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Virus clouds prospects for Hawaii’s mental health reforms

HONOLULU — Among the business Hawaii lawmakers left unfinished when they abruptly suspended the Legislature to help slow the spread of the coronavirus were proposals to improve psychiatric care for the state’s mentally ill.

Lawmakers had convened with a new sense of urgency on this topic after a Honolulu man shot and killed two police officers, fatally attacked his landlord and burned down several houses in a morning of stunning violence in January. The man’s neighbors had sought restraining orders against him, detailing his erratic, violent behavior in court filings.

Yet just two months later, uncertainty is clouding the bills’ prospects as the number of people testing positive for the coronavirus increases daily. A mandatory 14-quarantine for all arriving travelers and a statewide stay-at-home order have crippled the state’s tourism industry and are expected to make a large dent in state tax revenue. Lawmakers don’t know when they’ll be able to resume deliberating.

The proposed reforms come as Hawaii tries to shift toward more assertively nudging, or even forcing, people to get care when medical professionals and judges determine it’s necessary.

Ed Mersereau, who leads the state Department of Health’s behavioral health division, noted that historically, the mental health care pendulum in Hawaii and the rest of the U.S. has swung from relatively easily committing people to a very hands-off approach.

“These measures are designed to bring us a little bit more of a middle ground,” Mersereau said.

Some proposals, notably one that would increase the amount of time hospitals may hold a patient against their will in an emergency to three days from two days, have generated objections on civil liberties grounds.

The state public defender said this rule would allow someone to be held five or six days if they were brought in over a weekend or a holiday.

“This exceedingly long detention period based upon a police officer’s opinion and a mental health emergency worker’s over-the-telephone judgment is not justifiable,” the public defender’s office said in written testimony.

Mersereau hopes the state will address the virus and mental health care in tandem because helping the mentally ill is also a way to help limit the pandemic. Many struggling with mental illness are living on the streets and coming into close contact with people with substance abuse disorders and other conditions that put them at risk, he said.

“If it becomes more of an issue and community spread becomes the issue, we’re going to see the mental health and substance abuse populations pretty hard-hit, and those are going to be hotbeds for additional community transmission,” he said.

One bill would create what are called stabilization beds, where patients could spend about a week getting treatment.

Hawaii lacks such beds even though Mersereau said not having them is analogous to a medical hospital not having a recovery room where patients can go after spending time in intensive care.

Their absence means patients are often released from the emergency room to their families, the streets or a homeless shelter if they’re not sick enough to warrant acute psychiatric care. But these patients often wind up returning to the emergency room soon after because they’re not yet well enough to be in the community.

The medical field calls this phenomenon “bounce back” or “revolving door.” It burdens hospitals, emergency rooms, paramedics, police and the patients themselves.

Mersereau said he’d like about 250 stabilization beds across the state. He’s already identified space in underused state facilities, including Leahi Hospital in Honolulu and a former hospital in Kealakekua on the Big Island, where they can be located.

One measure named after the two officers killed by Jerry Hanel in January would help authorities guide people into treatment.

“Tiffany and Kaulike’s Law” would allow police officers and paramedics with special training to determine that an individual should be taken to a psychiatric facility or to a crisis care center for further evaluation if they believe that person is imminently dangerous to him or herself or to others. Mental health emergency workers are currently authorized to make such decisions, while police can take that step only if an individual is threatening or attempting suicide.

The legislation would create a crisis care center that would serve as a kind of “psychiatric urgent care center” and relieve pressure on emergency rooms.

Rep. John Mizuno, a Democrat who chairs the House Health Committee, said these provisions might have helped law enforcement in the Hanel situation.

“They could take the person to the crisis center to get the proper treatment they need, and thus possibly avert something horrific,” Mizuno said.

Another bill would allow courts to suspend judicial proceedings of defendants charged with petty misdemeanors, and send them to treatment instead.

Dr. Barry Carlton, a University of Hawaii psychiatry professor and doctor at The Queen’s Medical Center, said this measure would be an “excellent idea” so long as funding follows the patients out of the criminal justice system and into treatment.

He noted people accused of petty misdemeanors languish in jail if they can’t post bail. And it’s more expensive to jail people than to pay for intensive outpatient treatment or housing, Carlton said.

“If the dollars that are paying for these people to be (in jail) were then utilized for services — case management services being one of them, and housing being another — you would have a much improved outcome,” he said.

Carlton said communities across the country are struggling with how to best provide mental health care, but Hawaii’s chronic housing shortage requires care providers here to be “exceedingly creative.”

Hawaii has the nation’s second highest per capita rate of homelessness, after New York state. An estimated 60 to 80% of Hawaii’s homeless population is suffering from some form of mental health or substance abuse disorder or both, according to the state health agency.

“The housing problem is very real for people other than the mentally ill. Then you put mental illness on top of lack of access, and you’re exacerbating it,” Carlton said.
Source: Hawaii Tribune Herald

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