Report to the Legislature on 
 
Act 90 (SLH 2019)/ H.B. 1013 Relating to Involuntary 
Hospitalization  
and  

Act 263 (SLH 2019)/ S.B. 1494 Relating to Health   
 

 

PREPARED BY:  
STATE OF HAWAI‘I DEPARTMENT OF HEALTH 

 
Deputy Director of the Behavioral  
Health Administration, Edward Mersereau 
Chairperson 
 
December, 2019 
 

 Report to the Legislature on Act 90 (SLH 2019)/ H.B. 1013 
Relating to Involuntary Hospitalization and Act 263 (SLH 2019)/ 
S.B. 1494 Relating to Health   
 

December, 2019  
 

TABLE OF CONTENTS  
 

I. 
 
II. 

EXECUTIVE SUMMARY 

 

Task Force Mandate………………………………………………………………...  3 
INTRODUCTION 

 

 

Background……………………………………………………………………………….  5 

 

Overview of Involuntary Hospitalization, Current Behavioral 
 
Healthcare and Related Systems…………………………………………....  6 

 

Purpose…….…..…………...………………………………………………....………..  12 

III. 

FOCUSED WORKING GROUPS 

 

 

Workgroups……………………………………………………….…………………….. 

13 

 

Objectives………………………………………….…………………………………….. 

14 

IV. 

FINDINGS AND RECOMMENDATIONS OF THE TASK FORCE 

 

 

Finding A: Equal Access to Care…………………………………………….. 

15 

 

Finding B: Standardize and Centralize…………………………………... 

18 

 

Finding C: Continuum of Care and Resources…………………….... 

23 

 

Finding D: Jail Diversion and Recovery………………………………….. 

32 

V. 

NEXT STEPS…..…………...…………………………….……………………………………... 

37 

VI. 

REFERENCES……………………………………………………………………………………... 

38 

VII. 

APPENDICES 

 

 

APPENDIX A: Designated Task Force Members…………………….  40 

 

APPENDIX B: Other Task Force Participants………………………….  41 

 

APPENDIX C: Focused Workgroups Members………………………..  42 

 

APPENDIX D: Additional Resources…………………………….…………..  45 
2

  
 
 
 
 

A MANDATE BY THE 2019 LEGISLATURE TO EVALUATE THE CURRENT 
BEHAVIORAL HEALTH CARE SYSTEM AND MAKE RECOMMENDATIONS 
FOR IMPROVEMENT 
The 2019 Legislature passed two distinct measures which tasked the Department of
Health to gather various stakeholders in the community into a task force and working
group for the purpose of evaluating the current behavioral health care system and
making recommendations for improvement. Both measures, H.B. 1013 and S.B. 1494,
were signed into law by Governor David Ige and became Act 90 (SLH 2019) and Act
263 (SLH 2019), respectively. In general, both Acts called for a comprehensive review
of the current behavioral system of care, including the involuntary hospitalization
system, existing resources, systemic gaps, and identification of action steps that could
be taken to improve the overall system of care.
The approach taken to fulfill the mandates of the task force and working group in an
effective and efficient manner drew upon successes of the Hawai'i Opioid Initiative
which implemented a coordinated policy framework approach. This approach developed
specific subject matter working groups within the broader framework in order to more
effectively focus on the various components of the system. Additionally, the two entities
were merged into one task force in order to avoid duplication of efforts, broaden the
reach and scope of each entity, and to better respond to their mandated tasks. This was
accomplished by a unanimous vote by both entities.
There were five workgroups developed to focus on: 1) Data, 2) MH-1, 3) Post
Stabilization Community Support and Inventory of Resources, and Capacity, 4) Criteria
for Involuntary Treatment, and 5) Funding and Eligibility. The groups worked between
task force meetings and brought information and recommendations to the combined
task force to review and, where necessary, take action through formal vote. This
allowed the task force to use the time it met to address the broad system and
coordinate the various findings and recommendations coming from the workgroups.

3

 Generally, the combined task force findings and recommendations can be summarized
into several themes:
● Current processes and systemic components remain relatively fragmented and
siloed – highlighting the need to coordinate various efforts within the behavioral
healthcare system into a more comprehensive and connected continuum of care.
The need to develop coordinated entry systems that effectively “link and sync”
crisis, post-crisis, and crisis prevention efforts such as Law Enforcement Assisted
Diversion, Intensive Case Management and supportive housing is a vital and
necessary component of an effective system.
● The current approach to dealing with individuals who are in mental health crisis
imposes a significant burden on law enforcement and emergency medical
response systems – highlighting the need to expand and enhance coordinated
mental health crisis response protocols that allow for diversion, where
appropriate, to specialized crisis centers targeted specifically for behavioral
health crisis. These services should include short-term stabilization centers and
Intensive Case Management.
● Effectuating the above two themes will most certainly result in more effective and
efficient use of resources that exist and more clearly illustrate and identify the
areas where resources are lacking. It is vital that assertive efforts and
investments be made up front to realize a truly coordinated system of behavioral
health services in order to reduce duplication of effort and maximize the impact of
resources invested.
While much was accomplished by the combined task force, there remains a significant
amount of work to be done. The findings and recommendations outlined in this report
illustrate the need to continue efforts within the coordinated policy framework to assure
momentum and direction is maintained. Many of the recommendations identified in the
report validate initiatives and efforts currently underway at various stages; all of which
have promising value and impact by themselves. However, one of the most important
outcomes of the taskforce has been its effectiveness of bringing a wide range of
stakeholders together in a way that promotes coordination. While the Department of
Health may have been identified as the Lead Agency of the task force, the input and
cooperation of these stakeholders represent the beginnings of a collaborative effort that
should be continued in order to realize the achievement of the recommended actions.

4

  
 
 
 
 
BACKGROUND 
 
House Bill 1013 (H.B. 1013) was signed into law as Act 90 (Session Laws of Hawai'i
(SLH) 2019), on June 7th, 2019 by Governor David Ige, formally creating the
Involuntary Hospitalization Task Force and assigning primary responsibility for
convening its members to the Hawai'i State Department of Health. The task force
directive was to examine sections of Chapter 334, Hawai'i Revised Statutes, and make
recommendations to the legislature to address ambiguities and inconsistencies in the
statute, as expressed by stakeholders in the community, that contribute to concerns
about behavioral health access, resources, and capacity, and which may impact the
continuity of care and public safety. It put forth a primary goal to diminish unnecessary
emergency department admissions and improve overall access for behavioral health
patients to the most appropriate level of care.
Senate Bill 1494 (S.B. 1494) was also signed into law during the Thirtieth Legislative
session as Act 263 (SLH 2019). Act 263 designated responsibility to the Department of
Health to formally establish a working group to evaluate current behavioral health care
and related systems and identify steps to be taken to promote effective integration to
more effectively respond to and coordinate care for persons experiencing substance
abuse, mental health conditions, and homelessness. Several of the tasks asked of this
working group were parallel to the Involuntary Hospitalization Task Force mandates.
In an effort to consolidate and effectively carry out the tasks of both Acts, a motion to
merge the Act 90 Task Force and the Act 263 working group was introduced during two
separate meetings to both committees. The motion was unanimously carried and the
Task Force and the working group merged with the purpose of improving efficiency and
effectiveness and with the agreement to abide by the Sunshine Law requirements of Act
90. Act 263 working group members and the bill’s respective objectives were absorbed
into the Act 90 Task Force focus workgroups.

 
 
5

  
OVERVIEW OF INVOLUNTARY HOSPITALIZATION, CURRENT BEHAVIORAL 
HEALTHCARE AND RELATED SYSTEMS 
 
In 2015, behavioral health disorders represented the leading cause of disease burden in
the U.S., surpassing cancer and cardiovascular disease.1 Approximately one in five
adults in the U.S. experience mental illness in a given year.2 An increase in psychiatric
boarding challenges, escalating healthcare costs, public safety concerns around
behavioral health and higher rates of incarceration for individuals experiencing
behavioral health issues has solidified a desire to change how we address acute
behavioral health needs within our communities. Although rates of homelessness have
declined almost 10 percent since 2017, per capita, Hawai'i is tied for the highest rate of
homelessness in the nation.3 The overlapping issues of homelessness, substance use,
and behavioral health disorders present complex problems within our communities.
These ongoing issues and challenges highlight the imperative need to assess the
relationship between homelessness, addiction, and behavioral disorders in order to
understand the complexities of behavioral health issues in the community. These
problems are often co-occurring, and commonly, one exacerbates the other. For
example, the end result of homelessness is often substance use, and substance use
often contributes to homelessness. The National Coalition for the Homeless has found
that 38 percent of homeless individuals are alcohol dependent, and 26 percent are
dependent on other harmful chemicals. The difficult conditions of living on the street,
having to find food, struggling with ill-health, and being separated from loved ones
creates a highly stressful state of being. Substance use is the common coping
mechanism many turn to. Hawai'i community members who experience homelessness
and chronic homelessness are especially at risk for substance dependence issues.
Aside from alcohol, methamphetamine remains Hawai'i’s most prevalent drug use
among adults.4 Hawai'i also has one of the highest rates of incarceration due to

1

Rabah Kamal et al. Journal of the American Medical Association. Costs and Outcomes of Mental Health
and Substance Use Disorders in the U.S. 2017; 318 (5):415
2
NAMI. Mental Health by the Numbers.https://www.nami.org/Learn-More/Mental-Health-By-the-Numbers.
3
​Henry, Meghan, Anna Mahathey, Tyler Morrill, Anna Robertson, Azim Shivji, and Rian Watt. “The 2018
Annual Homeless Assessment Report (AHAR) to Congress.”
https://files.hudexchange.info/resources/documents/2018-AHAR-Part-1.pdf. The U.S. Department of
Housing and Urban Development Office Of Community Planning And Development, 2018.
4
Alcohol and Drug Abuse Division. Report to the Twenty-Ninth Legislature, State of Hawai'i. Kapolei, HI:
Department of Health December 2016

6

 methamphetamine related convictions.5 Furthermore, individuals suffering from
homelessness may also develop psychiatric conditions, and many individuals suffering
from mental illness have co-occurring substance use disorders (SUD). This cause and
effect relationship of SUDs and homelessness, homelessness and psychiatric illnesses
represent a “trifecta” of interwoven social problems facing our community. Reports
suggest that nationally, 33 percent of individuals who are homeless battle mental illness
and that mental illness is a major cause of homelessness, which can often lead to
substance use. In Hawai'i, the 2019 Oahu Homeless Point In Time Count for Oahu
reported 36.4 percent of single adults suffer from some type of mental illness, closely
reflecting the national average.6
Unfortunately, many of those suffering from substance use or other psychiatric
disorders do not recognize the need for treatment. The way that many of these
individuals land in our behavioral health and criminal justice systems are through
interactions with law enforcement personnel because of crisis situations. When a law
enforcement officer responds to a person in crisis whom they believe may be suffering
from a behavioral illness, they call on the help of a Mental Health Emergency Worker
(MHEW) which is a qualified mental health professional designated by the Department
of Health. The MHEW can determine if the individual is suffering from a behavioral
illness and is imminently dangerous to themselves or others, and can authorize
involuntary transportation to a licensed psychiatric facility for further evaluation, a
process known as “MH-1”.7
The current process for MH-1 patients has been to transport individuals experiencing a
mental health emergency to a designated psychiatric facility where they receive a
psychiatric evaluation and may require involuntary hospitalization. Psychiatric
hospitalization is the treatment option of last resort for individuals with acute or chronic
serious mental illness who need intensive care. The process to authorize an MH-1 for a
person in crisis requires a considerable amount of time and resources. In order to
deliver a consumer to a designated psychiatric facility, 911 systems are engaged,
followed by an encounter with a law enforcement officer. A law enforcement officer, in
the possible instance of a behavioral health related crisis, contacts a MHEW who
approves involuntary transportation by ambulance or other appropriate means. Most
5

U.S. Sentencing Commission, 2015 Datafile, USSCFY15. Retrieved from
https://www.ussc.gov/sites/default/files/.pdf/research-and-publication/federal-sentencing-statistis/state-dist
ric-circuit/2015/hi15.pdf
6
Partners in Care “Point In Time Count, Oahu” 2019. Retrieved from
https://www.partnersincareoahu.org/sites/default/files/PIC%202019%20Oahu%20PIT%20Count%20Repo
rt%20-%20FINAL_0.pdf
7
Hawai'i Revised Statutes §§334-59 - 334-62

7

 often, the law enforcement personnel is required to accompany the person in crisis to
the designated emergency facility, taking them off the street and away from their duties
for several hours.
Authorized transports of MH-1 patients are currently taken to emergency departments
that lack the physical infrastructure within their​ ​facilities, including secure rooms and
dedicated security personnel, which are critical to safely caring for MH-1 patients
needing psychiatric care. Additionally, many lack the kind of specialized staffing and
programming necessary to adequately and safely assess patients in psychiatric crisis.
These facilities regularly have trouble placing such patients in need of admission to
licensed psychiatric beds. There is a significant strain on emergency departments that
are within designated licensed psychiatric facilities given that these facilities receive
the bulk of MH-1 patients.
A 3rd quarter 2018 MHEW report revealed that the Queen’s Health System in Honolulu
and Adventist Health Castle Medical Center in Kaneohe receive over 95 percent of the
MH-1 emergency department visits on Oahu. Queens admits approximately 30 percent
of their cases while Castle admits approximately 50 percent.8 Although the data is not
as readily available on the prevalence of MH-1 cases. Anecdotally, the safety concerns
and impacts on emergency departments receiving MH-1 patients are very similar. The
neighbor islands have greater gaps in care and a lack of needed resources than Oahu.
Kauai and Hawai'i counties, for example, are lacking adequate resources such as
MHEWs and designated psychiatric facilities to appropriately triage and treat individuals
who are experiencing a behavioral health crisis. Kauai has only one hospital with
inpatient psychiatric beds, but it has a very small emergency department and no general
medical services. On Hawai'i Island, there are only two hospitals with psychiatric
services with much greater geographical distances to cover. Patients who are brought
to hospitals without psychiatric services often wait days in the emergency department
before being transferred to another facility that has adequate psychiatric services. Maui,
although the county has begun MHEW implementation, has only one designated
psychiatric facility to which mental health emergency workers, through Aloha House,
can authorize involuntary transportation. Emergency facilities throughout the entire state
have simultaneously experienced a substantial increase in psychiatric emergency
admissions which has resulted in overcrowding and unsafe environments for MH-1
patients, medical staff and other patients.

8

AMHD. “AMHD and MH1 Program Update May 2018” 2018.

8

 Emergency department overcrowding factors are complex, and it is clear that substance
use and behavioral health patients play a significant role in this. ​“Emergency Room (ER)
Boarding” is a term used for the extended stay that psychiatric patients experience in
the ER. ​Behavioral health patients experience more than twice as long wait times than
other patients while arrangements are made for their psychiatric services elsewhere.
According to an American Psychiatric Association study, 81 percent of the 340 survey
respondents stated the increase in patients holding for an inpatient psychiatric bed
negatively affects the care of other patients, reduces the availability of emergency
department staff for other patients, and contributes to longer wait times for all patients
often causing patient frustration.9
One significant contributing factor to emergency department overcrowding, specifically
for behavioral health patients, is the declining psychiatric bed capacity in the nation. The
decrease of psychiatric inpatient beds in hospitals and the increase in the number of
psychiatric patients has become a major national issue which has had detrimental
economic, community behavioral health, and recidivism effects. Today, there are fewer
psychiatric beds per capita in the United States than there were in 1850. An analysis of
the broader system of both inpatient and other 24-hour residential-treatment beds
revealed a stark 77.4 percent decrease from 1970 to 2014.10 Hospital beds, in general,
have plummeted from their historic peak in 1955 by 97 percent in 2016. A Treatment
Advocacy Center report on psychiatric bed shortages disclosed that even when private
hospitals are included, the number of psychiatric beds per 100,000 people in the United
States ranks the nation 29th among the 34 countries in the Organization for Economic
Cooperation and Development.11 Without access to psychiatric beds, acutely ill
individuals are forced to wait for appropriate level of psychiatric care, while families
watch helplessly as their loved ones deteriorate in the absence of appropriate care.
With nowhere else to turn, those in need end up in other systems, a process known as
transinstitutionalization. These systems include emergency rooms without psychiatric
beds, homeless shelters and, too often, jails and prisons.
Delays in treatment reduce patient satisfaction and increase the risk of patients leaving
without treatment. Extended stays can often cause the patient’s condition to deteriorate
without the adequate level of care for their clinical needs. Delays in receiving crisis
stabilization services significantly increase the risk of physical injury to the patient and to
​ Mulligan K. ER docs report large increase in psychiatric patients. Psychiatr News, 2004.
Snook, John, and E. Fuller Torrey. “America Badly Needs More Psychiatric Treatment Beds.”
Treatment Advocacy Center. National Review, 2018.
11
Treatment Advocacy Center. “Psychiatric Bed Shortages.” Treatment Advocacy Center, 2018.
https://www.treatmentadvocacycenter.org/key-issues/bed-shortages.
9

10

9

 others around them.12 In the state of Hawai'i, one testimony from a local hospital
reported it had experienced a disproportionately high increase in the number of MH-1
patients brought into its facility, despite the expansion of designated psychiatric
receiving facilities in 2012. In 2018, a reported 60 percent of the MH-1 patients
transported to the facility’s emergency department did not require psychiatric
hospitalization and could have been transported to another psychiatric facility with a
more appropriate level of care. While many of these initial visits to the emergency
department are necessary, having other psychiatric facilities that could assist in triaging
MH-1 individuals would lessen the overall burden on emergency departments. Because
emergency departments serve individuals with acute needs, they often are not the
appropriate setting for meeting post-stabilization, or long-term needs of patients with
serious behavioral health needs. There is currently no available data regarding the
MH-1 population to assess the viable and effective alternatives that may need to be
developed to address this population.
Poor access to care, including long waiting times as a result of inadequate psychiatric
resources, can lead to higher rates of attendance at emergency departments. Inevitably,
this results in profound economic and population health consequences. The Oahu
Coordinated Entry System Homeless data from August to October 2017 revealed that
the average cost per emergency department visit including ambulance transportation is
$3,633 while the average cost of Hospital stay per day including the initial visit is
$6,952. On average, the length of inpatient stay for MH-1 emergency department
admissions is 3 days.13
In addition to costly emergency department visits, those who do not receive appropriate
post acute or preventive care are not afforded crucial diversion opportunities which can
also cause the criminal justice system to become a de facto behavioral health system.
Over 2 million people with serious mental illnesses are booked into jail each year.14 One
study showed that by 2014, ten times the number of people with serious behavioral
health illness were in prisons and jails as in state mental hospitals, nationally.15
Evidence shows that the prevalence of mental illness in jails is 3-4 times higher than the
general population. Furthermore, people with mental illness in jail are more likely to be
homeless post release. Given the multiple behavioral health and social risk factors, this
population is especially at risk of “recycling” through both the criminal justice and
12

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3627782/
Oahu Coordinated Entry System. “High Utilizer/ Super Utilizer - ER Visits/ Hospital Stays Data from
August to October 2017.” 2017.
14
NAMI. “Jailing People With Mental Illness.” NAMI, 2019. Retrieved from
https://www.nami.org/Learn-More/Public-Policy/Jailing-People-with-Mental-Illness
15
Snook, John, and E. Fuller Torrey. “America Badly Needs More Psychiatric Treatment Beds.”
Treatment Advocacy Center. National Review, 2018. .
13

10

 healthcare systems. A “Revolving Hospital Door” study which measured the rate of
hospital readmissions among homeless individuals revealed that half (50.8 percent) of
all hospitalizations resulted in a 30-day hospital inpatient readmission and 70.3 percent
resulted in either an inpatient readmission, observation status stay, or emergency
department visit within 30 days of hospital discharge.16 The lack of adequate behavioral
health settings to serve this population, along with siloed services, creates a
considerable cyclical systemic burden.
Comprehensive crisis response and stabilization services are crucial elements of the
continuum of care. Reducing unnecessary transportation to emergency departments
and appropriately placing clients in more suitable levels of care will improve outcomes
for consumers, reduce inpatient hospital stays and costs, and facilitate access to other
necessary behavioral health services and community supports. 

 

​Doran, Kelly M., Kyle T. Ragins, Andrea L. Iacomacci, Alison Cunningham, Karen J. Jubanyik, and
Grace Y. Jenq. "The revolving hospital door: hospital readmissions among patients who are homeless."
Medical care​ 51, no. 9 (2013): 767-773.
16

11

 PURPOSE 
The purpose of this combined task force was to fulfill the mandate of the Legislature to
engage a multidisciplinary team of stakeholders to form a collaborative body to examine
the existing laws and systems surrounding involuntary transportation and hospitalization
of individuals who are at risk of harm to themselves or others due to behavioral health
needs. Five working groups established within the task force examined sections of
Chapter 334, Hawai'i Revised Statutes, developed recommendations on how to reduce
unnecessary emergency department admissions, and explored ways to improve access
for involuntarily hospitalized (MH-1) patients to the most appropriate level of care.
Through this task force, the Legislature sought to identify action steps that the State can
adopt in order to improve and construct a more comprehensive system of care and flow
of patients through the continuum of care. Furthermore, the task force is committed to
reviewing the progress that has been made thus far so as to ensure that previous work
on this issue is organized and considered in a cohesive manner. This approach assured
that the task force was able to identify gaps and operationalize policies more effectively
for the overall enhancement of the behavioral healthcare system.
The central goal is to improve efficiencies within the system and increase efficacy and
maximization of current resources by reducing unnecessary emergency department
admissions and improving standardized access for MH-1 patients. Recommended
systematic improvements include a balanced utilization of behavioral and psychiatric
facilities, which not only creates safer healthcare environments but supports placement
at appropriate levels of care, decreases emergency department admissions, and
promotes significant economic savings through jail diversion efforts and effective client
transition through the continuum of care.
The task force envisions a behavioral healthcare system that is more reflective of how
we intervene in primary healthcare crises, in which those in need are able to access the
appropriate level of care, on-demand, and with no barriers to vital crisis interventions.
The recommendations contained in this report were developed in part by evaluating and
addressing gaps within our own system and looking to other states who have
exceptional behavioral healthcare standards and programs.  

12

 

   
 
 
 
 
 
WORKGROUPS AND OBJECTIVES 
The issues surrounding involuntary hospitalization and the gaps in the continuum of
care have been a longstanding topic among stakeholders. Incremental improvements
have been made for decades in an effort to restructure behavioral health treatment
within the state. While acknowledging the abundance of information and previous work
that has been accomplished within the community, the mobilization and coordination of
these key stakeholders was essential to constructing a collaborative framework to
address these challenges.
By examining the success of previous task force planning strategies such as the Hawai'i
Opioid Initiative, it was apparent that utilizing this collaborative framework provided a
structured approach to coordinating efforts across various state and community
systems. Additionally, it provided an opportunity to place key stakeholders into
subcommittees that were synonymous with their areas of expertise. Within each of
these working groups, specific sets of action items were assigned which included:
reviewing existing laws and policies, standardizing criteria for designated facilities,
assessing gaps in
current law enforcement
and healthcare facilities,
examining funding and
reimbursement, and
developing
recommendations for a
more robust coordinated
system of care
throughout the State.

13

 MH-1 Statute Review Objective 
To review the statute and protocols from the point of contact through triage to
emergency departments or other community support. T
​ his focus workgroup assessed
gaps and shortcomings in the MH-1 system. Specifically, the workgroup examined
patient experiences, the hand-off which occurs when a patient is reintegrated into the
community, the rights and responsibilities of emergency medical services, current
availability of alternate receiving sites, facility challenges when addressing MH-1
cases, security and safety concerns of intaking facilities, and patient wait times. 
Post Stabilization Community Support and Inventory of Resources and
Capacity Objective 
To identify community resources available by island and their capacity.​ This focus
workgroup examined existing behavioral health resources within the state and
geographically inventoried outpatient and residential substance use treatment and
mental health providers for each county.  
Data Collection Objective 
To quantify the needs and outcomes. T
​ his focus workgroup examined existing data
collection and sharing strategies between the Department of Health’s Behavioral
Health Administration and other human service entities throughout the State. The
workgroup assessed the need for data sharing strategies in order to make reliable
data-driven decisions throughout the entire behavioral healthcare system.  
Criteria for Involuntary Treatment Objective 
To review MH-4, MH-6, and ACT and identify criteria for involuntary treatment.​ T
​ his
focus workgroup examined gaps and barriers in the MH-1 process, as well as the
Hawai'i Revised Statute, Chapter 334-59, to determine a complete and accurate
interpretation of the law. The workgroup also assessed the required time of
commitment, the extent to which facilities can accommodate involuntary commitment
cases based upon their existing capabilities and barriers to broader implementation of
ACT orders where appropriate. 
Funding and Eligibility Objective 
To determine the funding necessary to support the solution.​ ​This focus workgroup
evaluated current funding sources and reviewed eligibility criteria that either promotes
or hinders access to care. It assessed all eligibility sets and criteria for services to
identify similarities and differences and if conflicting differences are causing barriers to
care. 

  
14

  
 
 
 
 
The following recommendations are structured around corresponding findings of the
task force’s focused workgroups on Data, MH-1, Post-stabilization Community Support
and Inventory of Resources and Capacity, Criteria for Involuntary Treatment, and
Funding and Eligibility.

FINDING A: ​The State of Hawai'i has unique geographical obstacles which has resulted
in a disparity of resources, services and qualified staff to meet the community’s
behavioral health needs. Access to behavioral healthcare is especially challenging on
the neighbor islands and rural areas of Oahu where there are significant shortages of
behavioral health and specialty care services. Additionally, transportation is a major
issue for those who need to obtain care, especially in the instance of a crisis situation.
Aside from geographical challenges, service access barriers exist for those who are
underinsured, and those who have complex needs. Federally designated underserved
populations and geographical areas make up the entirety of the neighboring islands and
the rural parts of Oahu which has resulted in recurring disproportionate access to
behavioral healthcare across the state. The following recommendations aim to address
access to behavioral healthcare especially for residents in rural areas.

15

 RECOMMENDATION 1A :​ Utilize readily available resources to employ a statewide
telepsych option for consumers for evaluation and treatment to ensure equal access
to care across each county.
The purpose of telepsych is to deliver behavioral health services using technology in
order to improve access to quality behavioral healthcare in rural and urban areas across
the state. The use of telepsych technology would allow patient access to psychiatric and
specialist services they might not otherwise have within the comfort of their local
community. Additionally, the use of telepsych can help minimize healthcare costs while
reducing patient travel time. It is recommended that Telepsych be a sustainable service
modality to reduce provider shortages, long waitlists, geographic barriers, and improve
access to behavioral health care. It was found that Hawai'i State Hospital in-house
psychiatrists who are on-call may be able to provide telepsych services to the
community. The Task Force recommends that these underutilized assets be employed
for statewide telepsych availability.
RECOMMENDATION 2A: ​Develop a reliable crisis triage, diversion, and
transportation process for MH-1 individuals.
In psychological or behavioral crisis situations it is important that an individual be
transported, voluntarily or involuntarily, in a timely manner to a behavioral health
treatment facility which has appropriate resources and staffing to immediately mitigate
the crisis. In needing to structure the behavioral health crisis system to reflect to the
primary healthcare trauma system, it is important to recognize that an individual
experiencing a primary healthcare crisis normally starts receiving treatment as soon as
they are in the ambulance. It is typically ensured that in a primary healthcare trauma
situation, the individual will be transported to an emergency department which has the
suitable resources and staffing to care for that patient immediately. Section 334-59,
Hawai'i Revised Statutes, specifies that after a Mental Health Emergency Worker
(MHEW) has examined a person and has reason to believe the person 1) is mentally ill
or suffering from substance abuse; 2) imminently dangerous to self or others; and 3) in
need of care or treatment, they may “direct transportation by ambulance or other
suitable means, to a licensed psychiatric facility for further evaluation and possible
emergency hospitalization.”17 This language limits the implementation of diversion
resources. The task force has found through examples of other states such as Arizona
and Florida, it is imperative to implement alternative reliable crisis triage, diversion, or
17

Hawai'i Revised Statutes §334-59

16

 transportation processes that ensure individuals in behavioral health crisis situations
receive care, appropriate to their clinical need, in a timely manner.
Mental Health Emergency Worker services face capacity constraints in being able to
screen individuals in crisis and triage them to alternative receiving sites and services.
Ideally, MHEWs would be able to screen and triage patients by their level of need to the
appropriate facility or service and reduce displacement out of their community. The work
group recommends that law enforcement and MHEWs develop a criteria that would
standardize the assessment process. The criteria would provide law enforcement and
MHEWs the ability to assess the needs of the individual prior to transport.
The Task Force also recommends that existing community sites and services are
provided additional resources to serve as alternative receiving sites for delivering the
appropriate level of care for patients who may have some needs but do not rise to the
level of an MH-1. Such sites and services would include: crisis services, residential
treatment facilities, subacute care residential facilities, intensive case management,
assisted community treatment, community paramedics, peer specialist, detox facilities
and/or services, outreach centers. This would allow for individuals in need to have
access to services in a less invasive manner. The ability to deliver care to people
without transportation to an ED, would mean that they would be able to remain in their
community and law enforcement officers would not be taken off the road or experience
lost time for patrol.

RECOMMENDATION 3A : ​Consolidate behavioral health contracts and collaborate
with entities who can readily, or through timely phasing, provide the infrastructure for
statewide behavioral health services.
In an effort to “link and sync” behavioral health services across the state, it is
recommended that contracts issued by the Behavioral Health Administration with
community service providers be consolidated and coordinated where appropriate for the
purpose of increasing access to all levels of services for providers and patients. This
approach also allows for more coordinated networking of providers and resources in the
community.

Current Initiatives Relating to Finding A  

17

 ● Community Paramedicine​ - Community paramedicine is a relatively new and
evolving healthcare model. It allows paramedics and emergency medical
technicians (EMTs) to operate in expanded roles by assisting with public health
and primary healthcare and preventive services to underserved populations in
the community. The goal is to improve access to care and avoid duplicating
existing services.
● Hawai'i Coordinated Access Resource Entry System (CARES)​ - A centralized
behavioral health referral center that authorizes individuals into the continuum of
care and manages a patient’s transition through substance use treatment and
behavioral health services.
● Subacute Stabilization Residential Services (SSRS)​ - A Behavioral Health
Administration contract (in progress) which will establish a facility, or multiple
facilities, that will provide post-stabilization treatment for the state of Hawai'i.
● Treat Alternative Transport​ - An Emergency Medical Services (EMS) initiative
that assists in transporting and triaging individuals who do not meet MH-1 criteria
but require behavioral health care to appropriate services within the community.

18

 FINDING B: ​Current inconsistencies
and fragmentation of behavioral
health services limit continuity of
care and patient outcomes. This
often results in inefficient use of
resources and funds to address
mental health, homelessness and substance use disorders.​ ​Consequences of a
fragmented behavioral health system include, but are not limited to, difficulty in
standardizing or setting quality outcome metrics, over-utilization of some services and
under-utilization of others without accurate assessment of their efficacy, and more
importantly, decreased capacity and client flow through a treatment continuum (if all
clients are kept for the maximum length of stay regardless of their progress, treatment
beds are prevented from being maximized). The following recommendations are related
to standardizing and centralizing behavioral health resources. In doing so, behavioral
health services throughout the state can more effectively and efficiently utilize
resources, and reach a more consistent continuum of care to improve patient outcomes.
RECOMMENDATION 1B: ​Develop and implement consistent trainings, delivered by
the Department of Health, to ensure standardized use of the Health Insurance
Portability and Accountability Act of 1996 (HIPAA) and Code of Federal Regulations
Title 42, Part 2​ (​42CFR).
The Health Insurance Portability and Accountability Act of 1996 is a Federal law that
restricts access to individuals' private medical information.18 Furthermore, 42 CFR, Part
2 (commonly referred to as "Part 2") are the federal regulations governing the
Dhcs.ca.gov. (2016). ​What is HIPAA.​ Retrieved from:
http://www.dhcs.ca.gov/formsandpubs/laws/hipaa/Pages/1.00WhatisHIPAA.aspx
18

19

 confidentiality of drug and alcohol abuse treatment and prevention records.19 The
implementation and adherence to HIPAA and 42CFR, Part 2 regulations are not
currently standardized throughout facilities/providers. Although there are clear
guidelines in both HIPAA and 42CFR, Part 2, the way these regulations are currently
adhered to is on an institution-by-institution basis. While these regulations are important
in any system of care to ensure patient privacy and ethical best-practices, they can
cause barriers when facilities are unaware of how to appropriately share data and
information between entities. Clearly understanding how to effectively share information
from provider to provider while still abiding by these regulations is essential for ensuring
a patient's treatment plan is not disrupted.
RECOMMENDATION 2B: ​Construct a comprehensive database of all providers and
services that will be maintained and updated in real-time, available on-line 24/7, and
would be easily accessible to all appropriate statewide organizations and agencies.
The Post Stabilization Community Support and Inventory of Resources and Capacity
workgroup identified 19 separate databases, each of which varied in depth of
information and services provided. There is currently no single reliable or regularly
updated database of providers and behavioral health services in the State that is easily
accessible to organizations, agencies, and consumers. Having access to a
comprehensive and centralized database would allow all behavioral health systems to
be visible in real time which would allow for uncomplicated client placement based on
their clinical need and level of care. This would significantly improve the care continuum
by ensuring a seamless entry into the continuum of care as well as transitions between
levels of care.
RECOMMENDATION 3B: ​Standardize the time of admission guidelines for all
involuntary hospitalization processes and protocols.
Current involuntary hospitalization forms do not give guidance to the status of the
patient while in an emergency department or other treatment site, awaiting management
by a qualified psychiatric facility. While it is understood that the MH-4 form is completed
when the patient is involuntarily admitted, the interval between the patient’s arrival
under terms of either the MH-1 or MH-2 has no defined boundaries. It is advised that: 1)
19

Milken Institute School of Public Health. “Health Information and the Law: 42 CFR Part 2.” Health
Information and The Law Project. 2019. Retrieved from
http://www.healthinfolaw.org/federal-law/42-cfr-part-2

20

 such boundaries be established (e.g., “reevaluation of patient’s safety and need for
hospitalization at 12 hour intervals, not to exceed 72 hours without engagement of the
Family Court”); 2) the Department of Health is to assess the current emergency
department or outpatient department length of stay for adults and for children who are
pending psychiatric hospitalization, by island; 3) the Department of Health is to publish
relevant guidelines on its website; and 4) the Department of Health is to provide training
on this topic across all affected emergency departments and law enforcement sites. It is
recommended that language be synchronized to clarify the definition of Time of
Admission across all involuntary hospitalization forms.
RECOMMENDATION 4B: ​Develop a centralized data sharing repository which abides
by HIPAA and 42CFR regulations and can be accessed by all State behavioral health
providers and related entities.
There is currently no centralized data sharing repository that is accessible by all State
behavioral health providers and related entities. The lack of a data sharing repository
limits providers from being able to access vital consumer protected health information
which, if accessible, could effectively assist in treatment planning, establishing a high
utilizer database, jail diversion, and more proactive intervention efforts. The absence of
information sharing between health systems on MH-1 individuals has resulted in gaps in
treatment with no warm hand-offs or coordinated efforts to connect patients with the
needed substance abuse and mental health services available. The sharing of
information, such as number of emergency room visits, location, conditions, etc. would
assist in managing this population and stakeholder’s ability to deliver the appropriate
level of care. We recommend that additional resources are either allocated to existing
systems or develop a community health record accessible to providers, law
enforcement, MHEWs, and case managers.
It is recommended that providers agree to participate in sharing real-time data with the
Hawai'i Health Information Exchange (HHIE) and the Department of Health, and that
HHIE agree to share identifiable data to providers of that person to assist in care
coordination. It is also recommended that there be mandated data sharing with other
related entities through a secure data portal that abides by HIPAA and 42CFR
regulations. Furthermore, a consideration was made to link the Department of Health’s
Utilization Management with Hawai'i CARES and that the Department of Health’s
epidemiologists or other designated staff will be responsible for reviewing data monthly,
cleaning data from combined data sets with HHIE, and drafting an annual report to the
legislature. The annual report will include MH-1 numbers, trends over time and patterns

21

 by socio-demographic, geographic, and other pertinent variables. A subsection will be
included to provide insight on high utilizers. Additionally, the report will include
conclusions, accomplishments, and future recommendations and will be shared with
providers and other stakeholders included in the behavioral health system. It is
expected that these reports will also assist with grant applications and in determining
and acquiring additional funds. An advisory committee will participate in the report while
the Department of Health’s Governance board will oversee any request for data for
research and will only release de-identified data that has been approved by the Data
Governance and IRB committees.
RECOMMENDATION 5B: ​Ensure standardized use of non-admission treatment
options such as ACT and PAD by developing consistent protocols and trainings
through the Department of Health and identify a pilot cohort of 40 patients to assure
refinement of both services.
Assisted Community Treatment (ACT) refers to a civil court procedure wherein a judge
orders an individual diagnosed with a severe mental disorder who is experiencing a
psychiatric crisis that requires intervention to adhere to an outpatient treatment plan
designed to prevent further deterioration that is harmful to themselves or others. This
form of involuntary treatment is distinct from involuntary commitment in that the
individual under the court order continues to live in their home community rather than
being detained in a hospital or incarcerated.20
A psychiatric advance directive (PAD), also known as an advance mental health care
directive, is a written document that describes what a person wants to happen if at
some time in the future they are judged to be suffering from a mental disorder in such a
way that they are deemed unable to decide for themselves or to communicate
effectively.21
These two services have been effectively implemented in various communities
throughout the nation and is a vital component to a comprehensive care continuum. The
use of these tools have been inconsistent across the behavioral health services in the
state of Hawai'i. Input from the Judiciary, Hawai'i Civil Rights Commission, Civil
Liberties Union, and other related stakeholders, has been and will continue to be
necessary to develop broadly accepted protocols to effectively and consistently
implement these services within our community. To ensure these tools are being
uniformly utilized, it is recommended that the Department of Health develop trainings on
20
21

Hawai'i Revised Statute Chapter 334 §121-134
Hawai'i Revised Statute Chapter 327G

22

 how to utilize ACT and PAD within our system. It is also recommended that during
phase one of implementation, that a pilot cohort of 40 patients is identified to assure
refinement of both services.

Current Initiatives Relating to Finding B
● Hawai'i CARES​ - A centralized behavioral health referral center that authorizes
individuals into the continuum of care and manages a patient’s transition through
substance use treatment and behavioral health services.
● Assisted Community Treatment (ACT)​ - A civil court procedure wherein a judge
orders an individual diagnosed with a severe mental disorder who is experiencing
a psychiatric crisis that requires intervention to adhere to an outpatient treatment
plan designed to prevent further deterioration that is harmful to themselves or
others.
● Psychiatric Advanced Directive (PAD)​ - A written document that describes what a
person wants to happen if at some time in the future they are judged to be
suffering from a mental disorder in such a way that they are deemed unable to
decide for themselves or to communicate effectively.

23

 FINDING C: ​Expanding on “linking
and syncing” efforts within the state,
it is integral that we encourage
collaboration and coordination both
within behavioral health systems and
between behavioral health, public
safety, and other related systems. A successful and effective care continuum depends
solely on the commitment of stakeholders throughout the community. Such
cross-system collaboration is essential for successful jail diversion efforts, transitions
from the justice system to the community behavioral healthcare system, and for patient
recovery and community reintegration.​ ​In addition to the need for a more robust
continuum of care, it was found that vital resources were lacking or entirely absent from
our present care continuum. Some of these critical resources that are insufficient within
our system include, but are not limited to, psychiatric beds, holistic programs for
individuals with co-occurring disorders, adequate psychiatric resources within
designated receiving facilities, and post-stabilization residential facilities. The
ramifications of inadequate or missing resources within a care continuum means that
individuals entering the behavioral health or criminal justice systems with incomplete
resources are at a higher risk of relapse, recidivism, and emergency department
readmissions. Ultimately, gaps in the continuum of care perpetuate a “revolving door”
which puts individuals at risk for worsening behavioral health conditions, chronic
homelessness, and a slew of other risk factors. Beyond patients, there is a significant
negative impact on emergency departments, law enforcement and other public safety
entities, and it substantially increases healthcare costs. The following recommendations
are related to creating a more robust continuum of care and ensuring access to

24

 treatment that is appropriate for every level of care by addressing gaps in the current
care continuum.
RECOMMENDATION 1C: ​Develop and implement a centralized behavioral health
managing entity which will assist consumers in entering the continuum of care, and
progress through the continuum of care based on clinical need and level of care that
encourage a coordinated and collaborative network of care that ensures best
practices and improved patient outcomes.
On October 1st, 2019, the Hawai Coordinated Access Resource Entry System (Hawai'i
CARES) was launched. This centralized behavioral health managing system assists
clients with entering into the continuum of care. Historically, SUD treatment programs in
Hawai'i have operated independently of each other, offering limited or little coordination
of services without ensuring that client care shifts freely between levels of care as
clinically appropriate. The goal of Hawai'i CARES is to implement a synchronized
system of care rather than an assortment of independent programs and treatment
modalities. There is currently a disparity of intake and access processes among
behavioral health systems including intake and assessment packets which can range
from 10-60 pages long depending on the contracted provider. Patients who are
unsuccessful in one program or who do not complete treatment as a direct result of
insufficient resources or capacity, are often forced to restart in another program which
requires them to complete new, lengthy intake and assessment packets. Also, providers
across all behavioral health systems are unable to effectively track patients through
their episode of care. Also, decentralized waitlists and bed inventories perpetuate cherry
picking, ER boarding and patient holding. Hawai'i CARES operates as a centralized
behavioral health managing entity which will effectively universalize screening and
assessment processes, thus reducing barriers to treatment and recovery support
services in the continuum of care. Hawai'i CARES will ensure treatment is available on
demand to those who need it, when they need it, and where they need it. Currently
Hawai'i CARES is working on linking all substance use treatment services. Later,
through phasing and provider collaboration, Hawai'i CARES will be connecting all
behavioral health services within the State.
RECOMMENDATION 2C: ​Identify either single or multiple providers, as well as a
facility that can readily, or through a timely phasing process, provide the infrastructure
to implement statewide post stabilization (subacute) residential services.

25

 An increase in psychiatric boarding challenges, escalating healthcare costs, public
safety concerns around behavioral health and higher rates of incarceration for
individuals experiencing behavioral health issues have solidified a desire to change how
we address acute behavioral health needs within our communities. Data collected in the
state of Hawai'i estimates that a significant portion of individuals experiencing a crisis
(54 percent) have needs that align better with services delivered within a subacute level
of care facility. Subacute Residential Stabilization Services (SSRS) have been a
missing component of our State’s comprehensive continuum of care, which in having,
would bridge the gap between acute hospitalization and lower level residential and
community resources. Individuals with behavioral or substance abuse disorders
experiencing a crisis enter the health care delivery system most often through
emergency departments. The acute phase may last only hours if it is primarily due to
substance abuse, or significantly longer if it is due to chronic severe mental illness
requiring days of treatment. Undiagnosed mental illness can be exacerbated in the
hospital. The period after the acute phase is often referred to as the “post-stabilization”
phase of services, meaning that the acute crisis is resolved or controlled to the degree
that inpatient treatment is no longer indicated. This does not mean that all treatment
goals have been accomplished and the patient is cured.
Within Hawai'i, especially on the neighboring islands, there are no available services
that provide subacute behavioral health stabilization services for consumers who meet
the post-stabilization criteria for two generally accepted Level of Care frameworks for
behavioral health care: Level of Care Utilization System for Psychiatric and Addiction
Services (LOCUS) – Level 5A Intensive -Short Term Residential Services, and
American Society of Addiction Medicine Patient Placement Criteria 3rd Edition (ASAM)
– Levels 3.5 and 3.7, Residential Services.
A LOCUS Level 5 residential treatment facility has capacity to treat persons who are
stepping down from acute inpatient care or people who are in crisis but who do not
require the security of a locked facility. These services are capable of providing intense
treatment programming (as described for all Level 5 services) and they are sometimes
referred to as subacute or respite care. Length of stay usually would not exceed 7-10
days.
Furthermore, the ASAM Level 3.5 – Clinically Managed High Intensity Residential
services are designed to serve individuals, who, because of specific functional
limitations, need safe and stable living environments in order to develop and/or
demonstrate sufficient recovery skills so that they do not immediately relapse or
continue to use in an imminently dangerous manner upon transfer to a less intensive
26

 level of care. Level 3.5 assists individuals whose addiction is currently so out of control
that they need a 24-hour supportive treatment environment to initiate or continue a
recovery process that has failed to progress. Their multidimensional needs are of such
severity that they cannot safely be treated in less intensive levels of care.
ASAM Level 3.7 require Medically Monitored Intensive Inpatient Services to provide a
planned and structured regimen of 24-hour professionally directed evaluation,
observation, medical monitoring, and addiction treatment in an inpatient setting. They
feature permanent facilities, including inpatient beds, and function under a defined set of
policies, procedures, and clinical protocols. They are appropriate for patients whose
subacute biomedical and emotional, behavioral, or cognitive problems are so severe
that they require inpatient treatment, but who do not need the full resources of an acute
care general hospital or a medically managed inpatient treatment program.
Both ASAM levels are characterized by their focus on individuals who need secure safe
environments where targeted treatment can focus on stabilizing their level of functioning
so that they may be successfully treated in less intensive levels of care, but whose
acuity does not meet acute hospitalization levels of care.
The post-stabilization phase can be as simple and direct as a discharge home with a
follow-up appointment to a health care provider. But often it is not that easy, especially
if the patient is experiencing homelessness. While the acute crisis may be resolved,
further specialized treatment is often needed on a timely basis to prepare an individual
to benefit from longer term rehabilitation. This could be an addiction treatment program,
or therapeutic behavioral health program, or even ACT. The community health care
settings where the various levels of treatment are available are limited (very limited on
neighboring islands) especially if a residential component is needed. Those that do exist
often have to address complex patient management and programming issues, making
admission decisions complex in order to serve the needs of the entire community.
Emergency departments are the most accessible and easiest/quickest part of the
system and if the condition is severe enough a hospital bed will be provided for the
patient. But after that, if a patient cannot go home, the options are extremely limited,
particularly on the neighbor islands. Without treatment options, the patient will not
progress towards recovery but regress and cycle back to the emergency department or
languish on the streets in our community. This tragic cycle occurs because we have
failed to stand up enough stabilization options that are accessible in the community.
There needs to be options so that a “warm handoff” to a community setting can be

27

 made after initial stabilization to facilitate continued treatment/healing and reduce the
risk of recurrence of crisis acute admissions.
For hospitalized patients, it currently takes significant time for a referral to occur from
the point of initial contact through assessment and referral to an agency for assistance.
During this time, the patient may no longer have an acute inpatient treatment need and
therefore will be discharged. In order to provide timely case management and referrals
for transitions out of the hospital, we recommend that health plan care coordinators and
community providers be contacted and involved early during the hospitalization.
Least restrictive level of care is often not available, especially on neighboring islands,
because we only have high levels of care that are easily accessible and very little
options that provide lower levels of care such that the people with high acuity and
multiple chronic conditions are often placed into higher levels of care for a longer period
of time than is necessary or more likely, they are discharged from expensive, emergent
care in a very short time and released back to the community to a much lower level of
care that is not adequate for them, because the right level of care does not exist in our
system, or is unavailable. Without enough step-down treatment and differing acuity
options for this population, such patients become frequent utilizers of short doses of
easily accessible high level, expensive care and never truly reach long term recovery
and normalcy.
It is recommended that a system be designed for the few people with very complex
problems involving substance use disorder (SUD) and co-occurring (COD) mental
health disorders as well as comorbid physical chronic medical conditions. In such a
system, patients would move according to their needs, accessing the “least restrictive”
levels of care at the appropriate intensity. They would access services from any point on
the continuum and move to the least restrictive level of care according to need, even
skipping steps if appropriate. Different pathways will be developed for different
populations and needs, such as those who are homeless and will need varying levels of
housing support. This can be done by collaborating with the Coordinated Entry System
(CES) in each county whose function is to match housing needs with housing
resources.
The Task Force recommends identification and removal of barriers to improve access to
community programs that currently exist, and increased funding to more robustly fund
current options and develop additional community treatment options. In addition,
resources would be needed as well as new, creative uses of funding (housing, etc.)
could be used to establish step down services as a means to improve recovery rates for
complex patients. The committee also recommends investment in Certified Peer

28

 Specialists and Peer Navigators to help patients navigate the continuum of care and
transitions between steps.
RECOMMENDATION 3C: ​Continue to support and encourage collaboration with H4,
Joint Outreach Centers, and Hawai'i HOME and increase promoting strategies to
maximize community attendance.
Hawai'i Homeless Healthcare Hui (H4) is a comprehensive homeless service facility
serving Oahu’s chronically homeless population. The center provides four levels of
services including 1) Hygiene, 2) Non-emergency healthcare, 3) Medical Respite, and
4) Transitional Housing. The H4 center currently serves 1,200-1,400 chronically
homeless individuals, saving Hawai’i taxpayers $30-$40M per year by curbing the tide
of healthcare demand. Services are available on a walk-in basis on Monday,
Wednesday, and Friday each week, from 8:00 a.m. to 12:00 p.m. at the Institute for
Human Services (IHS) site and from 1:00 p.m. to 8:00 p.m. at the Joint Outreach Center
in Chinatown.22
The Hawai'i Homeless Outreach and Medical Education (Hawai'i HOME) project was
established in 2006 and offers free clinic services to homeless individuals. To date, the
project has had over 10,500 patient visits and has serviced over 5,200 individuals. The
Hawai'i HOME project currently operates out of 10 sites in various locations on Oahu
and offers acute and chronic medical services, social resources, vision screenings and
eyeglass prescriptions.
These services are readily available and easily accessible for individuals experiencing
homelessness within the community. Promoting these services ensures an opportunity
for entry into the system of care. Continued support and collaboration with these
services will increase the number of individuals experiencing homelessness being
linked to medical care, case management, and other necessary services.
RECOMMENDATION 4C: ​Implement a Recovery House pilot program to more
appropriately care for individuals with co-occurring behavioral health disorders and
that would insure a seamless consumer transitioning process.

22

“Hawai'i Homeless Healthcare Hui.” Retrieved from ​http://www.h4Hawai'i.org/

29

 Co-occurring behavioral health conditions affect nearly 8.2 million Americans each year.
About 60 percent of state and federal prisoners have a substance use disorder.23 In the
Hawai'i State Hospital, the average number of patients that have a substance use
disorder (causing frequent re-hospitalization) is 85 percent; 75 percent of which have a
co-occurring disorder. Unfortunately, 36 percent of patients reenter the Hawai'i State
Hospital within 6 months after being released, most of which have co-occurring
disorders. Studies have consistently shown that all best practice programs for
co-occurring disorders require a safe and supportive space for recovery. Currently,
consumers struggling with co-occurring disorders in Hawai'i often relapse due to gaps in
services and a lack of housing that is dedicated to their unique needs. There is a need
for such housing that will support the wellness and recovery of these patients. In a
recent report from the Substance Abuse and Mental Health Services Administration
(SAMHSA), “Best Practices for Recovery Housing,” recovery housing programs for
co-occurring disorders decreased drug related deaths and hospitalizations by 60
percent. It is recommended that a pilot program be implemented that would specifically
target the co-occurring population and would utilize an unused wing of the Leahi House
Pilot. Leahi House Pilot program is a 5-6 months long, 24 hour residential recovery
program for consumers with co-occurring disorders. It is intended to assist consumers in
avoiding hospitalizations, re-hospitalizations, and incarceration. The recovery house
pilot program would expand on current contracts for 24 hour housing, ICM+, Supported
Employment, Representative Payee, Outpatient Treatment, and Community Based
Case Management. This would allow for proof of concept without the necessity of
adding additional contracts. The pilot program will enroll 6-8 patients with co-occurring
disorders. A Transitional Living Program (TLP) is also recommended to be added in the
future which would allow the possibility of an additional 32 patients into the program.
RECOMMENDATION 5C: ​Coordinate and maximize existing funding to address
capacity shortages within the States behavioral health care continuum and then
identify funding needs, if any, to support the envisioned comprehensive continuum of
care.
In order for licenced psychiatric facilities to take MH-1s, they need to have adequate
resources that will ensure a safe environment and the clinical expertise needed to
provide a psychiatric assessment. We are recommending that additional resources and
supports are provided to facilities.

23

SAMHSA. “Behavioral Health Barometer”. 2015. Retrived from
https://www.samhsa.gov/data/sites/default/files/2015_Hawai'i_BHBarometer.pdf

30

 A comprehensive inventory of resources is needed to address capacity issues for
available beds and/or various services in order to effectively treat, prevent and/or avoid
unnecessary transport or hospitalization. Furthermore, additional funding sources need
to be identified or reallocated to ensure licensed psychiatric facilities are adequately
equipped and staffed to receive MH-1 and acute behavioral health patients. This
funding is needed to ensure sufficient reimbursements for creating or enhancing
services with qualified staff to meet chronic behavioral health needs. Existing resources
need to be utilized and appropriately reallocated, where possible, to fund an effective
and cost-efficient coordinated framework, leverage funding from the Hawai'i Opioid
Initiative and access other available grant sources. Also, short term plans and long term
visions for funding need to be developed across the behavioral health system in order to
ensure sustainable expenditure.

Current Initiatives Relating to Finding C 
● Hawai'i CARES​ - A centralized behavioral health referral center that authorizes
individuals into the continuum of care and manages a patient’s transition through
substance use treatment and behavioral health services.
● Subacute Stabilization Residential Services (SSRS)​ - A current Behavioral
Health Administration contract which will establish a facility, or multiple facilities,
that will provide post-stabilization treatment for the state of Hawai'i.
● Hawai'i Homeless Healthcare Hui (H4) Center​ - A comprehensive homeless
service facility serving Oahu’s chronically homeless population by providing
hygiene services, non-emergency medical services, medical respite, and
transitional housing.
● Hawai'i Homeless Outreach and Medical Education (HOME) project​ - Offers free
clinical services to Oahu’s homeless population and currently serves out of 10
locations throughout the City and County of Honolulu.
● Leahi Pilot Program ​- A recovery house which provides clinical and holistic care
for individuals who have co-occurring behavioral health disorders.

31

 FINDING D: ​Since the 19th century,
the United States has turned to jails
and prisons to manage individuals suffering with behavioral health conditions. Today,
individuals experiencing a behavioral health crisis are more likely to encounter police
than get medical help. As a result, 2 million people with mental illness are booked into
jails each year.24 The vast majority of those individuals have not committed a violent
crime and most who are currently in jail have not yet gone to trial, so they are not yet
convicted of a crime. The rest are serving short sentences for minor crimes.
At least 83 percent of jail inmates with a mental illness did not have access to needed
treatment.25 Criminalizing people with mental illness creates an unnecessary burden on
law enforcement, corrections, and state and local budgets. It does not protect public
safety and people who would greatly benefit from community behavioral health
resources are being ignored.
Studies have shown that diversion efforts are successful at interrupting the traditional
criminal justice process for individuals with behavioral health illnesses by increasing
access to community treatment, housing, and adjunctive services, avoiding or
shortening criminal justice confinement, and, by linkage into treatment, will reduce
substance use, psychiatric symptoms, and criminal justice recidivism.26 While there
24

NAMI. “Jailing People With Mental Illness.” NAMI, 2019. Retrieved from
https://www.nami.org/Learn-More/Public-Policy/Jailing-People-with-Mental-Illness
25

NAMI. “Jailing People With Mental Illness.” NAMI, 2019. Retrieved from
https://www.nami.org/Learn-More/Public-Policy/Jailing-People-with-Mental-Illness
26
Broner, Nahama, Pamela K. Lattimore, Alexander J. Cowell, and William E. Schlenger. "Effects of
diversion on adults with co-occurring mental illness and substance use: Outcomes from a national
multi-site study." ​Behavioral Sciences & the Law​ 22, no. 4 (2004): 519-541.

32

 have been various efforts within the state to effectively divert behavioral health patients
from the justice system, the following recommendations address the need to create a
more robust coordinated and reliable system to effectively divert individuals with mental
illness from jails, and to ensure recovery oriented treatment within all State institutions
that engage with these patients.
RECOMMENDATION 1D:​ Locate an existing facility or facilities within the state that
have suitable infrastructure (or with minimal effort can be made suitable) to support
central receiving facilities for jail diversion and behavioral health crises and allocate
resources to appropriately staff these facilities as alternatives to ER’s and jails.
One exemplary location which has successfully implemented a designated central
receiving facility into their care continuum is Arizona. The implementation of a new care
model effectively addressed the influx of mental health patients in their emergency
departments. This goal of the care model is to move behavioral health patients from the
emergency department to a safe, secure, and appropriate care setting in a timely
manner. An emergency psychiatric center called the Banner Psychiatric Center was
opened in September 2010 and is staffed 24/7 by a psychiatrist or behavioral health
nurse practitioner along with other behavioral health support staff. Additionally, a
transfer process was developed using a regional transfer center at Banner Health
known as the Regional Patient Placement Office; a call center that is staffed 24/7 by
registered nurses who match requests for patient transfers to available resources. The
office assists an average of 2,000 transfers per month, including more than 400
behavioral health patients transferred from emergency departments. Behavioral health
services were put under this centralized model, which enables the Regional Patient
Placement Office to facilitate the transfers from the emergency departments to the
Banner Psychiatric Center in a timely manner and allows access to real-time updated
lists of psychiatric bed availability within Banner Health and the community.
As a result, the Banner Psychiatric Center has treated more than 6,000 patients. Hold
times in the hospital Emergency Departments decreased by more than 40 percent. Less
than 50 percent of the patients who are brought to the Banner Psychiatric Center are
later admitted to an inpatient unit. Before implementation of the center, that rate was 75
percent. This has freed up acute inpatient beds in local hospitals to be able to accept
higher acuity patients who require that level of care.27

​Pat Little-Upah, MA​; ​Chris Carson, MD​; ​Robert Williamson, MD​; ​Tom Williams, MC​; ​Michael Cimino,
MBA​; ​Neena Mehta, MSN​; ​Jeff Buehrle, MBA​; ​Steve Kisiel​. “The Banner Psychiatric Center: A Model for
27

33

 RECOMMENDATION 2D: ​Implement a statewide response system to address
behavioral health crisis situations which enables an effective collaboration between
each county’s law enforcement personnel and Mental Health Emergency Workers.
The Mental Health Emergency Worker (MHEW) program, implemented in 2006 on the
Island of Oahu, consists of designated qualified mental health professionals who are
contracted to provide consultation to law enforcement officers to assist in intervening in
psychiatric crisis situations and diverting individuals with mental illnesses from the
criminal justice system. The role of MHEWs are to assess the crisis situation via
telephone to determine if the individual is suffering from a behavioral health illness and
if they are a danger to themselves or others, in which case they authorize involuntary
transport to a designated licensed psychiatric receiving facility (MH-1). The contract was
recently expanded to provide these services statewide. In addition to law enforcement
consultation, the MHEW program will assist in collaborating with law enforcement
officers receiving Crisis Intervention Trainings (CIT) to include a basic understanding of
mental illness and possible signs and symptoms a person may exhibit as a result of
their illness in order to effectively determine when to call an MHEW. It is recommended,
in addition to the continued support of the statewide MHEW program implementation,
that an increased number of law enforcement personnel receive CIT to assist in
handling behavioral health crisis situations. In 2018, Oahu’s MHEWs received 3,657
calls in which 2,899 resulted in MH-1. The expansion of the services to cover the
neighboring islands is expected to assist law enforcement personnel in effectively
intervening in behavioral health crisis situations while being sensitive to each county’s
specific geographical and cultural needs. Support and collaboration from the justice
system, EMS, public safety personnel, behavioral health system, and other related
systems are needed to effectively implement the service statewide.
RECOMMENDATION 3D: ​Continued support for the Law Enforcement Assisted
Diversion (LEAD), other Jail Diversion efforts and the Help Honolulu program.
The Law Enforcement Assisted Diversion Honolulu (LEAD HNL) program, overseen by
Hawai'i Health and Harm Reduction Center in assistance with the University of Hawai'i
at Manoa, is a community-based diversion program for people whose criminal activity is
due to behavioral health issues. The goal of LEAD HNL is to reduce recidivism for minor
Providing Psychiatric Crisis Care to the Community while Easing Behavioral Health Holds in Emergency
Departments” The Permanente Journal. 2013. Retrieved from ​https://doi.org/10.7812/TPP/12-016

34

 offenses by referred clients in an effort to reduce the burden on the criminal justice
system and improve clients’ health and wellness. The program engages clients in social
services aimed at addressing housing, substance use, behavioral health, and health
issues. After one year of implementation, the program saw 55 percent fewer cited
encounters with law enforcement after referral to the program, a decrease in time spent
unsheltered by 38 percent, and a decrease of 18 percent of methamphetamine use for
those who self-reported use.28
Another program aimed at jail diversion is the Health, Efficiency, and Long-term
Partnerships (H.E.L.P. Honolulu) program. This is a new unit within the Honolulu Police
Department that teaches plainclothes officers how to interact with individuals who are
homeless so they are more apt to accept help. Basic information about interactions with
the individuals can be accessed by officers in order to assist them if they come into
contact with that individual in the future.
Continued support for these programs are necessary to prevent individuals with
behavioral health illnesses from entering the justice system. Additionally, jail diversion
programs support a recovery based model in which individuals with behavioral health
illnesses, including substance use disorders, are able to receive necessary treatment
and successfully transition back into the community.
RECOMMENDATION 4D:​ ​Consider re-working the Hawai'i State Hospital master plan
to include continued utilization of the Guensberg facility and repurposed use of the
Bishop building.
The current Hawai'i State Hospital (HSH) master plan includes the closure of the
Guensberg facility which currently houses 90 psychiatric beds. Instead, a new facility
with 144 psychiatric beds is being constructed which will yield a total of 54 additional
psychiatric beds. The task force recommends considering re-working the HSH master
plan in order to continue utilizing the 90 beds in the Guensberg facility to yield, in total,
144 new beds. It is also suggested that the use of the Bishop building on the HSH
campus be reconsidered in order expand transitional beds for individuals leaving high
acuity care at the HSH who are transitioning into the community. Additional funding may
be required to repair and update older facilities on the Campus.
28

“​Law Enforcement Assisted Diversion Honolulu 1 -Year Program Evaluation Report”. 2019.

Retrieved from
https://homelessness.Hawai'i.gov/wp-content/uploads/2019/10/191030-LEAD-Honolulu-Evaluation-FINAL
-USE-THIS-ONE-2.pdf

35

 Current Initiatives Relating to Finding D 
● Mental Health Emergency Worker (MHEW) program​ - Designated qualified
mental health professionals who provide consultation services to law
enforcement and public safety personnel which assist in intervening in behavioral
health crisis situations as well as authorizing MH-1 and involuntary transport to a
designated licensed psychiatric facility.
● Crisis Intervention Training (CIT)​ - A training that assists law enforcement in
recognizing and appropriately managing a mental health problem. The training is
available to a variety of jail diversion programs, re-entry programs, and provides
education and support to individuals and families at risk of involvement with the
justice system.
● Law Enforcement Assisted Diversion Honolulu program (LEAD HNL)​ - A
community-based diversion program for people whose criminal activity is due to
behavioral health issues.
● H.E.L.P Honolulu​ - Health, Efficiency, and Long-term Partnerships (H.E.L.P.
Honolulu) is a new unit within HPD that teaches plainclothes officers how to
interact with individuals who are homeless so they are more apt to accepting
help. Information about the individuals can be accessed by officers in order to
assist them if they come into contact with that individual in the future.

36

  
 
 
 
 
The combined task force has reviewed several behavioral health systems, policies, and
other related systems in order to compile a set of findings and recommendations for the
Legislature. These recommendations will effectively address gaps within our State’s
care continuum as well as maximize the utilization of existing systems and current
initiatives.
The task force is deeply committed to building a system of care which is rooted and
grounded in the recovery model and is responsive to the needs of the community.
While there are critical gaps within our continuum of care, various components of the
continuum exist within our State already. In order to operationalize the most
comprehensive continuum of care, it is essential that we encourage and continue
collaboration and coordination both within behavioral health systems and between
behavioral health, public safety, judiciary, and other related systems.
Several initiatives are currently in place or in the process of implementation that will
address many of the gaps found within the continuum. Moreover, existing contracts that
have proven effective on the island of Oahu are being extended to provide services on
the neighboring islands. It is necessary that we continue to coalesce the presently
fragmented behavioral health services so that we can more effectively rehabilitate those
in the community with behavioral healthcare needs.
Going forward, it will be important to maintain the momentum of these current efforts
through documentation of progress and effectiveness as well as through adjusting
objectives as needed. We ask for continued support for our current initiatives and
existing systems, as well as a commitment of ongoing evaluation of our behavioral
healthcare and related systems so that we can continue to build a continuum that is
more accessible along a cohesive and coordinated system of care. It is recommended
that the combined task force continue its efforts into 2020 to continue evaluating the
current laws, systems, and policies relating to involuntary hospitalization and health
systems. 

 

37

 References 
 
1. Rabah Kamal et al. Journal of the American Medical Association. Costs and Outcomes of Mental
Health and Substance Use Disorders in the U.S. 2017; 318 (5):415
2. NAMI. “Mental Health by the Numbers.” Retrieved from
https://www.nami.org/Learn-More/Mental-Health-By-the-Numbers
3. Henry, Meghan, Anna Mahathey, Tyler Morrill, Anna Robertson, Azim Shivji, and Rian Watt. “The
2018 Annual Homeless Assessment Report (AHAR) to Congress.” The U.S. Department of
Housing and Urban Development Office Of Community Planning And Development. 2018.
Retrieved from ​https://files.hudexchange.info/resources/documents/2018-AHAR-Part-1.pdf​.
4. Alcohol and Drug Abuse Division. Report to the Twenty-Ninth Legislature, State of Hawai'i.
Kapolei, HI: Department of Health. 2016
5. U.S. Sentencing Commission, 2015 Datafile, USSCFY15. Retrieved from
https://www.ussc.gov/sites/default/files/.pdf/research-and-publication/federal-sentencing-statistis/
state-distric-circuit/2015/hi15.pdf
6. Partners in Care “Point In Time Count, Oahu” 2019. Retrieved from
https://www.partnersincareoahu.org/sites/default/files/PIC%202019%20Oahu%20PIT%20Count%
20Report%20-%20FINAL_0.pdf
7. Hawai'i Revised Statutes §§334-59 - 334-62
8. AMHD. “AMHD and MH1 Program Update May 2018” 2018.
9. Mulligan K. ER docs report large increase in psychiatric patients. Psychiatr News, 2004.
10. Snook, John, and E. Fuller Torrey. “America Badly Needs More Psychiatric Treatment Beds.”
Treatment Advocacy Center. National Review, 2018.
11. Treatment Advocacy Center. “Psychiatric Bed Shortages.” Treatment Advocacy Center, 2018.
Retrieved from ​https://www.treatmentadvocacycenter.org/key-issues/bed-shortages
12. Pat Little-Upah, MA​; ​Chris Carson, MD​; ​Robert Williamson, MD​; ​Tom Williams, MC​; ​Michael
Cimino, MBA​; ​Neena Mehta, MSN​; J​ eff Buehrle, MBA​; ​Steve Kisiel​. “The Banner Psychiatric
Center: A Model for Providing Psychiatric Crisis Care to the Community while Easing Behavioral
Health Holds in Emergency Departments” The Permanente Journal. 2013. Retrieved from
https://doi.org/10.7812/TPP/12-016
13. Oahu Coordinated Entry System. “High Utilizer/ Super Utilizer - ER Visits/ Hospital Stays Data
from August to October 2017.” 2017.
14. NAMI. “Jailing People With Mental Illness.” NAMI, 2019. Retrieved from
https://www.nami.org/Learn-More/Public-Policy/Jailing-People-with-Mental-Illness
15. Snook, John, and E. Fuller Torrey. “America Badly Needs More Psychiatric Treatment Beds.”
Treatment Advocacy Center. National Review, 2018.
16. Doran, Kelly M., Kyle T. Ragins, Andrea L. Iacomacci, Alison Cunningham, Karen J. Jubanyik,
and Grace Y. Jenq. "The revolving hospital door: hospital readmissions among patients who are
homeless." ​Medical care​ 51, no. 9 (2013): 767-773.
17. Hawai'i Revised Statutes §§334-59
18. Dhcs.ca.gov. (2016). ​What is HIPAA​. Retrieved from:
http://www.dhcs.ca.gov/formsandpubs/laws/hipaa/Pages/1.00WhatisHIPAA.aspx
19. Milken Institute School of Public Health. “Health Information and the Law: 42 CFR Part 2.” Health
Information and The Law Project. 2019. Retrieved from
http://www.healthinfolaw.org/federal-law/42-cfr-part-2
20. Hawai'i Revised Statute Chapter 334 §§121-134
21. Hawai'i Revised Statute Chapter 327G
22. American Association of Community Psychiatrists. levels of Care Utilization System for
Psychiatric and Addiction Services Adult Version 2010”, 2009. Retrieved from
https://cchealth.org/mentalhealth/pdf/LOCUS.pdf
23. “Hawai'i Homeless Healthcare Hui.” Retrieved from ​http://www.h4Hawai'i.org/

38

 24. Kampman, Kyle, and Margaret Jarvis. "American Society of Addiction Medicine (ASAM) national
practice guideline for the use of medications in the treatment of addiction involving opioid use."
Journal of addiction medicine​ 9, no. 5 (2015): 358.
25. SAMHSA. “Behavioral Health Barometer”. 2015. Retrived from
https://www.samhsa.gov/data/sites/default/files/2015_Hawai'i_BHBarometer.pdf
26. NAMI. “Jailing People With Mental Illness.” NAMI, 2019. Retrieved from
https://www.nami.org/Learn-More/Public-Policy/Jailing-People-with-Mental-Illness
27. NAMI. “Jailing People With Mental Illness.” NAMI, 2019. Retrieved from
https://www.nami.org/Learn-More/Public-Policy/Jailing-People-with-Mental-Illness
28. Broner, Nahama, Pamela K. Lattimore, Alexander J. Cowell, and William E. Schlenger. "Effects of
diversion on adults with co-occurring mental illness and substance use: Outcomes from a
national multi-site study." ​Behavioral Sciences & the Law​ 22, no. 4 (2004): 519-541
29. Pat Little-Upah, MA​; ​Chris Carson, MD​; ​Robert Williamson, MD​; ​Tom Williams, MC​; ​Michael
Cimino, MBA​; ​Neena Mehta, MSN​; J​ eff Buehrle, MBA​; ​Steve Kisiel​. “The Banner Psychiatric
Center: A Model for Providing Psychiatric Crisis Care to the Community while Easing Behavioral
Health Holds in Emergency Departments” The Permanente Journal. 2013. Retrieved from
https://doi.org/10.7812/TPP/12-016
30. “Law Enforcement Assisted Diversion Honolulu 1 -Year Program Evaluation Report”. 2019.
Retrieved from
https://homelessness.Hawai'i.gov/wp-content/uploads/2019/10/191030-LEAD-Honolulu-Evaluatio
n-FINAL-USE-THIS-ONE-2.pdf

 

39

 APPENDIX A: 
DESIGNATED TASK FORCE MEMBERS PURSUANT TO ACT 90 & ACT 263
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●

Arcena, Paula – AlohaCare
Baker, Rosalyn (Senator) - Hawai'i Opioid Initiative, Executive Steering Committee
Bazin, Patti - Hawai'i Medical Service Association
Chang, Jason - Queen’s Health System
Cunningham, Brian - Wahiawa General Hospital
Esslinger, Laura - AlohaCare
Ferreira, Paul (Chief) - Hawai'i Island Police Department
Friend, Renee - Maui Health Systems
Fujiwara, David, MD - Kaiser Permanente
Garcia, Lyndsey – Hawai'i Medical Service Association
Gonce, Randy - Hawai'i Interagency Council on Homelessness
Green, Rod (Captain) - Kauai Police Department
Haning, William, MD - University of Hawai'i, JABSOM
Hayashida, Colin - Department of Commerce and Consumer Affairs, Insurance Division
Hughey, Nicholas - Waianae Coast Comprehensive Center
Johnson, Alan - Hawai'i Substance Abuse Coalition
Kajimura, Tricia - Mental Health America of Hawai'i
Lambert, Mike (Lieutenant) - Honolulu Police Department
Lusk, Heather - Hawai'i Health and Harm Reduction Center
Medeiros, Dyan (Judge) - Judiciary
Mersereau, Edward, Chairperson - Deputy Director, Behavioral Health Administration
(DOH)
Mitchell, Constance - Institute for Human Services
Mizuno, John (Representative) – Hawai'i Opioid Initiative, Executive Steering
Committee
Mohr-Peterson, Judy - Department of Human Services
Pontanilla, Jan (Sergeant) – Maui Police Department
Prince, Merry - Maui Police Department
Raethel, Kathy - Adventist Health Castle
Raethel, Hilton - Healthcare Association of Hawai'i
Robinson, Michael - Hawai'i Pacific Health
Rosen, Linda, MD - Hawai'i Health Systems Corporation
Segawa, Lance - Hawai'i Health Systems Corporation – Kauai Region
Sivik, Scott - Ohana Health Plan
Sonobe-Hong, Renee - Department of Public Safety
Yoo, Kristine (Judge) - Judiciary

40

 APPENDIX B: 
OTHER TASK FORCE PARTICIPANTS 
1. Anderson, Erik – Adventist Health
Castle
2. Apter, George – Kaiser Permanente
3. Armitage, Andrea – Department of
the Attorney General
4. Ashlock, Ryan – Adventist Health
Castle
5. Champion, Michael, MD –
Department of Health
6. Ching, Jonathan – Kaiser
Permanente
7. Clemente, Mark – Senator Gil
Riviere’s Office
8. Cravalho, Andreas – AlohaCare
9. Cunningham, Brian – Wahiawa
General Hospital
10. Curtis, Amy – Department of Health
11. Erteschik, Louis – Hawai'i Disability
Rights Center
12. Espinda, Malia – Hawai'i Health
Systems Corporation
13. Esslinger, Laura – AlohaCare
14. Faige, Jessie – Senator Karl Rhoads
Office
15. Garrett, Colleen – Healthcare
Association of Hawai'i
16. Gass, Mestisa – Mental Health
American Hawai'i
17. Gonzales, Violeta – Leahi Hospital
18. Grambs, Marya – Partners in Care
19. Green, Josh (Lt. Governor) – Office
of the Lieutenant Governor
20. Hardie, Lydia – Hawai'i Disability
Rights Center
21. Hiraoka, Debbie – SH Consulting
LLC
22. Ige, Arlene – Department of
Commerce and Consumer Affairs –
Insurance Division
23. Ishikawa, Nandi – Hawai'i Health
and Harm Reduction Center)

24. Kim, Duk Whan – Hawai'i Cedar
Church
25. Kohrer, Tammy – Wahiawa General
Hospital
26. Leiggi-Brandon, Sondra – The
Queen’s Health System
27. Luke, Kenneth – Ohana Health Plan
28. Manding, Allysen – Senator Rosalyn
Baker’s Office
29. Markeley, Maryellen
30. Masunaga, Colette – The Queen’s
Health System
31. Merriam, Kathleen – Department of
Health
32. Mitchell, Mark – Institute on
Violence, Abuse and Trauma
33. Ocsow, Margarete – Senator Gil
Riviere’s Office
34. Ogawa, Quin – Kahi Mohala
35. Rhoads, Karl (Senator) – Hawai'i
State Legislature
36. Riviere, Gil (Senator) – Hawai'i
State Legislature
37. Robertson, Ian – Department of
Commerce and Consumer Affair –
Insurance Division
38. Rodriguez, Alicia – Honolulu Police
Department
39. Sanada, Sean – Hawai'i Health
Systems Corporation
40. Schultz, Taylor – Department of
Health
41. Tanigan, Courtney – Hawai'i Health
and Harm Reduction Center
42. Torres, Juanito – Hawai'i Medical
Services Association
43. Wilkinson, Rachel – Ohana Health
Plan
44. Won, Tricia – Maluhia Hospital

41

 APPENDIX C: 
TASK FORCE MEMBERS BY FOCUSED WORKGROUPS 
 
22. Dr. Michael Champion​ – Department of
Health

Criteria for Involuntary Hospitalization
1. Dr. William Haning​ – UH, JABSOM
(Co-Chairperson)
2. Lt. Governor Josh Green​ – Office of the
Lieutenant Governor (Co-Chairperson)
3. Heather Lusk​ – Hawai'i Health and Harm
Reduction Center
4. Dr. Linda Rosen​ – Hawai'i Health Systems
Corporation
5. Malia Espinda​ – Hawai'i Health Systems
Corporation
6. Cheryl Tennberg​ – Hawai'i Health
Systems Corporation
7. Jonathan Ching​ – Kaiser Permanente
8. George Apter​ - Kaiser Permanente
9. Frank Richardson​ – Kaiser Permanente
10. Dr. Tina Melendrez-Chu​ – Kaiser
Permanente – Kauai Region
11. Diane Lee​ – Kaiser Permanente
12. Dr. David Fujiwara​ – Kaiser Permanente
13. Dr. James Ford​ – Kaiser Permanente
14. Tricia Won​ – Maluhia Hospital
15. Renee Friend​ – Maui Memorial Medical
Center
16. Jessie Faige​ – Office of Senator Rhoads
17. Marya Grambs​ – Partners in Care
18. Jennifer Wong​ – Judiciary
19. Kathleen Merriam​ – Department of Health
20. Louis Erteschik​ – Hawai'i Disability Rights
Center
21. Andrea Armitage​ – Department of the
Attorney General

Data Gathering
1. Eddie Mersereau​ – Department of Health
(Chairperson)
2. Dr. Amy Curtis​ – Department of Health
3. Dr. Linda Rosen​ – Hawai'i Health Systems
Corporation
4. Malia Espinda​ – Hawai'i Health Systems
Corporation
5. Connie Mitchell​ – Institute for Human
Services
6. Jonathan Ching​ – Kaiser Permanente
7. Rowena Fuata​ – Kaiser Permanente
8. Andy Mounthongdy​ – The Queen’s
Health Systems
9. Francis Chan​ – Hawai'i Health
Information Exchange
10. Mark Mitchell​ – Institute on Violence,
Abuse and Trauma
11. Todd Morgan​ – AlohaCare
12. Ryan Ashlock​ – Adventist Castle
13. Dr. James Lin​ – Hawai'i Pacific Health
14. Thaddeus Pham​ – DOH / Hawai'i Opioid

42

 Post-Stabilization Community Support

23. Colette Masunaga​ – Queens Health
System
24. Debbie Hiraoka​ – SH Consulting
25. Judy Suzuki ​– Straub Medical Center
26. Jean Roberts​ – Straub Medical Center
27. Dr. John Myhre ​–​ ​Waianae Coast
Comprehensive Center

1. Hilton Raethel​ – Healthcare Association of
Hawai'i (Chairperson)
2. Steven Balcom​ – AlohaCare
3. Janelle Saucedo​ – Department of Health
4. Colleen Garrett​ – Healthcare Association
of Hawai'i
5. Paige Heckathorn Choy​ – Healthcare
Association of Hawai'i
6. Heather Lusk​ – Hawai'i Health and Harm
Reduction Center
7. Malia Espinda​ – Hawai'i Health Systems
Corporation
8. Sean Sanada​ – Hawai'i Health Systems
Corporation
9. Derek Akiyoshi​ – Hawai'i Health Systems
Corporation
10. Lyndsey Garcia​ – Hawai'i Medical Service
Association
11. Patti Bazin​ – Hawai'i Medical Service
Association
12. Michael Robinson​ – Hawai'i Pacific Health
13. Alan Johnson​ – Hawai'i Substance Abuse
Coalition/ Hina Mauka)
14. Connie Mitchell​ – Institute for Human
Services
15. Jonathan Ching​ – Kaiser Permanente
16. Dr. Tina Melendrez-Chu​ – Kaiser
Permanente
17. Diane Lee​ – Kaiser Permanente
18. Haley Hsieh​ – Laulima Data Alliance
19. Violeta Gonzales​ – Leahi Hospital
20. Renee Friend​ – Maui Memorial Medical
Center
21. Trisha Kajimura​ – Mental Health America
of Hawai'i
22. Dr. Scott Miscovich​ – Physician

Funding and Eligibility
1. Alan Johnson​ - Hawai'i Substance Abuse
Coalition (Co-chairperson)
2. Laura Esslinger​ - AlohaCare
(Co-chairperson)
3. Cheryl Tennberg​ – Hawai'i Health
Systems Corporation​ – Kauai Region
4. Malia Espinda​ – Hawai'i Health Systems
Corporation
5. Michael Hamamoto​ – Hawai'i Health
Systems Corporation – Oahu Region
6. Lyndsey Garcia​ – Hawai'i Medical Service
Association
7. Patti Bazin​ – Hawai'i Medical Service
Association
8. Jonathan Ching​ – Kaiser Permanente
9. Dr. Kelley Yim​ – Kaiser Permanente
10. George Apter​ – Kaiser Permanente
11. Frank Richardson​ – Kaiser Permanente
12. Renee Friend​ – Maui Memorial Medical
Center
13. Kenneth Luke​ – Ohana Health Plan
14. Marya Grambs​ – Partners in Care

43

 MH-1 Statute Review
1. Dr. Rick Bruno​ – The Queen’s Health
Systems (Chairperson)
2. Sondra Leiggi-Brandon​ – The Queen’s
Health Systems (Co-chairperson)
3. Ryan Ashlock​ – Adventist Health Castle
4. Erik Anderson​ – Adventist Health Castle
5. Steven Balcom​ – AlohaCare
6. Andrea Armitage​ – Department of the
Attorney General
7. Dr. Michael Champion​ – Department of
Health
8. Dr. Mary Eckert ​– Department of
Psychiatry, UH Manoa
9. Dean Nakano​ – Emergency Medical
Services
10. James Howe (Jim)​ – Emergency Medical
Services
11. Korey Chock ​– Emergency Medical
Services
12. Dr. Linda Rosen​ – Hawai'i Health Systems
Corporation
13. Malia Espinda​ – Hawai'i Health Systems
Corporation
14. Michael Robinson​ – Hawai'i Pacific Health
15. James O’Connor ​– Hawai'i Police
Department
16. Alicia Rodriguez​, Psy.D. – Honolulu
Police Department
17. Dr. David Fujiwara​ – Kaiser Permanente
18. Dr. Kelley Yim​ – Kaiser Permanente
19. Sam Balukoff ​– Kaiser Permanente

20. Renee Friend​ – Maui Memorial Medical
Center​Jan Pontanilla​ – Maui Police
Department
21. Merry Greer Prince​ – Maui Police
Department
22. Jessie Faige​ – Office of Senator Rhoads
23. Dr. Nathan Angle​ – Straub Medical Center
24. Dr. Nate Arnone ​– Straub Medical Center
25. Brian Cunningham​ – Wahiawa General
hospital
26. Tammy Kohrer ​– Wahiawa General
Hospital
27. Nicholas Hughey​ – Waianae Coast
Comprehensive Health Center

44

 APPENDIX D: 
Additional Resources 
Current Related Initiatives
Hawai'i CARES: ​https://health.Hawai'i.gov/amhd/files/2013/06/AMHCD-Short-Form1.pdf
Referral Line: (808) 832-3100 (Neighbor Island residents, call toll free 1-800-753-6879).
Hawai'i Homeless Healthcare Hui (H4) Center: ​http://www.h4Hawai'i.org/
Hawai'i Homeless Outreach and Medical Education (HOME) Program:
https://Hawai'ihomeproject.org/clinic-schedule/
Hawai'i Opioid Initiative
● Website: ​https://Hawai'iopioid.org/
● HOI Report:
https://health.Hawai'i.gov/substance-abuse/files/2019/01/The-Hawai'i-Opioid-Initiative_2.
pdf
Law Enforcement Assisted Diversion (LEAD) Report:
https://homelessness.Hawai'i.gov/wp-content/uploads/2019/10/191030-LEAD-Honolulu-Evaluati
on-FINAL-USE-THIS-ONE-2.pdf

Mental Health Statutes
Hawai'i Revised Statutes Chapter 334 (General):
https://www.capitol.Hawai'i.gov/hrscurrent/Vol06_Ch0321-0344/HRS0334/HRS_0334-.htm
Assisted Community Treatment Criteria (Hawai'i Revised Statutes Chapter 334, Part VIII):
https://www.capitol.Hawai'i.gov/hrscurrent/Vol06_Ch0321-0344/HRS0334/HRS_0334-0121.htm
Involuntary Hospitalization Criteria (Hawai'i Revised Statutes Chapter 334-59):
https://www.capitol.Hawai'i.gov/hrscurrent/Vol06_Ch0321-0344/HRS0334/HRS_0334-0059.htm
Psychiatric Advanced Directives (Hawai'i Revised Statutes Chapter 327G):
https://health.Hawai'i.gov/amhd/files/2013/06/AMHCD-Short-Form1.pdf
https://www.capitol.Hawai'i.gov/hrs/isysquery/186cded6-3c6e-46f8-a988-388ff118a9fe/1/doc/#hi
t1

45

 Other Resources
Health Insurance Portability and Accountability Act of 1996
https://aspe.hhs.gov/report/health-insurance-portability-and-accountability-act-1996
42 Code of Federal Regulations Part 2 - CONFIDENTIALITY OF SUBSTANCE USE
DISORDER PATIENT RECORDS
https://www.law.cornell.edu/cfr/text/42/part-2

46