NAMIGrading the States: A Report on America's Health Care System for Serious Mental Illness
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Grading the States 2006: Hawaii - Narrative

Hawaii's mental health system consistently came in dead last in previous NAMI ratings (1986, 1988, and 1990). There appeared to be few causes for hope. Everything about the situation was dire - an abysmal state hospital with disgraceful conditions, poor outpatient care, poor vocational supports, and poor housing. In the ensuing 16 years, through hard work and federal pressure, Hawaii is potentially poised to be applauded as most improved of any state in this report. 

The Department of Justice (DOJ) entered the state in 1991 to address egregious civil rights violations of patients at the Hawaii State Hospital and has since been actively monitoring the quality of care. As a result, the Hawaii State Hospital has made a number of improvements and was released from federal monitoring in December 2004. In lifting the 13 years of oversight, U.S. District Judge David Ezra called the improvements at Hawaii State Hospital "astonishing."

To ensure a continuum of services for Hawaiians with serious mental illnesses, however, the federal court has retained oversight of the state's community system of care. Hawaii's Adult Mental Health Division (AMHD) has just months until the June 30, 2006, deadline to fully implement a 2002 court-ordered community mental health plan. Clearly, this is a critical time for Hawaii's mental health system.

Although the deadline is fast approaching, the AMHD has been working for years to develop a community system under the leadership of Thomas Hester, M.D., a veteran community psychiatrist. While the speed of this process has been criticized, most notably by U.S. Magistrate Kevin Chang, change does take time. The community system is being built upon a foundation of solid plans to ensure that it is sustainable long after the court oversight leaves Hawaii's shores. 

The result is currently a community mental health system that is far from perfect, but that clearly has made progress. In 2003, AMHD established a Center for Evidence-Based Practice in partnership with the University of Hawaii to advance the adoption of such important services as Assertive Community Treatment (ACT), integrated treatment for co-occurring disorders, supported employment, and illness management programs. Supported housing exists across the islands, and the state is supporting several jail diversion programs as well. Although some of these programs are still getting off the ground, the state is working hard to advance these key community system components. 

The availability of effective services is critical, but for a state like Hawaii with a majority-minority population, those services must meet the needs of the state's population. In response, AMHD has developed a three-year multicultural strategic plan to ensure that culturally competent services are infused throughout the developing community system. 

Additionally, Governor Linda Lingle's discussion of her mother's mental illness has helped debunk stigma in the state during this important transition time for the mental health system. In 2003, during legislative debate around insurance parity, Governor Lingle testified in favor of the legislation and spoke of her family experience. As Governor Lingle so aptly stated, "It just doesn't make any sense why we would have to come and even testify on something like this. It's a sickness. It's an illness. You don't come and testify for diabetes or high blood pressure." Governor Lingle's bravery and leadership on parity helped move the legislation into law and brought mental illness into the open for Hawaiians. 

Even though Hawaii's system is on the right leadership track, change also takes money. The Hawaii legislature has supported the mental health system over the past few years, with an increase in funds from fiscal year 2003 to 2005 of almost $35 million. Now is the time for the state to demonstrate its commitment to the mental health system in this final stretch before the June 30, 2006, deadline. 

In early 2006, AMHD requested an emergency appropriation from the legislature of approximately $10 million, a request still in debate at the time this report went to press. The additional funds are needed in the short term to help the system comply with the court deadline, and are also necessary for the long term. The funds will also be used to meet the growing need for services as increasing numbers of individuals access the developing community system. 

But, even with an influx of additional funds, there is still much work to be done in Hawaii's system, as noted by Mr. Chang's July 2005 report. A recent spate of 16 deaths, including six by suicide, among individuals receiving state mental health services was cited as one major concern. In his report, Mr. Chang said that the deaths reflected system dysfunction and a lack of judgment in the AMHD's response. And, despite the turnaround at Hawaii State Hospital, the challenge now is overcapacity, due to an increasing forensic population and a community system that does not yet possess the resources to provide appropriate services for individuals discharged from inpatient care. As a result, the state has contracted with another mental health provider (Kahi Mohala) for an additional 40 beds, at an annual cost of $10 million. 

Clearly, Hawaii has not yet fully arrived. With the help of the federal court, the leadership of the state system, and the involvement of consumers and family members in the state, however, Hawaii's mental health system has a chance to address these problems and continue the tremendous progress made by the state since 1991. 

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