Senate Standing Committee on Health and Human Services

Calling the depart. Calling the September, October 2025. 2:30 informational briefing by the Committee on Health and Human Services. Present is myself as well as Senate Chair of Public Safety, Senator Elefante. Thank you for being present. Okay. We are calling this briefing today.

As some of the presenters know, we've done this a year earlier and we want status at Hawaii State Hospital. At that time we were Talking about Act 26, jail diversion and my huge concerns of the lack of ACOs at Hawaii State Hospital.

The requirement by the Clark consent order for the timelines requiring defendants being transferred from Department of Corrections and Rehabilitation over to Hawaii State Hospital. Hawaii State Hospital basically becoming more a forensic only state hospital and not having the ability to help local citizens and with their civil needs.

You know, those parents who have a schizophrenic son who they can't handle. We don't have Hawaii State Hospital anymore. And, and the fact that since then, and it's only been slightly over a year, we lost Kahi Mohala, which means less psychiatric beds.

State Hospital having to go even after the 400 million plus addition, having to go through major renovations requiring. Thank you. Requiring an expenditure of another 10 million-plus a potential lawsuit with a contractor because of the problems with a 400 million plus dollar addition to the Hawaii State Hospital and the fact that Act 26 has. Act.

I mean the good news is last time Department of Health said only 1% was being diverted. Apparently now it's substantially more according to the Civil Beat article. And it's about time we start looking at it again. And I have present also Director Tommy Johnson from the Department of Correctional and Rehabilitation to answer questions.

And we also have present the Attorney General's Office to answer questions as to whether or not there is a way we can sideline or at least file another file a complaint for an amendment to the Clark injunction so that we do not have the timelines requirements for the transfer from Department of Corrections and Rehabilitation to Hawaii State Hospital.

And hopefully we can lower the overcrowding, especially because we lost Kahi Mohala. The addition had major construction defects so we have even less beds than we had one year ago.

And since I'm also Chair of Human Services and I have the report and you're not of the last year's report, we're going to need an updated report from the housing person showing that there really is no supportive housing being planned.

The revolving door referred to by the Civil Beat article may continue unless hopefully we could have some solutions going forward. So with that in mind and with that as the backdrop of why we're having this informational briefing, we have Here State Administrator from the Hawaii State Hospital. Could you identify yourself?

I'm Mark Linscott.

Mark Linscott. And instead of Deputy Director Marion Higa. We have Dr. Courtenay Matsu. Courtenay Matsu in her stead. Okay, so really fast because that's not the reason why we are here today. What's the status of the construction defects with Hawaii State Hospital?

So we're continuing to collaborate with DAGS and the Attorney General. They are exploring all options, including the vendor, and we continue to identify those areas for repair and repair those that we can.

Okay, but because of the construction defects, how many beds, how many of the original beds before the construction defects came to light? Percentage that, that we are losing?

Well, I think we haven't lost them yet, Senator. Okay, good. So we're using all the maximum beds that we have, which is 292 licensed beds for the entire hospital. And there's about 166 at the Haleho'. Ola.

And of those we are also using 113 wave beds which we have to go for exemption periodically with the Department of Health and Shipta.

Okay. And hopefully with the 10 million plus that hopefully was released and remediation, you will continue to be able to use all the beds that's allocated in this new addition to the.

That is the goal. And what we're trying to do is make sure that we do that and we'll talk about some of the other opportunities with the decompression plan for the state hospital to right size the census.

Okay, thank you, thank you very much. And we also have Dr. Matsu here. Now you folks have a presentation and I really want the public to know how dire the old overpopulation problem is with Hawaii State Hospital. So please proceed.

Okay. Good afternoon Chair and Committee Members. I'm Courtenay Matsu, the Acting Deputy Director for Behavioral Health Administration and Medical Director for Adult Mental Health Division.

So thank you for inviting us to share an update on the Hawaii State Hospital and our work together with the Governor's office to ensure that there's a continuum of care that is available to address our state's behavioral health needs. Today we wanted to discuss the factors that are contributing to the high census at Hawaii State Hospital.

And we look at this in two ways. Factors that are increasing admissions and factors that keep us from discharging patients. So starting with increased admissions, the loss of patient beds, as you said at Kahi Mohala in 2020, resulted in those patients returning back to Hawaii State Hospital.

Secondly, charges in proceedings for defendants charged with petty misdemeanors are also contributing to the increased admissions. And these changes are often referred to as Act 26, Session Laws of Hawaii 2020. And we'll discuss this a little bit in more detail in the next slides.

And then regarding discharge barriers, there are limited placement options at lower levels of care that continue to delay the discharges. So I'd like to turn it over to Mark Linscott, Hawaii State Hospital administrator.

Thank you, Dr. Matsu. Next slide. So the hospital continues to have high census. As you can see, over the last five years, it continues to rise. We did note the Kahi Mohala as well as we do have a mainland facility that takes assaults and highly violent folks at our hospital. And we do use that facility.

As I stated before, there's 292 license beds and last fiscal year we had 376 average daily census. Next slide. So among who are the individuals that get admitted? So a lot of our patients have been admitted at the hospital before. It's about 66% and we have about of those 22% were unhoused prior to the admission.

And one of our goals is to work on connecting them to housing at the time of discharge. I do want to point out that on this slide we continue to have our highest admissions. So these are the actual counts, not the average daily census. So the last two years we've tipped at 600 patients in a given year.

And that's quite a lot for our hospital to manage. Next slide. So rehospitalization status of admission. So what this really measures is the need for community continuity of care and community support structures. So if we can get our patients to the next level of care and keep them from coming back into the hospital, that's our goal. Right?

So we've treated them, we've stabilized them. We need to go to the next level of care. If you looked in FYI, 24 to 25, our number of episodes. So this is the number of actual readmissions.

So it's 35 and 24 and 46 in 2025 of those 46 episodes, separate episodes of readmits, that accounts for 27 patients that are coming into the hospital. And this is one of the areas that we need to kind of look at and correct. And they actually account for 8 to 14 day stays.

So this is part of our challenge is getting to the next level of care that's appropriate. Next slide. So patients by legal status and you know, what we have is a pie chart. So evaluation of the so about 18% of our patients there account for that unfit to proceed.

So these are the restore we want to restore patients to be able to proceed their court hearings which is our bread and butter and this has typically always been part of the patient population at the State of Hawaii Hospital. And then violation of conditional release is 20%, not guilty by reason of uncertainty is about 2%.

And then we do have some civil commits which we would like to be able to do more of in the future. In terms of the violation of condition of release, 18% are actually hospitalized temporarily because they violated their condition. It's not a revoke of their condition, it's a violation.

And so this is really the stabilization work so that's a part that we want to look at and then the evaluation of fitness. These are the folks that really haven't been evaluated for unfit or fit and that's the other group that we think we can have that done in another facility or somewhere else.

My esteemed colleague Brenda Smith Bauer is going to come talk to us about the legal status.

Yes. Good afternoon, Senator. Thank you for having us today. I'm Brenda Bauer Smith. I'm representing the Department of Health court evaluation branch. So I think Mr. Linscott could covered the majority of the slides. One of the questions that might come up would be why are they separated into the different pie pieces?

Why is it important to identify the patients or defendants based on their legal status? So when I look at the orange section, I am thinking about or these are the defendants who have been ordered for an initial evaluation. They aren't unfit yet.

And those are the ones that could be evaluated in another location, whether that's the community or in a correctional facility. The group in the turquoise section are those who are appropriate for the hospital in so much as the courts have found them to be unfit and needing hospital level of care. Those are the ones who.

A percentage of those. If there was appropriate level of care in the community, they could have been diverted or they could be discharged and they could be released on conditions. Additional housing could help that for those group, for that group to move forward, they do need to be reevaluated by an examiner.

So somebody from the treatment team at the hospital has to reach out to the court and a motion will be made, an order cut and then they'll be re examined. The green section are those, as Mark said, who have been acquitted and committed.

They've been released to the community on conditional release and they have violated their conditional release. They can go back to the hospital in for as short a time as 72 hours and they can be re stabilized. Those defendants don't need a reevaluation. They could be moved back out to the community.

But again, sometimes once they leave their housing in the community, it's difficult to get them back out into appropriate level of care during that 72 hours. And then finally there's that last group who have been found not guilty by reason of insanity. And those would be waiting an evaluation for conditional release to get out to the community.

Okay, thank you. We also have Senator Keohokalole who is also present. I have questions of the Director and you if there is a point that I can ask now or do you have more to say? I know you have more slides. Okay. But if you don't mind. Okay.

So when you have percentages, it looks to me I. I did quick math. You have 376 patients. You're only licensed for 292. So you're about 84 patients over and above what you're already licensed, which comes out to about 29%.

So which means if we look at this chart here, if you're able to remove the evaluation of fitness to a separate facility, then you will be able to reduce that population by another down to only about 10%. And if you're able to reduce that violation of conditional release population 2930 you'll.

You'll have actually a 10% in favor of more beds that could be hopefully used for civil commitments, right?

That is correct. So.

So we can actually use a state hospital for more than criminal defendants.

Which is what it used to be back in the 90s. And so. Yes, when it was primarily civil, in fact, rather than forensic.

That is absolutely.

Absolutely. So the evaluation of fitness, that number is 107. And the 20% for the violation of conditional release is 118. And 116 are the ones that were temporary violating their CR.

So the violations of conditional release, have you looked at. At why they violated. Is it because, like, I mean, like I said, I'm human services chair also, and I've been human services chair before I was chair of felt.

So I look at the housing component and I see that we have not put in, we haven't added to support of housing, which to me is what you need after you get released from the state hospital. Because the state hospital gets you to the point of stabilization, Right? That's my understanding.

That's correct.

Okay. I'm not a Doctor, but this is my understanding from just being a human services chair. But you need the supportive housing to be able to have somebody remind you here, you need to take your pills so that you can, if you don't have family, to be that supportive housing, Correct?

Correct.

And if you have, although your prior chart showed only a small percentage, 22% were unhoused prior to admission. According to your predecessor, Luke, he said, I guess, Prior to admission, 70% of the population were unhoused or considered homeless prior to admission. Is that percentage still correct? It's not in any of your charts.

Yeah, I think we. I know the 22% is accurate because we looked at the data that way. What I can do is go back and go look at the past years prior to admission. Exactly. And then get that back to this Committee if you're so inclined, because I don't have that data at the top of my fingertips.

Okay. Because it seems to me if they were already unhoused prior to admission, they do not have a supportive family or community prior to admission. And so those are the people who are more in need of supportive housing, correct? That's correct.

Because all your job is to just get them stabilized, which is just like if somebody with a physical illness goes to the hospital, they just get them cured, but then to remain healthy, somebody needs to, especially with this population, somebody needs to coach them to make sure that they take their meds, they stay away from the people who get them into these things.

Right. Okay. So. But if we're able to increase stabilization, we can. And evaluation of fitness.

That's correct.

I have Deputy AG David Day here, and I challenged him. And so you might have to come up here and add a chair here. Okay. Before we go to Dr. Matsu, I challenge you to look at the Clark consent order, which I have here. And since we're both attorneys, I can parse this thing down.

It seems to me that somebody who is conditionally released under 704, which is Act 26, says shall not be held in a facility controlled by Department of Public Safety, which is now DCR.

And that is why they are required to, if there's a 704, they are required to, within 72 hours, three days, send a detainee to Department of bills. Is that your understanding as Attorney General?

Yes.

Yes. Okay. And that's what I've read, too. If we're looking at this, and all it is, is according to this, lacks fitness to proceed, which is down here at the 60%, we can still.

And I know that Director Johnson may not be prepared for this, but I'm just brainstorming here because we have session coming up, and I want to make sure it looks like to me we need money for supportive housing. Okay. And I'm going to use this informational briefing as support for my need for support housing.

But Director Johnson, if you know, and I know you're probably not prepared for this. Are there any portions in the violation of conditional release or evaluation of fitness where you can retain the detainees and Department of DCR? No. And I'm sorry. Let's get your microphone. And why is that. And you can maybe can switch.

If the patient is court ordered to the custody and care of the Department of Health, the Director.

Then the court would have to order that person to come to dcr. I could not take that person in the custody of our jurisdiction in the case.

Yes.

Okay, so you lose jurisdiction is what you're saying. Court order.

Yes, happily so.

Okay. But if they just. If it's just an evaluation of fitness, because my understanding as a former defense attorney, you have the fitness to proceed evaluation and Then there's the insanity, which is that small itty bitty red part, the 2%. I don't think there's any question that the 2% is required to be the Hawaii State Hospital.

My question is the 18% where they are, not where all they said was we need. We are evaluating them as to whether or not they're unfit to proceed in the green area and even before the red area because that's before they were even judged to be insane. So why can't we?

They get arrested, they're homeless, they get arrested, they can't make bail, they go to occc. The public defender says, I can't deal with them, so I need a 704 evaluation. Why can't they stay in DCR while they are being evaluated?

Because we can't provide the level of care that they need. And to have them in an incarceral setting where they need to be in a therapeutic setting only damages them more, I believe.

Okay, but there's no legal requirement and you can ask. I have Attorney General Ann Lopez here also and I have asked you guys during the interim to really look at the Clark consent order.

Is there a legal requirement when at the time homeless person gets arrested, goes to OCCC because they can't make bail and public defender says I want an evaluation. Why can't they stay at DCR instead of going to Hawaii State Hospital? So that way we can free up some of those beds.

So to be clear, when the court orders someone to the custody of the Department of Director of the Department of Health, the court's not ordering them to the state hospital. The Department of Health could have a step down facility or someplace else where they could do the evaluation.

But I want to make it clear we just had two experts come here based on an Opalando lawsuit and they identified. Opilando lawsuit? Yeah, Opelinto. Opelinto. Excuse me. They identified over 40 inmates. Over 40 inmates at Halawa that need to be in a higher level of care that we just simply cannot provide.

So we cannot now take more bodies in when the experts are already telling us that we have 40 something people that need to go somewhere.

40 out of how many at Halawa? Well, no, not at Halawa because we're talking about fitness, the procedure. I'm talking about OCCC.

Well, OCC has about 954 or so, so only folks there.

40 out of 954?

No, no, that's out of. That was that. That was at Halawa.

Okay, how about OCC?

I don't have those numbers. But Halawa is only designed for 658 people. We have 954.

Okay. 40 out of 658 in Halawa. Okay.

No, no, no. I said O triple C is designed for 658. There's about 800 folks at Halawa.

Okay, so OCCC is 658 and 40 people is the people who need to be evaluated.

Those 47 people at Halawa, though, they're not in OTTC.

How many in O triple C?

I don't have those numbers. Yeah, I didn't. I didn't bring those. I didn't know I'd be asked that question.

Okay. Okay, thank you. Thank you. I'm going to ask AG and then we're going to get to. Because I'm looking at. I'm looking at your opportunities. Okay. And I want to figure out whether or not we can figure out more opportunities other than the ones you've identified here. So tell me about this Alento lawsuit.

Deputy Director Day, do you know. Pardon me. Which.

The one that Director Johnson referred to. Do you know anything about that?

Which lawsuit?

No, I don't off the top of my head.

Okay. Okay. We're talking about evaluation of fitness, which means people in OCCC, not Halawa, because Halawa is after they've already been convicted. Right. So O triple C. Is there anything in. I gave you the example. Homeless person gets arrested, doesn't make bail, goes to OCCC. Right, because that's where they go.

They don't go to Halawa, they go to O triple C. Okay. Public defender says I can't. He doesn't make sense to me. I want a Fitness 704 Fitness to proceed. Is there anything. The Clark consent order that requires DCR to transfer to H. Hawaii State Hospital.

So it's not going to be in. So to answer your question directly, the answer is it's not in the Clark injunction. It is in section 704404 of the Hawaii Revised Statutes that requires them to be in the custody of the Director of. health. So that's in the statute.

So we can change the statute.

Yes. Yeah, you could. And the. So section seven, and that's the reason why courts order the defendant into the custody of the Director of Health is because it's in the statute. But the Clark injunction doesn't speak about fitness to proceed proceedings.

It's limited to, if I can recall, violation of conditional release, acquittal on the basis of insanity, and 406, basically lack of penal responsibility.

Okay. Okay, thank you very much. Do you folks have any questions based upon the questions I've asked?

I do. Madam Chair.

Senator Elefante.

Thank you, thank you for having this hearing and thank you to the folks here in attendance. So I want to go back to and follow up to the chair's question regarding when you discharge, I guess you would call them, would it be patients? I don't know. The correct term would be patients.

So when you discharge patients, is the issue finding them supportive treatment, housing that's available or is what's, what's sort of the issue or problematic as you release them?

So in terms of discharge, and so most of our patients, we do get them into housing or try to. Some of the challenges with short stay and I'll just say the petty misdemeanor. So that's the seven to 14 days.

Those folks, we get them stabilized but as soon as they are released from the state hospital and we try to connect them with IHS other places so that they actually have a good discharge plan and a safe one, they often self sabotage.

So our issue around this population, I'm going to get very specific here because it's the comorbidity of substance use and mental health disorder. And I've been in health care in this community for over 30 plus years. And we have to figure a way to solve that group because the ones that the ACT orders actually help.

That's, that's great. But the readmissions are also the challenge that this community as a whole, we have to figure out how do we help them.

And a lot of the folks that are in that evaluation for fitness, they just need to kind of clean up, you know, and get normal to some extent and you have a good conversation with them so that they could be fit to proceed.

The problem is they're still coming off of whatever illicit drug use or whatever it is that they need some stabilization. And then you do the fitness evaluation, we might have a better outcome. And that's the challenge for our community because if we solve this then we don't have the reoccurring, revolving, frequent flyer, whatever you want to say.

And we're helping the people. I think this is the social stigma. It's, you know, do we self soothe in this community? And I'm not, you know, it's just the overall how do we solve social issues in this state?

And you know, I think we can do a better job which we have the laws, we just need to apply them.

Okay. And then I would imagine with your experience and expertise with your team, that you might have potential solutions as you describe, you know, sort of what is sort of the issue for some of these folks. Yes.

Okay. And I'd also like to point out, and maybe it's because of my experience as a former defense attorney, it's that sometimes they are required to release upon determination of being clinically discharged.

Can I ask one more question, Chair, if you don't mind? Yeah. Oh, please. I know there was six. In one of your slides, there was six folks who are in out of state facilities. Correct. In last year. Okay. And that's for more of the violent crimes.

Yes. So they're mentally ill. We're treating them. And they're still assaultive. They're the higher challenging patients. And you know, as a state hospital, we treat psychiatric as a general condition. And that hospital actually has specialized treatment to handle those type of events.

Which is the reason for why. Exactly. Got it. Yeah. Okay. Thank you. Thank you, Chair.

Okay. Any other questions? Okay. Senator Keohokalole?

Yeah. Thank you. Thank you for being here. Without grossly over generalizing, you caught my attention on the discussion about. I guess. I guess you're saying people who have severe mental health conditions who are on drugs.

Yeah, it's the comorbidity group that, you know, often get. And when I say that is dual diagnosis.

So that's someone with a severe persistent mental health condition and they're. And they're using substances. Yeah. Yes.

You know, when the, when the, when the new facility opened at the hospital campus, we went through, and at the time, I think when we were going on one of the tours, somebody in the group asked what percentage of the population that's the most acute is addicted to meth? And they said 90%.

So is that what we're talking about here?

Yes. And that's a lot of our patients. So even if we get the medication to treat them, the science says get the medication to treat, but the issue is there's petty misdemeanance that we have to release. That's the challenge. Right. Because we try to get them that.

Have mental health conditions that are addicted to meth.

Yes. And then they want to get out of the state hospital or get discharged and use. And that really undermines the whole treatment plan for them. And so this is the challenge because.

They haven't committed a serious enough crime.

Yes. And they haven't committed to themselves that they're going to improve their life, certainly.

Well, yeah, I mean, that's an important point to make. But, you know, I mean, if they did, then we'd never see them again in the system. Right. They most likely wouldn't offend, commit any more crimes and then they don't see the system. Right, Right. Okay. Thank you. Thank you, Chair.

Okay. And frankly, I think because I wanted to point out where we could potential decompress, and I understand your decompression plan is coming soon. The next slide is going to show the seriousness of the offense. Right. So why don't you proceed with that? Because that leads into what Senator Kefukololi was bringing up. No, it's all good.

It's all great.

You introduce the next slide for us.

So here are the serious charges or offenses that our patients actually are coming into the state hospital. And I want to draw your attention to the far right, which is the petty misdemeanors. Right. So this is the challenging group which has been driving some of our admission high census. That's the group.

And so the others, that's our normal population. We should be helping them, figuring that, helping them to their best lives. But this is the group that we need to work on. They also account for only eight. So average length of stay is about eight days.

So remember, the 704,421s, they're expedited and then they need to be released after seven days. So this is the one that we've got to figure out a solution to.

And that's the one I think the supportive housing is, especially when you're talking about 90% homeless people. They're the ones probably that would be. Could be helped with somebody nagging them. Here's your meds before you go out. Okay. That sort of thing. Having a stable home.

Exactly.

Okay, One last question before you go into your decompression plan. And it may lead up to your decompression plan. So you've heard Director Johnson, they don't believe they have the capacity at this time to handle even the ones who have done the 704.

And that's the reason why they believe the State Department, I mean Department Hawaii State Hospital should handle them. And you also said that if we have a separate facility for the evaluation of fitness, that would also be a decompress that would also decompress. Have you folks thought of a separate facility somewhere? An intermediate facility? Okay.

And you're nodding your head, so please proceed. Is that part of your decompression plan?

I think it's on the collaborative solutions. Okay. Okay, go ahead. Okay, so we'll go to the decompression plan. So this summer, the governor's office asked us to develop a strategy to reduce the Hawaii State hospital census by 100 patients. Our goal is to maintain Hawaii State Hospital census to at or below its license capacity of 292 patients.

We are still ensuring that patients receive the most appropriate care but we feel that there might be other facilities that could be more appropriate.

So when we were asked this we also want to look at the individual. Right. So behind all these numbers are actual people and the Hawaii State Hospital. So the fortuitous of the Governor's office.

We were already looking at assessing our patient population who belongs to where an appropriate setting are frail and elderly and those folks that are unable to do activities of daily living. Right. So these folks have aged out.

They've been in the state hospital for many many years and part of their challenge is getting them into a placement for that next level of care. Dignity and respect as you as we age in the population.

So we have worked thanks to the legislators with getting that bill and we have provider, we sign the contract plus we have our current with our current state hospital. So that's moving. And he's willing to take 23 of the patients over there. So that's a good thing. Our longer term needs are psychiatric care that meet conditional release.

So this is where we're working and partnering with our sister organizations adult mental health CCS to make sure that we get the patient monitored in a safe place working on those places. And this is the placement issue, right. Will they take our patient? Do they meet the criteria for the further program? That's the area we're working towards.

This is the next group is the frequent utilizers because of the nonviolent petty misdemeanor. So these are the ones that are coming through the front door typically readmissions, that kind of group.

Now I will say thanks to the legislators if we didn't do anything with the Act 2687704 orders the state hospital when if you go back five years we actually would be in a much harder place because the average length of stay was 60 to 90 days.

So if we did not do anything and thanks to our legislators it actually has helped. We just got to figure out how to make this one group work and I think we'll be successful. The other is transition to the community. So neighbor islands, right.

So if I live in Hilo I should be able to transition from the state hospital. And these are the folks that are most likely to be restored. They can get conditional release. They need to belong in their community. They get their family support structure.

We can transfer them to an inpatient forensic bed on that island, and that will help them assimilate better into the community. The other one is the long term NGRI or the. These are the highly assaultive psychotic patients that are a challenge for the state hospital.

And that group is where we have our vendor on the mainland to help them. And this group is not, you know, from a cultural perspective, making sure we're thoughtful about our patients. We have to be thinking about that because this isn't just send patients up to the mainland and make sure that they're taken care of.

This really has to be a certain kind of individual treatment plan, making sure that they're long term and is this the right facility for them based upon their behaviors? And then finally, it doesn't require inpatient psych. So this is the group. I will say that they malinger. Right.

So we'd have to go back and petition, but they're malingering. They're not really doing active treatment. They're not participating. And so now we're just doing confinement at the state hospital level. Now, this is a very small percent. I don't want, you know, this is not.

These are the weeds, not the large one, but there are a percentage of patients that do malinger at the Hawaii State Hospital.

Okay, so can you help me? Yeah, can I go ahead, please? Can you help me understand that?

Sure. So they've been. They're unfit. Right. So they've. And we're trying to get them to condition release. So we're trying to restore to restoration. Right. So they're not complying to treatment. They don't want to take their meds. They're malingering and challenging. What I say by that is they're a challenging group. There's only five if you want to.

I mean, these numbers are very small, but they do account for some of the folks that need confinement and not treatment. Basically, they're saying, okay, judge, I hear you, but I'm not going to comply to treatment.

And so we have to go back and petition the court, as Tommy alluded to, to get them back to another facility if confinement is really what they need.

So I guess where I'm confused is if they are refusing treatment, doesn't it take fitness in order to be able to refuse treatment?

So can I clarify? Okay, so this population, it's a small group, very small group, but these are folks who. Malingering is a. It's folks who might look like they have a primary mental illness that's like schizophrenia, but they, they don't they. They're actually, I. I guess pretending to.

To be severely mentally ill, perhaps for other types of, you know, motives, maybe to be in the hospital instead of in jail or the. Yeah. Corrections.

But the judge determined. Yeah.

How'd they get in in the first place?

Because. Because they're gonna try. Right. I mean, so they work. I will just say so.

I will tell you that I've had constituents who are employed at the state hospital who have said this is a thing. Yeah. That individuals will fake mental illness so that they can get out of O triple C and they can get into the state hospital because it's a better ride or whatever.

So I just want to make sure I understand what I'm hearing from you. When they essentially fake it for the judge, and then after a defined period of time, you guys figure that out, and then they need to go back. Because. They're not meeting the criteria that put them in which they got admitted in the first place.

Okay. Yeah. Okay.

Thank you, Deputy. Come on back up here. So for those five people, because you have pointed out, 704-406 requires us to put them in state hospital, but they're saying that these people really need to go back to DCR. That population is ripe for a statutory fish.

Yeah. So. Well, so it's a 704-404. So this is when the examination is ordered, basically. So the person comes in, the fitness to proceed is questioned, and then there needs to be either a one panel or a three panel, depending on the severity of the crimes of examiners. And that's what Dr. Bauer-Smith does over there.

The statute there empowers the judge. It doesn't necessarily require it, as I understand it, but it empowers the judge to then, during this process, send the defendant to the state hospital. My understanding is that basically that in most cases, that will be done. So basically there is, you know, that.

And that's the reason why people who are undergoing this examination are sent there. It's pursuant to a court order, but it's not pursuant to the Clark injunction.

That it's being sent. It's by statute. Oh, but it is by court order.

But it's by court order. The statute empowers the judge to make the determination.

Can the state hospital petition the court to reconsider its order?

So this is something that actually we've looked at in our sort of. During the penal code review that we did last year. It proved to be very difficult to come to a solution in that way. Regarding the petition.

One of the things that Dr. Bauer-Smith and I worked on in the context of the penal code review, which is ongoing, is a process for speeding up the examination process. So that basically a person who is in HSH, you know, basically waiting for a determination on whether they're fit to proceed or not, that will go faster.

And so that's one of the things that we're doing to try to at least alleviate the amount of time that the person's going to be in HSH awaiting a determination on fitness to proceed.

Okay, but for this tiny population, is there a way for the State Department of Health to petition the judge to reconsider its order requiring that person to be in the custody of HSH if they are determined to be a malingerer?

My understanding is that there's no statutory mechanism besides just basically a motion to the court maybe to reconsider. But there's no. But the stand. There's really no standard.

So maybe that's one of the things we can work with the deputy with AG off session to create statutory language coming up on the 2026 session. So for at least this population, Department of Health is empowered to put malingerers back into the DCR population. Director Johnson, do you have any objections? You do? Okay, wait.

I'd like to ask my question, follow up before the Director tries to convince us this is a bad idea. The. What I thought I heard you say is the difference between a one panel and a three panel is dependent on the charge. Did I hear that right?

Yeah, I believe it's. It's like a. What is it, a class C felony or higher? It's a three panel. It's like a misdemeanor. Lower.

We try to get down to a one panel. So we'll work. We'll talk about that later. To try to speed it up.

That's on the examination.

Yeah, I didn't realize. Okay, well, this is a helpful conversation then, because I do feel like we create a pretty significant incentive to malinger. If that's the right way. You use that word. I don't know. Right there. There should.

It does seem like from the moment the hospital determines that we have somebody who's not sick in admitted as a patient and they need to get out of there, and we should figure out how to do that as fast as we can. That's what we're talking about. Okay. Okay. Thank you. Thank you.

Okay. Thank you. Okay. Senator Elefante.

Thank you. Madam Chair, in your fitness to procedure evaluation, what is sort of the average timeline or length? I know it depends on each individual patient, but.

Okay. I got, I got DCR there too. Why don't you come on up. Yeah. Speaking to the mic. That way the people on YouTube can.

Hear you because a part of that is. That's what the Legislature was.

Yeah. Trying to.

Attempting to do.

Hi, I'm sorry. Yeah. The question was what? How? Average time, average length of time for an evaluation for somebody who's already at the hospital for re examination. That's, that's looking at still under 60 days. So we are understaffed, whereas our branch is 60% understaffed.

But we are able to address those evaluations for examination or re examination for the competency or fitness within 58 to 60 days, typically.

Okay, 58 to 60 days. Okay. Senator Keohokalole.

Senator, you have five right now. But over time, like how often are these populate the five people who we think it hasn't been proven because they haven't been in the panel. We think they are malingerers.

So I'm giving you the stat for the whole year. So there's only five. That's why we're really down in the weeds here because the bigger effort is the other areas. Right. But I will say it is an issue because as you all know, there's no real recourse other than to petition that court to send the patient back.

So. Okay. Yeah. Thank you. Thank you.

Okay, so you're looking at the 58 to 60 days. Because I want to go back to the seriousness of the charge. Can we go back to that slide there? How many people are in the petting misdemeanor range?

So 200. 200 something. Almost 200.

Okay. I mean like right there. If we got rid of that, that would have been. That would decompress. Yes. Okay. The defense bar. Okay, I shouldn't talk by. For all the defense bar, but we are looking at a normal charge for petty misdemeanor. According to statute, incarceration is maxed at 30 days.

Maxed if it takes them 60 days for evaluation. The defense bar is going to be chomping at the bit. Just, just to clarify.

So those who are evaluated for the nonviolent petty misdemeanor offense or misdemeanor offenses, those are taking seven to 14 days for the reevaluation. And it's 200 or 100, 200 some six or whatever it was over the course of the year, who are, who are admitted there.

Because of the one.

Tongue for, for those non violent.

It's one panel, I think. Correct.

So those who are the Act 26 in this new year, Act 87 under the Nonviolent. If it's a non violent, petty misdemeanor offense, they can be. If they're found unfit, the first go around two days, usually done in DCR, they go to the hospital and then they're reevaluated, evaluated within seven to 14 days.

If they're still unfit, which 90 something percent of them are still unfit because it's such a short amount of time that they've had any care and treatment, then if they don't meet civil commitment criteria, they have to go. The court discharges them to the community.

And that's where we get the revolving door unless we find supportive policies for them. But thank you. So, any other questions before we move on to Department of Health's decompression plan? Okay, please proceed, Dr. Matsu. So, okay, we talked about the first one as being 23 patients and the back way over here as five patients.

How many patients in each of those other categories?

So there are 29 in the long term needs. So remember, this is a snapshot in time and it was at the request of the governor's office that we gave this snapshot. So. So 29 in that category. There were eight Act 20. Well, I'll just say eight petty misdemeanants.

They've all been discharged and some have been readmitted within the 30 days. The neighbor island, we had eight folks that could move to Hawaii island or other neighbor islands. And then there are approximately 20 or so for NGRI to the mainland. And then the 5 to, you know, the malingering patients.

How many to the diversion to community facility? 8.

8.

So and these folks add these up, but it doesn't seem like it's 100. Was that the weekly number? Eight? Two.

Yeah, eight was the weekly number. And then the, the total was 119 total, to be honest. So that was the total number. So there's 39 in the first category of the elderly. Yes. So we've sent 23. Sorry, didn't want to miss.

So we're working with the facility to send 23, but there are 39 patients in our frail and elderly or parage folks.

Okay, now that adds up to 100. But 23 didn't. Sorry. It's okay. So how successful are you in? Well, we know the five. We need a statutory fix for that and we need to talk to dcrs to what their needs are in order for them to be able to handle those five. What about the other?

So I just go left to right.

So how successful are you?

So we're moving at Least today, three patients from the unit I which is a success because we just started the contract. We'll get to the 20 others and hopefully the 39 in that category. We've discharged about 15 of the 30 to community placement. The frequent utilizers, we've discharged all of them except for one.

So he there's one patient still at our state hospital and we have one person potentially going to Kona. And then the long term we're moving four patients in the next two weeks and we'll work that later list as well.

Okay. So for the ones that are going to go out of state, the skilled nursing, those don't look like they'll come back, right?

Yes, that's the goal.

It's the ones where you release to community facilities or community based care or home in the event that they do not get the supportive, the support there to stay on their meds, Right?

Correct.

And then they will recidivate. Okay, go ahead.

Okay, I'm going to go to the Opportunities for collaborative solutions. So to address the increased number of admissions, the solutions do revolve around early identification and appropriate intervention. Dr. Koinogi, I'm just going to talk a little bit about it.

Please identify yourself even though we know who you are.

Chad Koinagi, Medical Director of Crisis Continuum. Throw out some ideas and some are a little bit more than ideas regarding opportunities to decompress. These are more on the front end of HSH hospitalization.

So as Dr. Matsu was starting to talk about, there could be opportunities that cell block to intervene with folks who are often some of these low level misdemeanor type folks who are just kind of chronically homeless without housing, difficult to engage.

The previous vendor who provided nursing care at CRD spent a lot of their time trying to get the outside case management agencies to come in identify what CRD means. Central receiving desk is where the cell block HPD places people prior to being sent to court.

And so they would try to get outside agencies to engage their client, go to court, maybe sometimes even ask if they could bring in their long acting injectable medication. Sending out follow up. This is the second bullet point. Lead was a thing that was funded a few years back and it was being run.

Lead is a pre booking diversion program. Eventually I think that, I think Covid killed the lead program which was supposed to be in on Oahu and Hilo.

I believe one in the neighbor islands.

And also I think there were some issues with HPD only wanting it to be applied to certain districts and not others. Third bullet point found out recently about this thing called DUCC or DCC, which is to address the fitness restoration churn, which is a nationwide problem which we're talking about today.

The UCC is process where when someone gets arrested for a petty misdemeanor, rather than go through the fitness restoration or fitness evaluation or restoration process, if appropriate, can be deemed appropriate for civil commitment and AOT pursuit with dismissal of the criminal charges.

So is that part of the ACT process?

It's connected, yeah. So we have going to our other bullet point. So we did get some funding, block grant funding, funding to do some consultation and training for AOT. So we have a meeting on Wednesday with someone from Treatment Advocacy Center, which is the leaders in technical assistance for some of the states.

So I think there are a handful of states that do this DUCC process, including Texas and Nevada. So we hopefully can connect with one of the judges from one of these states and see if this concept is viable.

And it would probably be quite complicated to probably involve the criminal court side and the family court side since it involves criminal charges and civil commitment and AOT or ACT, the.

And then the last bullet is considering other suitable facilities for placement and evaluation. So we, we have been exploring possibilities of other areas on this island. We did. Tommy was kind enough to let us know a little bit about waiava there. There had been some buildings that might be. That he thought might be usable.

We did take a look. I don't know if it's. It would be viable for this population in the sense that the location is quite remote and some other limitations. But we're still looking at some other areas to consider regarding readmissions.

We are looking at engaging with outpatient providers prior to discharge and to partner with them to petition for assisted community treatment orders. And, you know, really for individuals with SMI or serious mental illness who have limited insight or awareness of their need for medication treatment, treatment ACT or AOT can increase adherence to the medications and other treatment.

In addition, we're working with Medicaid to facilitate linkage to CCS or community care services prior to discharge. And this will help to promote a smoother transition to the outpatient as well as increase engagement with these outpatient treatment teams. So hopefully they would stay in treatment. To address discharge barriers. We're looking at increasing avenues to. Look.

At the improve the capacity for difficult to place populations. And specifically these are those patients who've got a history of arson or sexual offense. But also in relation to housing, we are looking at affordability of placements for the population in general because the Housing facilities often charge rent that is about 30% of their income.

And it's been a challenge to place some of our general population patients out of HSH.

Thank you.

Yeah. And then he talked a little bit more about the education piece.

Okay. Before I go to that. So back when I was in the house was when we started putting money into the lead and the pre booking diversion programs. And they were both supposed to be pilot programs. Do you know what the results are?

I mean, that's the reason why last year we had the informational on the jail diversion. And at that time, to me it seemed like it was a failure because DOH came up with like one person. Okay. Or even. Which is even worse than 1%.

But according to Civil Beat, you know, they got you folks had done better with that. But in order for us to. In order for me and those Senators and legislators who want to give you folks money for the diversion program, we need to see results of those pilot programs. Do you know who has those results?

I believe H3RC has the results which ended up. H3RC I believe was the one that. Did the Hawaii community.

I mean, Civil Rights Commission. Hawaii Health and Harm Reduction. Hawaii Health. Oh, that's right. Because it used to be called the Child Family. The Child Project, which was their predecessor. Yes.

And it ended I think 2022 or 23.

Yes, yes. Heather. Love schools. Right. Okay, thank you very much. I interrupted you. You can go to the next one.

Well, the last one is just about providing education. And so Dr. Koinagi mentioned it already, but it's looking at. We realized education is key to educate not just the providers, but our community at large, the courts, law enforcement.

And so we applied for and received a small amount of supplemental grant funding to support an AOT or ACT conference that we are looking to put on in 2020.

If folks have any questions. Okay, it seems to me that first paragraph looks at jail diversion because it talks about screening at the cell block before it goes to dcr. So that way we don't even address the DCR population. Right. And same thing with the pre booking diversion.

And same thing with the viability of dismissal upon civil contempt in other place. So maybe the next info briefing will be talk to Dr. Champion again because he's supposed to be the jail diversion guru as to how successful we are with that. But as far as you folks know right now, these are your solutions.

Do you folks have any metrics to see how successful any of these solutions are? Or are these just. I mean, how did you guys think that this Is a solution when after last year it didn't look like it was a solution because last year you guys only had 1%.

So we're talking about pre booking jail diversion. And I think the other one is the post booking jail diversion.

Okay, so post booking jail diversion didn't work is what you're saying. The 1%. But maybe we did not explore the pre booking. I thought we did.

I don't think so.

No. Okay. That was, I thought was the part of the Florida model. Right. Judge Linman talked about emptying out his jail by having these collaborative agreements between. That's post.

Post booking.

That was still post booking. And that didn't seem to work. Yeah. Okay. But hopefully we'll try this. Any questions? Because it doesn't look like post booking is one of your solutions, except for maybe the providing education, an increasing capacity for discharge barriers.

Yeah, we did not put that there. I think for the post booking jail diversion, we need to consider the referrals that are coming in from both from the different courts because there might be some differences in terms of motivation and you know, having folks the incentives to choose to go into.

It's a voluntary program to choose to go into it or not.

It's also voluntary for both the prosecutor and the public defender or whoever the defense attorney is to see whether or not they could have an agreement. Right?

Okay, so it sounds like this one is primarily focused on Department of Health and Hawaii State Hospital. Yes. But maybe the next info briefing should be the courts.

Yeah.

Just have a quick follow up Chair. What is the relationship with judiciary and working with judges and courts? You know, I would speculate. They are clearly aware of your situation at HSH. Are they or is that an incorrect speculation?

You are correct. So when I first started almost a year ago, we invited all the state judges to the state hospital. We talked about our challenges with the census and making sure are we putting patients in the right place so they are aware with aware of it?

I think this is what I said in the beginning where we have to look at it from a holistic perspective and figure out how do we help the patient or the defendant get to the services that they need.

And if we can prevent them from even going into the penal system, that would be the best because then you prevent all this, you know, the law going into place because they still need the help. And at the end of the day that's what we probably should be providing as public servants of public health.

And I just want to say I do appreciate you folks. But more importantly, the staff at your hospital for what they do and going above and beyond with just short staff. So really appreciate that. We're very grateful. Thank you, Chair.

Okay. Yes. And any other questions? No. And. And I do appreciate you folks coming here. I wanted the public to know how dire it was at the Hawaii State Hospital. We are trying to find solutions to decompress what is going on. Because I'm also hearing from my community about the need for civil commitment.

I've been hearing that a lot lately. I mean, why is it that we don't have any places to put those who are schizophrenic that they cannot handle at home? Because we don't want it to be to the point where they end up having to commit a crime. And the big example of that is the Pacamini issue, right?

Where it ends up deaths in the family, and we don't want that to happen. So decompression is huge because there are those consequences when we don't have the civil commitment, when family tries to do it on their own, but they just need help.

And I thank you folks because I know you folks are having a hard job, and I want to make sure the public knows that. The reason why we are looking at the need for decompression is because we don't have ACOs at the state hospital, because their job is to treat patients and not to confine them.

But they have become a forensic hospital. So security is a big issue that you folks really need to think about, especially for your employees. Right? I know you folks are thinking about it, but being short staff, it's very difficult to be both a warden as well as a clinician. Thank you. Thank you folks for being here.

And with that, we are adjourned.