Saturday, June 14, 2008


Now that the federal court isn't watching, the Dept of Health cuts back on mental health services

by Larry Geller

I doubt that the Hawaii Department of Health could get away with cutting Assertive Community Treatment (ACT) services if Judge David Ezra was still breathing down their neck. Actually, the judge was quite lenient, allowing both the childrens' (Felix) and the adult (State Hospital) lawsuits to drag on for years, but at least there were busy attorneys able to bring violations to the attention of the Court.

The DOH announcement that it will cut off ACT services should not be viewed in isolation. There is a dark history here, of which this may be only the latest part. Knowing a little of it may help put the current controversy in perspective.

The big federal lawsuits are over, and the DOH appears to be reverting to its its "blame the providers" modality to excuse its own management failure and to cut back on services to consumers. The evidence is in the articles just appearing in the daily papers, but the problem is of very long standing.

Today's Star-Bulletin article, State defends change to mental health help, raises questions about DOH's oversight of the contracts serving its mental health clients:

"We have been cast as having made frivolous, overnight decisions, and that is not the case," Michelle Hill, deputy health director for behavioral health and Adult Mental Health Division acting director, said yesterday. "I believe we have made appropriate business decisions ... to better insure good outcomes for consumers and accountability to the public," she said, explaining that ACT programs have experienced problems nationally.

She said providers were not following the ACT model and that the department was paying for a full array of services whether clients needed them or not.

Because ACT services were not being provided, Medicaid had to be billed for a lower level of services, Hill said.

If "providers were not following the ACT model" you have to ask why the DOH allowed that situation to continue. We'll get back to this point in a moment.

Cost cutting has taken precedence over consumer needs

The community has rallied in the past against DOH cutbacks, as for example when the DOH under Bruce Anderson stubbornly insisted on closing down the Diamond Head mental health facility despite overwhelming community and professional opposition.

Consumers who had moved close to the facility were told they'd have to take buses to get to Lanakila instead, even though some were probably not able to do so. Anderson's heart was not softened, and it took a call to Gov. Cayetano who was in California as I recall, to quash that unfortunate plan.

Autism parents reacted angrily and ultimately successfully when DOH illegally cut back on services to their children. Only a meeting at the school, as prescribed by law, can make that decision, but the DOH didn't care much for the law (the state was found in contempt of the Felix Consent Decree). It took TV cameras and parents waving the proof, papers they received demonstrating illegal DOH cutbacks, to get the DOH to reluctantly relent and restore the cuts.

DOH's ongoing war against its provider network

Through the years DOH (and state legislators) have found it convenient to blame service providers for the high costs of the system they created. There were indeed some provider excesses, but one must say also that those were made possible by DOH contracting inadequacies and oversight lapses or they would not have happened.

From my days working with Felix children I know that the DOH is quite happy to set up a provider to fail with lack of guidance/oversight, then crack down by withholding funds and attacking the provider. Often the rules that the provider "failed to follow" were never explicated prior to a DOH crackdown. DOH also employed audits punitively rather than remedially, targeting specific providers or agencies.

Even if a provider agency did a good job, DOH would withhold funds to the point where payrolls could not be met and individual providers were forced to leave the state because they couldn't afford to live here without pay. One situation I have in mind is the Mokihana Project in Kauai, which was considered a model during the Felix lawsuit. Nevertheless, DOH authorized services but withheld contract payment for months. I interviewed a psychologist by phone from the airport, on his way to the Mainland because he had not been paid. His work was not in question. It was DOH mismanagement (and that's being generous to them, since rumors circulated that the strangulation might have been deliberate).

When Felix services were privatized because the DOH Family Guidance Centers could not deliver services in the quantities needed, DOH repeatedly and illegally cut back on services to individual children in reaction, no doubt, to the increased cost of providing services as the law and the federal court required. Later on they concentrated more on training and managing their many contracts, and just before the baby was thrown out with the bathwater as services were transferred to the Department of Education, training and better oversight replaced cost cutting in contract management.

No doubt there is more to this than has come out so far in the papers. From today's Advertiser story, State defends planned change in providing services for mentally ill:

The state Department of Health says it plans a more effective way to deliver care to its most severely mentally ill patients. Critics contend the plan could throw DOH's Adult Mental Health Division into chaos, overwhelm the system and pose a risk to patients and the public.
"What we have discovered upon monitoring all the ACT providers is that we have not been able to achieve the true ACT service," Hill said. "What we're finding instead is that they have actually been delivering is more consistent with CBCM."

These services have been provided since 2003, plenty of time for DOH to get the house in order, if it were interested in doing that. Perhaps it is time to investigate whether DOH is properly managing its mental health services before there needs to be another federal lawsuit.

Maui neglected, now to be cut off

Maui has long been the neglected stepchild in Hawaii's mental health system, with service deficiencies that linger for years after Oahu is attended to. Understaffing, accusations of discharging patients from the hospital to the beach without meds, waiting lists, lack of services—and now discontinuation of a program that started only last year, lagging about four years after Oahu, according to this article, State orders change in mental health care programs. It seems that Maui is about to get shortchanged again:

Established on Maui in March 2007, the ACT program just had begun to treat patients successfully. [Colleen O’Shea Wallace, ED of Mental Health America in Maui County] said she was concerned discontinuation of ACT would set back care of Maui County’s most severe mentally ill.

“These people will get lost again,” she said.

Harriet Collopy, a member of National Alliance on Mentally Illness who runs two 12-week support groups for families with mentally ill loved ones, said she knew at least one woman who would not get needed ACT services due to the pending changes.

Collopy said her own son, also diagnosed with schizophrenia, gets services on Oahu because of limited services available on Maui.

“We hear this over and over again. . . . People are just not getting the services they need here,” she said.

How this will play out is not yet known, it depends on who will prevail in the clash between consumers, advocates, service providers and parents on one side and the Department of Health on the other.

You need attorneys to get mental health services here

Consumers in Hawaii historically have had to rely on a dedicated group of attorneys and the federal court for the services they have received from an uncaring state government, and that's very sad indeed. If the system is indeed thrown into chaos, then it will be attorneys again who provide the repairs.

So I think it's reasonable, in view of the long history of neglect and cutbacks, to question this decision for the sake of all those who will lose the services that have benefited them up till now.


The state administration and the judges in this state have been battling over these matters for years. Legally, Hawai'i has one of the most progressive (if that would can be used) legal definition for who is mentally ill and very strict requirements to qualify for confinement.

Of course, the practical or hegemonic effect of such progress is that every state administration and county prosecutor has done everything possible to undermine it created a variety of legal gray zones were the mentally ill become confined. One example is that a mentally ill person, who engages in conduct that would otherwise be a crime sentenced to 90 days in jail, may end up waiting six months to a year for a judicial evaluation of their mental illness and fitness for trial.

I think a study of how mental illness, criminality and culture in a place like Hawai'i create this legal schizophrenia would be fascinating.

The first place the state always cuts costs is in services at the bottom. God forbid the Turtle Bay bailout be delayed.

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