daily per-person cost for those contracted beds is about $750.
Loretta Fuddy, director of the state Health Department, said she believes eliminating adult mental health services in 2009 because of budget shortfalls are behind the increased number of patients.
"One could have predicted that when you cut the safety net, it doesn’t appear overnight, in terms of increases for demands for services," Fuddy said in an interview last week. "People really try to manage as best they can and then it bubbles up to a crisis. I think what we were seeing (at the hospital) was basically a crisis, the tipping point."
To tackle the problem, the department has partially restored some services — and is considering the possibility of more expansions.
In August, the department made it easier for severely mentally ill clients to receive additional publicly funded help.
The department has also increased mental health crisis services, though they are still far shy of pre-2009 levels, and is studying the possibility of reviving specialized treatment teams that provide intensive mental health outreach services.
Fuddy said the state is focusing on a "holistic approach," and getting help to people earlier so fewer will end up at the hospital. Mental health advocates are applauding the services increases, but emphasize more must be done to meet the needs of those with severe mental health problems.
With reduction of services, "what you see happening is that people start falling through the cracks," said Marya Grambs, executive director of Mental Health America of Hawaii. "There’s not a safety net of services. There’s not enough front-end services to keep people from getting sicker and sicker."
The increased number of patients at the hospital comes six years after federal monitoring of the facility was lifted, and as police and service providers report greater numbers of people with severe psychological needs.
Michael Christopher, a psychologist for the Honolulu Police Department, said police are responding to more emergencies involving people in a mental health crisis.
In such instances, officers call one of two HPD on-call psychologists for guidance on whether a person should be involuntarily taken to a hospital.
In the past 12 months, HPD psychologists got about 3,500 crisis calls, up from about 1,300 in 2007, the first year of the program.
Christopher notes that some of that increase can be attributed to improved training, and police knowing which situations warrant a call.
However, "the data also indicate that the number of people with untreated mental illness is going up," he said.
About 85 percent of the calls to the psychologists result in an involuntary trip to one of three Oahu hospitals with psychological units, he said. About 7 percent of cases result in arrests, either with or without a mental health intervention.
Christopher said HPD is working with the department to strengthen its on-call team and provide improved intervention services. The department has said it may be able to fund at least one additional psychologist position at HPD.
"We’re trying to coordinate so more people get help and don’t get clogged up in the criminal justice system," he said.
Dr. Michael Sheehan, chief of the state Adult Mental Health Division, said courts are referring more than 25 percent more people to the hospital for sanity examinations compared with years past.
Hospital officials say those who do end up at the facility appear to be, on the whole, much sicker, both physically and mentally.
During the summer especially, when the numbers were particularly high, "there was a high level of acuity," said Mark Fridovich, hospital administrator. "People were coming in quite sick, including quite physically sick."
The current hospital census of 228 patients is down slightly from a high of 232 in June, but is still more than 20 patients higher than the norm seen in the past three years.
Fridovich said in a busy month last year, hospital admissions would average 18 to 20.
But starting this summer, admissions climbed. For several months, the hospital had about 29 admissions per month. In May, 37 people were admitted.
Last month, the hospital expected to close out at 26 admissions.
Also this summer, Fridovich said, the hospital started seeing more new names. He estimated about half of the hospital’s patients have never been on the state’s mental health rolls. Previously, about one-third of the hospital’s patients were not "known to the system."
After seeing the increase, the governor convened a task force to look at the problem.
The panel of state health, public safety and human services officials along with mental health advocates is designed to improve coordination among agencies and come up with short- and long-term solutions to overcrowding.
Fuddy said restoring some services is expected to alleviate some of the problems, but she added there is work under way to study what more can be done to bolster community mental health services without dramatically increasing spending.
The department says the most recent service restorations are covered by its existing budget.
Advocates and state health officials say among the biggest long-term concerns for the hospital is the lack of facilities in the community capable of taking patients once they are stabilized.
"We’re finding it difficult trying to find placements because they’re very complex patients and require multiple levels of care," Fuddy said.
This isn’t the first time the state has had to deal with overcrowding at the hospital. But the last time there were so many patients under the hospital’s care was in early 2008.
In 2006, the hospital was averaging more than 193 patients, with an additional 40 patients being cared for at a private facility by Kahi Mohala Behavioral Health.
Two years later, the state was able to reduce the number of contracted Kahi Mohala beds to 32. In 2009, the contract went to 16 beds.
But in July, with admissions way up, the state brought the figure back up to 40.
The addition of 24 contracted beds is costing the state about $18,000 a day — or about $540,000 a month.
Sheehan said while it’s difficult to pin the increases at the state hospital solely on cuts to the mental health safety net, "there must be something happening."
The cuts, which included changes as to who is eligible for state-funded services, resulted in thousands fewer people on the state’s mental health rolls. In fiscal year 2012, the Adult Mental Health Division served 11,062 people in some capacity, from one crisis visit to an array of intensive services.
That’s way down from the 16,000 people being served in 2009.
Still, the number of people being served by the division is far higher than fiscal year 2003, when about 5,200 people received some type of state-funded mental health service.
The growth in clients in the past decade, only slowed by the 2009 cuts, was spurred by public outcries about the condition of the state’s mental health system. After a 1991 federal lawsuit, the state entered into a consent decree that kicked off 15 years of federal oversight of mental health services and treatment.
Mental health advocates say while the state’s system and its only state-run psychiatric facility is still far better today than it was in 1991, there is reason to be concerned about the recent increase of patients.
"To me, it’s like the pot boiling over a bit," said Louis Erteschik, executive director of the Hawaii Disability Rights Center, which regularly monitors conditions at the state hospital. "You begin to see the effects of what happens when you cut back on services."
