House Standing Committee on Public Safety

Good morning. Convening our House Committee on Public Safety. Today is Thursday, 10/22/2026, 9AM, and we are here in Conference Room 411. This is one of our interim informational briefings to get prepared and ready for the 2027 legislative session.

What we are picking up on today is in a very important policy that this committee, along with the Judiciary and Hawaiian Affairs Committee has been working on for, I think, maybe three or four sessions already.

The purpose of this committee, this briefing is to inform and educate the committee about compassionate release as a policy tool for addressing the needs of incarcerated people with terminal illness or severe medical conditions.

We have representatives from the community who are going to brief us on their work in this policy area and share their approaches from other jurisdictions, followed by a discussion of Hawaii's current processes, local conditions, and policy considerations for legislative action.

I wanna acknowledge that we don't have an agenda, but we do have in the room, Mister Reineke and Director Johnson from Hawaii Parole Authority and the Department of Corrections and Community Direction, Department of Corrections and Rehabilitation. So we may, by my discretion, invite them to participate as well in this informational briefing.

Again, I wanna provide a little bit of context. Last session, we got very close. We really wanna formalize a bill put into statute, our compassionate release policy, as it will guide and help make sure that we're using resources as well as well as treating humanely the individuals who are in the custody and care of the State of Hawaii. So I'd like to first introduce, Molly oh, let me back up. So House Bill 1628 got very far into the process.

We have been working again with community and with the department over these many sessions. And I think we're very close. We're very close in some of the policy language and the processes.

And what we're encountering now, based on some of the reporting that has been going on is actually the real challenges of care in the community that has to be addressed and may not be able to be addressed within legislation, but in the continued work that the community has to do in building up capacity to care for folks.

So that's kind of where we're at, and we're gonna look at some of these policies, challenges, and things to do for the future. I wanna invite, Molly Crane here who is not unfamiliar with this committee. She is with all families for justice reform. Molly, the floor is yours.

Thank you so much. I'm so grateful to be here. Mahalo to Chair Bellati, Vice Chair Iwamoto, and all the legislators who are here today. I know Kristen wanted to maybe give a few opening remarks if that's alright.

Okay. We can start with Kristen if wants to start for. And you, as she's coming up, actually, can I have my colleagues introduce themselves because these are? Will be individuals who are working on this matter as we head into the 2027 legislative session.

I will start from my far right.

David Tarnas, State Representative, current Chair of Judiciary and Hawaiian Affairs Committee.

Thank you. Good morning. Kim Coco Iwamoto, State Representative Partition 25, Ala Moana Kaka on Downtown Honolulu, current Vice Chair of Public Safety.

Amy Perruso, House Representative for House District 46.

And if we could start with Miss Johnson.

Awesome. Good morning, everyone. I'm Kristen Johnson.

You can have a seat if it's more comfortable than this one.

No. Stay there with me. I'm Kristen Johnson. I'm the Oversight Coordinator with the Hawaii Correctional System Oversight Commission. I really just wanna take the opportunity to properly introduce Molly. I know it's always kind of questionable when people from the continent come in and wanna present on different things, but I really wanted to highlight that when I met Molly last year, she really, really embedded herself in the community. She was in Waianae last night. She's been to our home.

She's met our families. She's really, really gotten to know the system, she's been to Halawa numerous times and she didn't come into this space to lead the work, she really came into the space to see how she could help. She is nationally known, nationally recognized. She really is the subject matter expert when it comes to compassionate release and so she'll be able to talk a little bit more about, you know, her organization.

But I really just wanted to highlight how grateful we are for her to be here. She's worked directly with myself, with Bob Merce, who we know is an expert in compassionate release. She's worked directly with Jean DiMello, our Chair of Hawaii Proling Authority with Cory Rinky, the administrator with Tommy Johnson, the Director of Corrections and Rehabilitation, and so many others. And so I really just wanted to welcome her and thank her so much. And I'm excited for the presentation.

Thank you. That's not what I thought she was going to say. I'm very honored. Thank you. We are just so grateful for the opportunity to share with you a little bit about Compassionate Release today.

I'm also very grateful to the agency staff who are here and the many community members who are supportive of this measure. We can go forward.

You're all good. Yes. So, who are we? We are a nonprofit nonpartisan organization.

We've existed for nearly 35 years. We work to elevate the voices of people impacted by the justice system and policy reform. We have over 75,000 members across the country, including community members here in Hawaii.

Okay. What do we do?

We work to create a more fair and effective justice system that respects individual accountability and dignity while keeping our communities safe. We focus on research, best practices, legislation, and agency partnerships at all levels of government with a particular emphasis on compassionate release.

How did we get here?

We are so grateful for so many local stakeholders in Hawaii who've shared with us about the need for Compassionate Release and the barriers to this form of relief for people who are in prison with critical illnesses and need help finding their way home. We are very, very honored to be welcomed by this community and to offer the support that we can.

Alright. So, Compassionate Release. This is a program that's created by lawmakers that allows people to be considered for early release for medical reasons. These programs are uniquely important when people are too ill or cognitively impaired to be aware of punishment, too sick to participate in rehabilitation, or too functionally compromised to pose a risk to public safety.

Compassionate Release is important for the legislature, for state agencies, for community members because this small population of those who would be eligible are the most complex and expensive to incarcerate and the least likely to reoffend.

We'll talk about each of these in a little bit more detail. Alright. So the people who would be eligible for a Compassionate Release are the least likely to reoffend. Research tells us that people age out of crime. 50 years after the start of mass incarceration, prison populations across the country today are graying, and that is true here in Hawaii as well.

The share of people who are over the age of 50 has quadrupled since 1990. On top of the sort of downward trend that we see with recidivism and age, people who are eligible for Compassionate Release are often physically or cognitively incapacitated, unable to move their arms and legs. Unable to feed themselves. Un uneven aware of where they are or who they are. For example, there was a gentleman who was incarcerated at Halawa who had advanced dementia.

When we asked why he was there, he said that he wasn't sure. He thought his son dropped him off there, and he was just waiting for his son to pick him up day after day. Because of barriers to Compassionate Release, this gentleman did die in prison. Unfortunately, we know the recidivism rate in Hawaii is 54%, which is pretty high compared to other states in the country. But nationwide for people who are elderly, sick, or incapacitated, this number drops to less than 1%.

There is limited to no public safety purpose met by continued incarceration. This population that does not pose a public safety risk is also the most complex to incarcerate. We know that a very small number of people take a disproportionate amount of DCR staff capacity and facility resources because of their acute medical needs and incapacitation.

This includes daily care, like administering medications and treatments, but also not what you would think of maybe as medical care, like changing diapers and spoon feeding, cleaning up vomit.

When medical providers are already stretched thin, providing this sort of ambulatory care takes those providers away from operating at the top of their medical license, which other patients in custody really need.

Further, those people with incurable conditions often need long term housing and infirmaries, which are designed for people who might have a short term injury or a brief illness. People who are critically ill also need acute care beyond what the facility is designed to provide. This means they might need external appointments off-site and that requires coordination from corrections officers, two of whom have to accompany each person every time they're off-site.

The burden of providing care for people who don't pose a public safety risk, but who nonetheless are very resource intensive takes a toll on staff. When the vacancy rate is nearly 30%, it's no surprise that staff are struggling with the on and off-site care of people who are critically ill require.

In fact, the deteriorating health of people who are dying in prison is actually harming staff health as well. Staff surveys found that over 60% of correction staff developed a serious health condition because of job stress and providing supervision for people who are dying in front of your eyes takes an emotional toll. Over 75% of correctional staff feel emotionally drained.

So, this is a quick perspective from a former medical provider in DCR. They said caring for medically fragile and incarcerated patients requires extraordinary overtime for both corrections officers and nursing staff. Corrections officers must provide 24 hour hospital security coverage during off-site admissions, often for weeks at a time.

While nurses must staff an overfilled infirmary increasingly dominated by high acuity patients. They shared over the past year, multiple correctional officers have died. And in recent years, the department also lost a primary care physician from Halawa who also died.

A physician known to delay his own care because of the growing demands of patients in his, in his care. These deaths occurred in a workforce already under extreme strain from chronic overtime, staffing shortages, and sustained burnout.

This level of strain directly affects staff retention, patient safety, and the department's ability to respond to psychiatric crises and suicide risk. Halawa has experienced an alarming rate of suicides and self harm, and every nurse or officer assigned to constant medical supervision of a debilitated person is one fewer staff member available to intervene elsewhere.

Alright. This population is also the most expensive to incarcerate. The average cost to incarcerate someone in Hawaii is over a $100,000 per year. That's a pretty high price point looking across the country, but also there are many additional costs when someone is very sick, both at the facility and outside of it. This includes numerous and expensive prescriptions.

Medical staff having to spend disproportionate time and resources on this small group. Critical illnesses often require specializations beyond what prison medical staff are trained in. So these apart. Appointments have to happen off-site. As we discussed, crushing officers have to supervise people and sit at bedside 24/7, often requiring overtime pay.

These conditions require regular monitoring like labs and imaging and interventions like surgery to reduce suffering. Medical equipment like oxygen tanks, suction pumps, infusion devices, and more are especially costly. People who are frail and have critical conditions are often on the verge of an emergency, particularly when their care needs exceed what the facility can provide, leading to costly hospitalizations and even medevac flights.

All of this means that people who are very sick cost the State of Hawaii and taxpayers far more. Alright. So for those who are eligible for Compassionate Release, the annual estimated taxpayer cost for a high acuity medically complex patient is actually six to eight times higher than our already very high annual cost to recurrence rate.

As you can see, we have the national average here, Hawaii general population, and the estimated cost for someone who is critically ill. And sometime, in some cases, this is more than a million dollars per year, even sort of before accounting for the opportunity cost of what that same staffing and funding could provide elsewhere in the system.

Compassionate Release alleviates the sort of outsized financial strain of a small number of patients who don't pose up to immeasurable risk to public safety on the correctional system in the state. Alright, so just as an example of the fiscal burden of a patient with significant medical needs.

This is a case study of a patient with cancer. Costs for this patient included out of state, out of facility medical costs like hospitalizations and surgeries, transport to and from appointments, medications, a medevac flight from Arizona to Halawa, and nursing care at Halawa. In only five months, this patient cost DCR in the state nearly $700,000. So to keep this person in custody for a year, that would be over $1,500,000.

An additional individual single prescription, because it was rare and specialized, took up more than 90% of the department's prescription budget for all people in custody. This expensive prescription doesn't change the care needs for everyone else in custody, meaning that people who need insulin or other medications to keep them alive may not have the same access.

But DCR has to pay for this person's prescription, leaving everyone else in custody at risk.

It's also the case that patients on dialysis need off-site dialysis treatment three times per week and corrections officers have to escort them. At Halawa, this means that from 2 to 10PM, Monday, Wednesday, and Friday, there's no movement at the facility. No rec time, no other medical appointments that can be scheduled. And we understand that DCR right now has a backlog of 300 medical appointments for other patients. Obviously, this is very concerning.

So once again, we're talking about a small population with limited to no public safety benefit of ongoing incarceration that causes a massive strain on the system in the state. When someone is in custody, with a few small exceptions if they're out at a hospital for certain situations, DCR and the state are responsible for 100% of the cost for incarcerated people who are critically ill.

If these people are granted Compassionate Release and on Medicaid, the Federal Government covers 60 to 90% of these costs depending on the Medicaid Program the patient is enrolled in instead of the state. Compassionate Release makes sense for taxpayers. Speaking about cost, a family member shared the following about her loved one who's a DCR.

She said, my loved one is terminally ill. We had to fight for him to return to the island because we were afraid of him dying alone in Arizona. He was medevac back to Halava. Between his many surgeries, lengthy hospitalizations, and the medevac, I can only imagine how expensive this was for DCR. She shared the prison is not equipped at all to provide the level of care my brother needs with his rare form of cancer.

She said, it's freezing cold in the infirmary. His hands are shaking from the cold when we visit, and being in this environment makes him want to give up. Every time he's in the hospital, his hands and ankles are handcuffed to the bed, even though he's bedridden.

Compassionate Release is especially important here because we know that Native Hawaiians are disproportionately represented among the incarcerated population and among those who need Compassionate Release. OHA has reflected the following about the importance of Compassionate Release.

It said Compassionate Release reflects Hawaii's deeply rooted values of Aloha, Malama, Kuleana, especially for people who are nearing the end of their life or experiencing profound illness. The ability to receive care from your Ohana to engage in cultural and spiritual practices and to maintain meaningful relationships is foundational to healing and dignity, particularly at the end of life.

These essential elements of care and connection cannot be replicated in a correctional facility, especially for people who are terminally ill, medically fragile, or cognitively impaired. OHA has further said, long term incarceration carries substantial intergenerational impacts, including destabilizing family networks and creating barriers to reintegration.

For our Native Hawaiian Ohana who are already facing structural inequities, the prolonged incarceration of an elder or a seriously ill family member can deepen and extend trauma, particularly when that individual's condition has progressed to a point where dignity and humane care are better provided in a community setting with adequate supports.

So, FAMM and Compassionate Release1. We have worked on this for over 25 years. We are, have been involved in every state and the federal system. We've studied these programs extensively. We've seen what works and what doesn't.

For example, we worked at the federal level to transform Compassionate Release to one of the worst, to one of the best. With these decades of experience, we are here and eager to provide support to you all to bring Hawaii into alignment with best practices with a bill that is uniquely tailored to this local context. So let's talk about where Hawaii is in the national landscape.

So first, what is sort of notable is that Hawaii is the only state whose compassion release program is not governed by statute. Hawaii is also the only state in the country where a Department of Corrections has explicitly opposed Compassionate Release legislation.

Instead, there are many examples all across the country, across partisan states, where the Department of Corrections has testified in support of Compassionate Release. Frequently citing fiscal concerns and overcrowding as the reasons for supporting compassionate release.

We really believe there's a real opportunity here in Hawaii to not only align with best practices, but to set an example for the rest of the country.

Why do we need a Compassionate Release statute if there's currently a program?

Well first, we know that statutes promote clarity for everyone involved, continuity across administrations, and collaboration. An agency policy can be revoked or changed at any time, whereas statutes allow for durability.

Benefits afforded by a statute here include transparency and accountability for agencies, improvements to the process, making sure that the appropriate people are eligible for Compassionate Release, that stability that we discussed and stakeholder involvement. The absence of a statute here in Hawaii means that people languish and even die in prison. These are people who I know, who I have met, whose faces I've seen, whose families I've talked to.

Some of them I saw again this week when I visited Halawa and there are others I know who are no longer there because they've already died in custody.

Alright, so let's talk through some of the best practices in Compassionate Release legislation across the country. Where Hawaii currently stands and why statute is important. The first, important factor is the medical criteria. Best practices consider someone's care needs, cognitive impairment, their incapacitation and functional status, and terminal illness.

This ensures that populations who are dying or impaired or who can't appropriately be cared for in prison and who are costly or complex are eligible for consideration.

Hawaii currently aligns, with best practices. DCR and HPA have been using these categories for over ten years successfully, and if these are codified, they could be a wonderful example for the rest of the country. Where things start to change is a lot of the other categories. So first, eligibility. The majority of parable based states across the country treat people serving mandatory minimums and or life without parole as eligible for compassionate release.

This is not a partisan issue. This includes states across the geographic and political spectrum. So just a few examples include Alabama, Georgia, Florida, Kentucky, Illinois, New Mexico, DC, Vermont, Alaska, and more. Rather than excluding entire classes of people, well designed programs empower decision makers to make individualized assessments and exercise their discretion on an individualized basis.

And this is because all states across country recognize that continuing to incarcerate this population that is very resource intensive does not provide a public safety benefit.

Right now in Hawaii, people serving life without parole and people who have uncomplete mandatory minimums are not eligible. The next piece is process. Best practices across the country focus on guideposts, meaning streamlined decisions, decision making and clear timelines for each step. This makes sure that cases involving rapid decline receive prompt attention and appropriate review.

Right now, as you can see from this diagram, there is a complicated process with many layers and there are no required timeframes for decision making.

The next piece is the factors that parole boards and departments of corrections consider. I know there's a lot of text on this slide, but what I just like to focus on is the best practice of legislators providing guidance to the Departments of Corrections and Parole Boards about how to weigh release, think through conditions of release, and revocation decisions that differentiate parole from Compassionate Release.

These are different processes with different considerations. Parole kind of focuses on the individual applicant, their participation in programs, their rehabilitation, their remorse, their ability to become a quote unquote productive member of society.

Medical release or Compassionate Release focuses on the system, the impact on the department and on taxpayers of keeping severely ill people in custody.

Right now here in Hawaii, Compassionate Release is subject to all the regular parole conditions. So factors like program participation, which is less the focus of Compassionate Release. Parole conditions also apply. So you shall actively seek and retain employment. You shall notify your parole officer in the event of termination of employment.

These are conditions that people have to sign. Instead, best practices involve legislators empowering decision makers to consider factors that are relevant to Compassionate Release. Namely, someone's diagnosis, their prognosis, the impact on the system, and non static factors about risk, meaning that they consider the person's present circumstances.

Instead, each person's case should be assessed individually and legislators can give decision makers the tools to do that effectively.

These are just a few examples of how legislators across the country have supported decision makers to employ criteria that are relevant to Compassionate Release, including the impact on the department's resources, finances, provision of care and overcrowding.

This also includes an assessment of the individual's current conditions and their current capacities. These factors give parole boards the ability to differentiate parole from compassionate release by focusing on the purpose of these programs.

Alright, transparency is critical to ensuring that Compassionate Release programs work as intended. Data collection reporting help lawmakers and the public assess whether the program is meeting the legislature's objectives. But the majority of states collect data and report publicly about Compassionate Release, and many of these are undesignated time frames.

Right now, there are no reporting requirements about Compassionate Release. And so we don't know how it's functioning. We don't know where the needs are and how we can better meet them. I know we talked briefly about community placement and how important this is. Finding appropriate placement people who have medical needs is a paramount priority for the Department of Corrections and Parole Authorities.

Individuals who are medically vulnerable need access to suitable care. The issue in a placement, in Hawaii has received some national attention. For example, in this piece by CBS News, we know from our work across the country that nursing homes do accept people with prior records and that these people are often reported to us as the most compliant and grateful residents. We need nursing homes to be welcoming to people who need their support.

These patients will have Medicaid coverage that the nursing homes need and will have the medical conditions that the nursing homes are designed to take care for.

Nursing homes need to understand that people who are granted Compassionate Release have already been identified as low risk both by the prison and the parole authority and will remain on supervision, so nursing homes will have people they could reach out to for help. People receiving care in the community as discussed by this piece is also better for taxpayers. What I will say is that Hawaii is a rare and shining example of community agency collaboration in this area.

I want to commend in particular, Corey Reinke of the Hawaii Paroling Authority who has collaborated closely with Bob Merce, and I know he can speak more about this, to find suitable placement in the community.

Our work here is not only to support the legislation getting passed, but also to assist agencies and individuals and families who have patients who need to be released, find placement, and find the care that they need in the community.

With your kind welcome, we are here for the long haul to make sure that the system is implemented. Because of this very inspirational work by Corey and Bob, more than 60% of the individuals who are referred to us as needing help have already found a transition into community placement. So we're really excited about the work that these people have done, even as we need to continue finding systemic solutions.

We've heard that the primary barrier for many agencies is actually having enough CNAs in place who can take care of these patients. From what we understand, for example, Leahi has, I think, 80 empty beds.

Is that right, Bob? And the issue is not necessarily stigma or statute, it's staffing. And so as we continue to look for solutions, I think we'll have to be a bit creative. I would like to take a moment to just sort of underscore the importance of compassionate legislation. We are so grateful for the legislature's support of this last year.

Both the House and the Senate inversions made it all the way to the finish line. We hope that this is the year that the bill can actually cross the finish line because of the real human costs for both individuals and for staff in the absence of this bill that we've seen in the last year. If it's all right, I'd like to invite Bob up to speak a little bit about the conditions. So Bob, will you join me?

So, we have some pictures here from the Corrections Oversight Commission of the infirmary at Halawa.

You can see one of the rooms in the infirmary. And you can also see the hallway that has all of the cells. Bob, do you wanna talk a little bit about what it's like there?

Yeah. There's basically six cells. Is that okay?

Yeah. Yeah. But, I think the mic. If there's there's mics in the room.

I'm sorry.

It's right there.

There are basically six cells. And each one is is very, very, very small, but there are two beds in each cell. And if you stand in the middle of the room and you reach out your hand, you can touch the bed on both sides. And there's no privacy whatsoever.

Having double cell occupancy like that for sick people, it encourages the spread of diseases and infections. And in fact, I've talked to Toctor Tresch and others. They have a terrible time in the facility trying to control infections that are running wild. And it's cold. It.

The whole facility, the whole infirmary smells of, I have a strong smell of bleach. And I wanna make, I'm gonna say some more things about the conditions there, but I wanna make it clear that I'm not criticizing the people who work in the facility. They're doing a great job.

They're my heroes. They're keeping people's heads above water. They're saving people's and, they're doing a great job, but they can't manage this terrible situation that they're in. The bleach smell is terrible. There are no.

There's nothing in the cells except for a steel toilet and a little table sometimes where they put the food for the people to eat. There's no natural light at all. There's a little tiny window, maybe, about, two feet or or less. And very little light comes in and it doesn't look out onto anything but another brick wall. It's so called that the, when you walk down the row of the cells, the people who are in there have cover their whole head with a blanket.

And the ones who were in the day room, as I saw just a couple of days ago when we walked in, One had a towel over his head to keep warm. Another was wrapped in blankets. And it was really, really terrible. People think that this is an infirmary, and that word has certain connotations. We all have an image of what an infirmary is.

This is not anything like an infirmary that you have ever seen. When you go into the cell, it is a cell and there's no television in there. There's no radio. There's no flowers. There's no nature.

There is, there's no monitoring equipment for heart rate or oxygen rate or that sort. There's nothing like that in these cells. They're terribly small. It's dark. You can't read in them.

So you have nothing to do if you can't watch television. You can't read. And if your cellmate wants to turn off the light, what, you're in the dark. And if you wanna sleep and he wants a light on, you have no choice.

There's rust, falling down from the ceilings. When we went into the shower, I think we have a slide of this.

I'm happy to send the picture.

I mean, I had never taken a close look at the shower, but this is in the day room. There's a shower. And I opened the door to the shower, and there's a a tub that is all rusted out and nobody could use. And hanging down from the ceiling is a hose, And the hose sits on the ground, and that's the way you shower. There's no water running down overhead.

You pick up a hose and you hold it over your head, and that's how you take a shower in the, in the infirmary. And I mean, I was just totally shocked by that. This facility is over 40 years old. It's there's rust on all of the doors. The patients have the trash cans haven't been emptied.

When you look at the end of the bed, you find the urine, urinal bottles hanging over the side of the bed that haven't been emptied. It's really disgraceful. We tried to get past the Governor, who's a physician, to go out and see it. And unfortunately, we haven't been able to get him to do it. But if this was a bit.

This is now turning into a long term care facility. And if this was a long term care facility in any private neighborhood and this in this, it would be closed down in five minutes. No. They wouldn't even look. They would walk in and close it down.

It is really a deplorable state of affairs. And that is why we need to move people out of it. Thank you.

Thank you so much, Bob. Thank you. And FAMM really believes strongly that people who are making decisions about incarceration should be proximal to the people affected by it. And so we're always happy to accompany you to visit the infirmary if you have not yet done so. Just to offer the medical staff perspective, this is from a former medical provider from DCR.

She said, Halawa Correctional Facility operates an infirmary, not a hospital, not a skilled nursing facility, and not a long term care center. This distinction is critical when evaluating what constitutes appropriate and humane medical care. The facility lacks continuous on-site physician or advanced practice provider coverage, dementia appropriate housing or safety design, long term rehabilitation services, specialized equipment required for total care and end of life patients, and staffing ratios necessary for medically complex and dependent patients.

She said despite these limitations, the infirmary is increasingly required to care for individuals with advanced dementia, stroke related disability, terminal cancer, and other high acuity conditions, often for prolonged periods of time.

This care exceeds what the infirmary is intended scope and places, intended scope and places patients in settings that are clinically inappropriate for their needs, while simultaneously straining staff and compromising the care for others.

She said, correctional facilities are not designed to function as nursing homes, hospice units, or dementia care centers. Continuing to rely on them as such is neither humane nor sustainable. So this these are pictures from the one hospice cell in all of DCR. There is a single cell for hospice. As you can see, it's here on the mental health block.

That means that people who are struggling with mental health might be making noise. They might be yelling. They might be banging on their cell doors. The department has painted the cell blue. You can see inside the hospice cell here.

This is what it looks like if you're dying in custody. It's very cold there. We visited a gentleman, not on this visit but on the last one, whose temples were concave. And he was not able to ask for help when he needed more palliative care medications to ease his pain and suffering. There was no one over there to ask.

And this is the door to the hospice cell, as you can see.

Just to offer the Corrections Officer perspective on this. This is a former Corrections Officer who said, people who are very sick need a lot of care outside of the prison. Every time two of us would have to lift them from the bed and try to clean them up and escort them to the doctors and back.

Sometimes this took us away from an already understaffed facility for an entire shift because the specialists were not at a facility nearby.

It's not easy on the corrections officers. We are not hired to be nurses aids. We are not skilled in IV poles or changing diapers. We are not qualified to take care of the sick inmates. All we could do was try to check to see if they were still alive and breathing and hope that the nurse can come at some point.

And the nurses are also overwhelmed. Taking care of sick people who are critically ill and who need a lot of care but are not a safety risk was an unnecessary strain on us as correction staff. Watching people die in shackles impacts correction staff morale deeply.

As to why prisons continue to gray and the Compassionate Release system experiences barriers without legislation, people are dying in custody. You can see how the numbers are trending upward dramatically even in the last twenty years.

Deaths in custody have tripled since the 1990s. Compassionate Release is part of reversing this trend. This is a quick family perspective that happened recently. This was a 62 year old gentleman with two forms of stage four cancer. He was on a feeding tube and he passed before being released to the community on Compassionate Release.

His loved ones had to come to the mortuary and not being able to see him, care for him, and heal together caused immense pain. Here are some of the questions that they were asking in that moment. If he was terminally ill for so long and we knew he was very sick, why did he still die in prison? Was he in any pain when he passed? What clothes was he wearing when he died?

Was he in a prison uniform when he died? Was he handcuffed in a hospital or in a cold cell when he passed away? Could he be dressed in the suit that he wore when he married our mom when he's cremated? Was he alone? These situations are preventable and we are very eager to collaborate with you all to make compassion or at least a reality here.

So the solution, we have worked very hard in the partnership with so many wonderful people in this room to create a bill on Compassionate Release. The Compassionate Release bill aligns with best practices while remaining tailored to this local context. We are so grateful to DCR HPA and the commission for their partnership in drafting this bill as well as you all, which maintains what works and solves problems that are resulting from, resulting in painful deaths behind bars.

DCR and HPA were very generous with their time and their expertise.

We spent at least six hours going line by line together in, with this bill. The bill can help in many ways, including streamlining the Compassionate Release process, creating deadlines to make decisions so that things move quickly when people are deteriorating, providing ongoing parole supervision for people who are granted, and collecting data to make sure the system works as designed.

We are so grateful for all the partnership in this room that will create a bill that eliminates roadblocks to Compassionate Release and stop Hawaii from being the last state without a Compassionate Release statute. We are eager to work with you to make Compassionate Release real.

We are so grateful to be welcomed here in Hawaii and we're available as a resource throughout the session. We're happy to answer any questions that you have.

So I know we have Kristen and Sean on the agenda, but I'd like to, at this time, open the floor to questions by committee members and lawmakers.

Questions.

Thank you. Thank you, Molly. How many critically ill patients do we have incarcerated at any given point or at any period of time?

Yeah. It's a great question. I think the biggest question right now is how many do we have at Saguaro? I think we have a sense of who is at Halawa. And if this bill were to pass and include everyone who is eligible irrespective of sentence, we know there's at least 15 people at Halawa, but we expect many more at Saguaro, as many people there have life without parole.

Okay. So, I mean, is it many more like, twice more? So it's part of it. Only because in my mind, I'm doing the calculations of the costs. So every year we delay.

Yes.

Addressing this. That's us a lot of money that our communities need.

Yes.

For other things.

I know particularly in the wake of some very severe weather this year, that's top of mind.

Right. So, but we don't have, who would I ask to get the number?

I'm saying is that the Medical Director is visiting Saguaro in the next month or so, and we'll have a better sense then of, of how many people are eligible there. Thank you.

Question. Go ahead.

Well I noticed the Senate draft has an amendment limiting eligibility to those, well, excluding those on life without parole. And you spoke briefly about that before. And I'm wondering, how many individuals are really talking about when we do that kind of exclusion?

Yeah. We have estimated that the bill would be dramatically reduced in the cost savings if we excluded life without parole by at least 50%. Now, this is not to say that everyone serving life without parole in DCR custody is sick enough or would be granted by the paroling authority. But for those who are sick who we imagine would qualify, we think it would be cut by about 50% if we exclude those people.

Yeah. How many, of the 49 of the states across the nation who have congressional release, how many of them exclude life without parole?

You know, so it's the majority of states include life without parole and mandatory minimums. So more than 30 include.

K. Thank you.

I have a quick question about the Leahy situation and the staffing. You mentioned that, you know, it's not for lack of beds. If there are somewhere around 80 beds available, but more a matter of the, certified nursing staff. So, has there been communication with the, Committee on Health or Community on Human Services around submitting a proposal to increase staffing for Leahy so that they could accept more of these patients? It's a great question.

And one I would maybe defer to Corey Rinke or Bob Maris. I don't know if either.

Or I think we all could also differ. We could have Sean come up and speak to that issue.

Because I think that's it. Let's, let's move to that. Unless there are other questions. Any other question? Okay.

Well, Sean, I'm putting you on notice. You're gonna be coming up soon because there's questions about kind of community placement issues and challenges within the community. Go ahead.

Thank you, Chair. Are there any of the other states that allow for, like, a cash bonus to a care facility, maybe a private care facility? Kind of like, you know, we use cash bonuses to recruit teachers in hard to play schools. We... I mean, so to me, it'd be kind of the equivalent.

Are there any ones that say in addition to the cost, we're gonna give you a bonus every month?

That's a really, really good question. So, we have seen other nursing homes achieve one, an enhanced Medicaid reimbursement rate. So, that is one option. For example, there's, a facility called Mission Care. They have several Mission Care.

It's several across several states. And, they receive an enhanced Medicaid rate to accept what is considered difficult to place individuals. So, people coming from state hospitals, people with severe illnesses, people on registries, people coming from incarceration. And they have that enhanced rate so that they can provide higher staffing ratios and make sure that the person receives transitional care and that they receive comprehensive care. You know, many people in this situation need not just medical care but other forms of support.

We have seen other states as well where it's not a Medicaid reimbursement rate, it's just a cash bonus. And that has helped nursing homes accept not only the potential of risk, which we have mitigated by determining that people are low risk to the community, but also to provide the services that people need. Okay. Thank you.

Before we shift to Sean, I have a question that's Yes. Follow-up. And, actually, because it's it's it's interesting to me, and I should have understood this, but it's a new facet that I don't think that the committee was focused on over the last year. Knowing that there's patients at Saguaro, have you been able... Or can you speak to any policies that you know at these other prisons?

Because you focus a lot about what's happening here, but do you know what the policies and conditions are like in those facilities? Because I would imagine that we have had people who have qualified for compassionate release, probably some who have had to have hospice care on those and have died there because of just natural causes.

Or people who've been medevaced back over.

Can you speak to a little bit about about that dynamic? Because that's a dynamic that I actually haven't really thought about. And I think it's gonna be important for future lawmakers to to think about those things. Yeah.

Yeah. Absolutely. I mean, I'm I'm not the department. I'm not the expert. But what I will say is I think when they have someone who's very acutely ill, they typically try to transfer them back to lava.

People don't always want to leave the la... Want to leave and head to lava because they know what the conditions are like in the infirmary. So, some people actually prefer to stay at Salboro. But, for many, they want to be close to their family or the department wants to be able to keep a closer eye on them, not knowing what the contractor is doing with their medical care there.

It's much harder for the medical director to make sure that someone's receiving appropriate care when they're at a facility in Arizona or in Mississippi, as we now have people in Mississippi.

Interesting. Thank you. Any other questions for miss, Crane?

I'll be here if more comes up. Thank you all so much.

So I think if we can shift to Sean's comments and about, conversations or placement, because that has come up recently. And I don't wanna forget that we also had asked Miss Johnson to... She wanted to offer any comments after Sean.

Good morning, Mister mayor, vice Chair, committee members. Sean Sonata. I'm the CEO for the Oahu Region of HHSC. First thing I wanna make clear is that Oahu Region and our respective facilities, we do not represent the opposition in this at all. I mean, we are very supportive of compassionate release.

We respect the dignity... Importance of dignity for these incarcerated individuals at end of life. And, you know, we believe that it's an important approach, to handling the situation as long as it's done, responsibly and respectfully of the concerns of nursing facilities, being the ones that we operate as well as in the community. So couple of things that I need to clarify. First of all, Leahy Hospital does not have 80 empty beds.

I think it's a matter of, interpretation. So to give some history to this issue, if we go back to... I mean, many of you were here, during the recession when it impacted the state. Prior to that, we at Leahy operated and were licensed for about a 156 beds, under ship designation, and we were pretty much full at that point in time.

Then when there was the the recession that hit the state general fund, we ended up having to do a big reduction in force, and we closed one entire unit.

So that took away some of those beds from the community. Then subsequently, we also allocated one of our other units to the Hale Muhale program. That's the enhanced disease disease unit, which now occupies one of our floors in the nursing home. So that takes away another, number of beds. So while we're licensed for 156 beds, we only operate...

Are able to operate about 117. Our census currently is about 90 something. So that needs about 20 something beds that would be available. So now to answer representative Perruso's question for staffing, it's not a matter of programs or funding for these positions. It's a matter of being able to secure the positions.

I mean, nursing homes, hospitals, health care facilities around the nation right now are experiencing a severe staff shortage. I mean, it's been going on for quite a while. And we've been implementing a number of programs, some partnerships with the Healthcare Association of Hawaii. They're good good jobs program. Also, we created our own CNE training program or partnership to try and increase the number of of staff in our facilities, but it's still been a challenge.

So while we have those beds, we have to temper our census because of the fact that we don't have the staff to, you know, provide quality care for that increased number of patients. So that's why we're around 90 or so right now, and that's what we kind of budget for. But, of course, we have a target to fill all beds if we can recruit and retain the the staff that's necessary.

So you have the positions.

We have the positions. We have the budget for it. Thank you, to the legislature for those funds. And we've been actively trying to recruit and retain. It's just been a challenge.

So, I guess, going back to what I started with is we do support this program. We would support admitting compassionate release and and and other, similarly situated patients as well. But admission of these... This demographic carries with it a number of challenges. First of all, would be the financial side.

That's easy. When we're going to admit someone, we need to make sure that we have the funding to pay for it. If Medicaid will cover it, first of all, they need to come in, Medicaid approved. Because if they come in Medicaid pending, then there's no guarantee, first of all, that we're gonna get the funding. Another thing is the, I'll call it HR 1 instead of the other name.

But because of that, on the... For Medicaid admissions, if they're Medicaid pending, normally, we have, oh, I think it's like ninety days. So if we admit someone, we have up to ninety days to, get their approval. And if we get their approval within that timeframe, then we get reimbursed by Medicaid retroactive to the beginning. But I think that period has been reduced to something like thirty days.

And that's unheard of, which means, necessarily, we will in fact admit someone. And when we admit that person, if they do qualify and it takes... Let's say it takes ninety days, that's sixty days we're on the hook for care that we're not getting reimbursed for. So that's that's one of the big problems.

I know that, what was offered to us was a faster, fast tracked Medicaid reimbursement, but that's at this lower level of care, which is, I think, only, like, a fraction of what our standard Medicaid rate is.

That can be approved quickly, but that's not sufficient to cover the cost. I mean, the Medicaid cost, the full reimbursement rate that we receive now is insufficient to cover all of our labor and overhead for a particular resident. So we cannot accept anything less than the the standard Medicaid rate. So that's the first, problem when it comes to... Or challenge, I'll say, when it comes to admitting, compassionate release patients.

I wanna group it together for for my discussion, the different referral sources we've had that are kinda similarly situated. So first, you have compassionate release. Another referral source that we have would be the Halepulama Mau facility over at Coquiti. It's operated by Queen's. The patients that are there are wait listed patients from the ERs.

So, there's no placement for them after they get treated at the ER, and they cannot be released into the community. So, they have to be situated someplace. But nursing homes generally have not been able to accept them for various reasons. And we've been asked on multiple occasions to admit these residents. And we've already admitted at our Mahalia facility, like, over 30.

The third referral source would be the Hawaii State Hospital. When it comes to these referrals, we have to make sure that they are conditionally released in order for us to get any type of reimbursement. And it carries with it other challenges as well. The main challenge for all three referral sources would be the majority of them, if not all of them, at least the ones that we've been referred have a severe, psychological, diagnoses. And of, these particular patients, I mean, primarily...

Predominantly, they all are on psychotropic medications. So the biggest challenge for us when we're going to admit someone is deciding if we are obligated to perform with kind of gradual dose reduction. So under nursing home regulations, which are completely different from where they're situated currently, they can be on a psychotropic medications with less documentation, you know, less determinations because, I mean, these people have been treated in other other environments.

But when you come to the nursing home environment where home is the keyword, we're obligated under CMS regulations to provide a home like environment and, you know, the dignity is, I won't say better, but a little bit more stringent, you know? So that requires us to avoid any type of restraint, whether it be physical restraints or chemical restraints, in this case, a psychotropic medication.

So what happens, when we try and and admit these types of, patients would be we'll go do an assessment at whatever whatever referring facility it is. We'll see a patient who's pretty docile, pretty calm, and we know what their physical limitations might be. Do the admission under CMS regulations, we're required, for the most part, to do a gradual dose reduction, to attempt it. And when we do that and the dosage gets a little bit less, then these, dangerous and risky behaviors then materialize.

I'm sorry. Can I interrupt? I'm getting confused. Are you speaking about the population we're talking about today?

Yes. Both. Both. So it's it's the same.

Even though they're critically critically ill you're saying they're they're... That you would see them as specifically threatening or they're on a mind controlling pharmaceutical drugs that they must be weaned off of. Even though they're critically ill to the point where they can't even

So what...

Right. It can be. So what I'm getting at is the the the representative patients that were described earlier. I mean, that could very well be a number of patients that are or another a number of inmates who are incarcerated. But in our specific experience, in terms of the ones that were referred to us for admission, they pretty much all had, some type of severe psychological disorder that required them to be on psychotropic medications.

Let me see. I can give you a little bit more specific information.

And this is even to representative questions. This is even the population that's within Kaneshit Remdes?

Yes. Correct.

I'm seeing some question marks, so we'll we'll we'll come back to that question. Wait. That's okay.

I can see that in... Sorry. I asked my staff to prepare, some background information regarding compassionate release in particular. They were unable to specify compassionate release, but I said, if you can't specify... Because they're unaware specifically know, of the program when it comes from the, Department of Corrections.

So what I mean is, it could be a person who was going to be placed in hospice, but may or may they're not sure if they were on compassionate release or not, but that they came from, from a correctional facility to our facility at Leahy. There were two that came from the women's correctional facility and two that came from Halawa. Both of the Halawa admissions had to be returned. I think one was due to...

While attempting the gradual dose reduction, it became untenable for us to continue caring for them.

What happens when when we do the gradual dose reduction for inmates or these other referral sources is that the behaviors, end up requiring a minimum one to one supervision. So if you look at the way we staff our our units, just giving you rough numbers. Let's say during the day shift, we have about 30 something residents on a unit. And then we have about five CNAs, one or two RNs to watch them. So if you look at just CNAs alone, let's just say only 30.

Five CNAs, 30 residents. That's each CNA covering five. Right? Or six. Six residents.

Right? Now if you take one of those CNAs off the floor because they have to do one to one, you know, for for one single resident, then you only have four for the remaining the remaining, residents on the floor. So that creates a situation where we're not gonna have the staffing to provide the level of care we want to provide.

And so, in essence, what happens is if a person comes in and they're on the psychotropic medications and they stay on the psychotropic medications, they'll be the same as they were when they were in the referring facility. Right?

But when we attempt the GDR, gradual dose reduction, then they become the most difficult residents to care for. So that's the risk that we're balancing when we when we do these admissions is if we admit someone, and we can keep we're working right now, all full disclosure, we see this as the biggest issue. We're working with, the Office of Healthcare Assurance, which surveys us and is able to cite us if they believe we're using chemical restraints inappropriately.

We're trying to develop a protocol where if we can have a determination, medical determination, that if you do the gradual dose reduction is contraindicated, meaning the risks outweigh the benefits of doing the GDR, then you don't have to do it. Right?

But then it requires a severe amount of documentation, to keep justifying it, you know, every every month, every quarter. I mean, I think it's monthly, when you do the assessments. So it's a it's a heavy investment. We currently don't have the resources from physicians to do that. So what's been going on is we're...

Would attempt the gradual dose reduction. And then we are met with the same, response every single time, whether it came from the, from the Department of Corrections or it came from the other referral sources. And that's been the challenge for us. Either have... If no GDR, we have the the one of the easier types of residents to care for, and we'd be all for it.

Right? But with the GDR, most difficult. So if we are able to find a way, which we're trying to do right now, we're try... We're able to find a way to... For these types of, patients to remain on the medication that they've been on for years, sometimes decades, and keep them in our facilities, then it's feasible.

Right? We just haven't had that experience thus far, and we're trying to work out a way to do it. Because what what could happen is we admit someone. We don't have set protocols in place that that are judged on a case by case basis when we get survey. Surveyor comes in and says, oh, you just admitted 10...

You had 10 admissions from Palawa. And then five of them, you know what? We're determining that it's a chemical restraint. You need to go and do the GDR. So number 1, we get cited for five things that we should have already done the GDR.

And two, we have to submit a plan of correction, which entails doing the GDR. But like I said, if we do GDRs for those five people, then you're gonna have, at a minimum, five CNAs less because they're gonna be committed to that one particular resident. And that's gonna ruin the operations for everybody else in our facility. So just to go back to to the compassionate release. I'm only speaking to our specific experience.

I mean, I believe that there are a slew of other, inmates who might not fit this bill. But the ones that we had direct experience with did have these, psychoses that that created the issues I described for our, staff and our administration. And for those reasons, we're very cautious in how we do admissions because just one, you know, could make things very difficult for an entire floor.

Other concerns that, arose from our direct experience in dealing with compassionate release and and other similar, types of residents or admissions would be we have to request a party to make medical decisions for these patients. Right? And oftentimes, in our experience... I mean, I have to extrapolate from other similar situations because we... We've only, in recent times, admitted four total.

Right? And this is over the past, like, four years, I think. We need a responsible party. So if we're gonna make a clinical decision, change your medication, or do something, we have to get permission from someone. We can't just unilaterally make that decision.

So, oftentimes, we've experienced that there's no power of attorney. There's no guardian. There might be family members, but none of them want to take responsibility so far. And so when we have to make health decisions, when we have to do Medicaid renewal decisions, you need a responsible party who's gonna sign off because these people are incapacitated where they cannot make decisions for themselves. So that's another challenge that we've we've encountered.

Another one would be if these people have to go to, an appointment. I think with... From what I've heard, the patients that we did admit, there were, trans... Transports that did occur, that were taken care of by corrections. And the same thing applied to Hawaii State Hospital in certain situations.

But sometimes we do run into a problem that even for our regular residents, we do not offer transportation. We don't have the capacity to take a CNA off the floor to escort someone to an appointment. And, therefore, either families pay for us to to hire someone to do it or they come and do it themselves. And that does create an issue for our staffing levels. We...

I'm not saying this is representative of of all compassionate release or other residents. But like I mentioned earlier, there are family members most unwilling to be the POA or be the responsible party. But when they're in... When they're incarcerated, there's strict rules on visitation. Right?

So there's full security ahead of time. There's limitation of the number of people that can visit at any given time. When you go to, again, the nursing home environment, we have to offer twenty four seven visitation. And and that's completely fair. But what we've encountered in the past is family members have said, oh, you know, I can go visit now.

So the whole family comes and crawls into a four bed ward, you know, to go visit with their, their loved one. But then it becomes very disruptive to all of the other people on the floor. We've had that as one experience. We had another experience where a particular family member, was the opposite. Got too involved, you know, in the care and came into the, to the facility and was was very difficult in supporting what we're trying to do to provide the highest quality of care.

And that particular patient had to be sent back as well. So we're not opposed to... But if it's done the right way and there's due consideration for what the challenges are that we face, and we're for it. We we agree that people at end of life or with these terminal illnesses have to... Have the right to die with dignity and and be in a better environment.

But we also have to care for all these other residents that are in our facility. And all our staff, we have to care for these residents. And if we're not respectful and mindful of of of that position, then we're doing a disservice to everyone. So I'm I'm open to any questions.

Go ahead. Thank you.

I just wanna... Sorry. I don't have this basic knowledge, but you're with Hawaii Health Systems Corporation.

Yes.

Are you a for profit corporation, or are you a nonprofit?

No. We are a quasi state, entity. We operate as a safety net for long term care on Oahu. The Oahu region operates three facilities...

Well, we're responsible for three facilities. We directly operate Leahe Hospital, Malibuya.

You know, it's not like you you, applied for a contract.

No. No. Yes. You're just funded. We are a we are a state jurisdiction.

Got it. So because I Aye... Because I get a little confused when you mentioned the Medicaid approved, because... And especially with the one big beautiful bill situation where people cannot be in prison with Medicaid, I think, and then you have to come out. So you're on parole.

Now you can get Medicaid, but you mentioned it takes a period of pending. So... But even if... I guess my point is you're... If you're not a private, if you're a

state, even if you have to eat the cost or taxpayers, it'll still be less costly, wouldn't it, than if they are still incarcerated. Yes. So we're still saving money is is my point. So when you're making that technicality, it feels like it's... Does...

That part doesn't make sense if we're talking about money and saving money and how much it's costing us.

Okay. I I can I can speak to that? Okay. Alright. So if the state general fund was just one pool that any agency, any facility that's considered state can just pull from, then we can say it's a one to one.

Right? We're saving the state money here. But then on on this end, we actually, for example, the Toronto corrections would save this much money that is investing to care for these inmates. Right? But then if they're being cared for in our facility, then it would cost less.

I mean, that could be a one to one transfer. But the way that we operate is we're not we are a state entity, but we're not a pure social service. Hawaii Health Systems Corporation was set up because we responsibly... Physically responsibly want to operate close to a private facility's way of operating because we get revenues. Right?

In other social services, it's a complete out of pocket. Right? For us, we want to maximize the revenues that we get so that we can use it, you know, to care for the safety net population. Now when we look at our operations, our revenues were a safety net because they do not cover, the full cost of care. I mean, to care for one particular individual in our in our nursing home, right, could cost maybe $600 a day.

You multiply that by three hundred sixty five days a year. Right? So we get a reimbursement rate from the Centers for Medicaid and Medicare Services. And that rate is still less than what the actual cost of care is. So the state subsidizes that shortfall.

Right? Now when we look at actual operations, we have a budget, right? It's not like if we're short, we there's a pool of money, we just go straight to the general fund, grab it and cover it. We have to operate like an actual business. So what happens is, when we come to the legislature, we have to project out what is our budget for that particular year.

We're gonna say, okay, we have this many positions that we need to staff. We anticipate this much in revenue from our admissions, reimbursements from Medicaid, some private pay. And then there's gonna be a shortfall. There's a shortfall every single year. So that projected shortfall, then we come to the legislature and we say, hey.

This... In order for us to care for everyone, right, appropriately, we're gonna need a subsidy of this amount. And then that's set. That... That's the cap of what we're gonna get, and that's what we're gonna budget.

Right? So now if we admit someone from a a facility, they come in, and then it's an admission that we're accounting for, right, that we anticipate we're gonna have this many beds occupied. That goes into the revenue we anticipate receiving. Right? Because the subsidy is not gonna grow anymore.

So if we get a shortfall from this particular admission, for example, someone's pending Medicaid, and it takes one year... I'm just exaggerating to make a point. It takes one year for Medicaid to be approved, but we only get reimbursed for one month, then that 600 something dollars a day spread out over the year, we're basically gonna get only eleven months of... I mean, eleven months of that. No.

I mean, one month of that. And then the other eleven months cuts into what we had budgeted in the first place. And then the result team... Yeah. I understand.

But I think it's the same issue that departments face. Right? When when their prescription, drug budget is tap... It goes over that locked amount, they will find themselves with a shortfall. And then they...

So to me, if you're both state departments and you're both relying on taxpayer money to cover expenses, you're not gonna... You know, I

mean, I hear your... I definitely hear your point. Okay. But can we move on to...

Oh, let me just... So I think I think... Thank you. I mean, I think I think representative, you know, one of your kind of highlighting is the complexity of the budgeting process. I think it's really important for us as lawmakers to understand that there's a cost savings to the general fund.

But Mister Sonata, as the operator, he doesn't have access to the general funds to immediately cover a short So he has to make decisions and operate his facilities with the constraints that he has. So I think it's for the lawmakers either when emergency appropriations come in and that's routine. It's routine that HHSC often comes in with emergency appropriations to meet the shortfalls. That's what we have to be prepared to do, or you folks will need to be prepared to do, because of these challenges.

Have we ever knocked on it?

No. And so that's why... But but I think... But he can't operate. They can't operate on that.

They have to make payroll and all and all these other things that they need to do. So that's why they're making the decisions and calls that they have to make. And then I think we need to make sure, or the lawmakers have to make sure is that the funding is there to be able to to care for these people who are in our care and custody. Before we leave this, I just wanna... Because this is...

I think this is an important piece. And this speaks to the coordination. Right? So you said, Mister Sonata, that some of the challenges are the Medicaid approval on Medicaid pending. We, as lawmakers, have focused very long on making sure that Medicaid is doing the appropriate, in advance kind of Medicaid qualifications.

Have you seen an improvement in the... Of that over time? And then miss Crane talked about other jurisdictions looking at enhanced Medicaid reimbursements. Have you folks had that conversations with Medicaid to be able to deal with this population? So those are the two questions I have, cost related, that maybe you can answer.

First to the enhanced Medicaid reimbursement rate, we have not, had conversations regarding that. For us, the... We're balancing we're balancing the, the cost issue with the clinical, you know, challenges that I I described earlier. So for us, the cost issue is secondary to to the other challenges. So that's why we haven't fully engaged, with, you know, MedQuest division regarding regarding getting more more funding. Because it's not just about the money. Right? It's do we have the capability? And the money would go to more staff.

But, again, the staffing issue is a big challenge for us.

I don't wanna let go of this because my understanding... And you said that on the other concerns that you have are sometimes transportation costs. My understanding... And I could be wrong about this, so this needs to have further follow-up with lawmakers. I believe that there is some transportation, costs that are absorbed by Medicaid.

Right? So, again, I'm putting it out there. I mean, I think this is why it's important that there is greater coordination between the agencies to make sure that when we're dealing with a population that is tapping very braided resources, right, fiscal resources, whether it's general funds, it's your funds that should get appropriated, or it's Medicaid, there There needs to be a lot of conversation and collaboration to care for this population.

I agree. I mean, I believe that we should explore that route further. But I guess to my... To to the point that I was trying to make was that, yes, it's a very important thing to consider. It's like one of the top considerations.

But what I meant is the reason we haven't fully dived in on the enhanced reimbursement rate is because we're trying to settle this first. Right? And but to answer your first question, yes, we have experienced an increase in the Medicaid rate, not particularly for this reason... For these reasons, but just, to her credit. I mean, Judy Moore Peterson, she did a stand up job when she was, still employed by the state.

And and she she stepped up and was able to get, you know, many facilities a higher, more reasonable, Medicaid, reimbursement rate, which we did experience and were beneficiaries.

What about the eligibility processing? The issue of being Medicaid pending versus Medicaid approved. Has that improved?

That has been pretty static

Okay.

In our experience. But what ties into that too is the responsible party. Right? Because if someone's going to get compassionately released, if we're speaking speaking to this topic, then when we apply for Medicaid, there needs to be a responsible party. Someone who can provide all have access to all of their financials.

Normally, there's there's nothing, right, but you have to have someone attest to that, that I have access to bank accounts, assets, everything, because there's a there's a financial qualification to qualify for Medicaid That needs to be affirmatively established. It's not, accepted and then, you know, prove otherwise. It's... You have to establish it, but you need a responsible party with that capability to help you do that and sign off on any documentation for the Medicaid application.

Thank you. Any other questions? No question. Yes.

Go ahead, representative. Do you know, or or miss Crane might know, how other jurisdictions are handling this GDR issue? Yes. Because I imagine that's a national problem.

I'm not sure how other people have done it.

I think let's... At this point, I I'm I'm actually curious about this question for miss Crane. But if if... Are you... Any other questions for Mister Sandoval?

I do. Okay. Sorry. Sorry. Thank you.

You mentioned decision making. So couldn't there be appointed a guardian ad item for health care or even a foster care or even a nonprofit assigned by DHS? I mean, there are there are many incapacitated adults who have no family, who are worth kind of, you know, responsibility for the state in some some form.

You're absolutely correct. We rely heavily on the office of the public guardian, but they are overwhelmed. And the timing for that, it takes a very long time. And if a prerequisite to a Medicaid application is having a guardian appointed, then the process gets delayed further and further. Right?

So that is... That might be an issue that needs to be addressed further further funding for that office so they they can expedite the appointment of a guardian. But as, you know, as people I've spoke to earlier, this is a this is a time concerning problem. Right? Because if someone's at end of life, let's say it's a hospice person who has maybe two weeks left, none of this is gonna happen in that particular period.

So if we're talking about these types of admissions where the state is anticipated to be relatively short, but to provide end of life dignity, I mean, another possibility that, you know, the legislature can consider is private or like a direct funding pool that excludes Medicaid, where it can cover for temporary periods of time, you know, the the the cost that caring for someone immediately would entail.

Because if you go through the regular process of securing Medicaid monies, but the person passes away, why are you even in the process? Then that becomes an issue as well. So I guess to answer your question though, there there are avenues, but the avenues for a solution take a lot of time.

My last question for Mister Sonata.

Yes, please.

Have you... Has somebody visited every single candidate for compassionate release to your facility? Have you... Has somebody from your organization actually met... Like, visited, gone through the medical file, witnessed the the state of incapacitation?

Yes.

So before you denied it?

Yes. We have an admissions team that I've directed to go and be active. And as a matter of fact, one clear thing that's been expressed to them and they they understand full well is whatever it was that put them in that situation, whatever crime they were convicted of or not, that's irrelevant. What matters is their actual physical or mental capacity. The issue that they've encountered is still...

Is the risk of if we need to reduce their dosage. That's the main risk that that takes them from a reasonable to care for resident to most difficult.

I hear that... I can see wheels turning, but I wanna bring Ms. Crane up, and maybe Ms. Rasa if you stay close, to address these these questions arising around GDR.

But also, I think as I'm looking at the bill and as I reflect on what you were identifying as some of the best practices, The need for the compassionate release statute also solidifies some timelines that might actually help this process because it will get folks maybe moving through ensuring that Medicaid is actually approved, that we have these, opportunities to make sure some of these issues are taken care of in advance, that people are getting the correct care plans, as they move into more community based settings.

So can you speak to some others and maybe the question of what is the experience of GDR in other jurisdictions with this population?

Absolutely.

And I thank you so much for sharing your experiences. It's, you know, a broader commentary about how we treat elders in our society, that it's so challenging for nursing care to be provided. So, I appreciate what you're doing and that you're here today. I just want to address a few things that came out. I think it's important to note that Sean said that they weren't able to disaggregate which people were coming on compassionate release.

And so I think it's important to note that the discussion that we had today may actually be related to people who have been granted compassionate release. I think one area where that's important is that there's a distinction between psychotropic medications and palliative care medications. There's a distinction between psychiatric conditions and physical conditions. So for example, I know that there was a patient who had glioblastoma, which is a terrible and aggressive form of brain cancer, who was Adlai Ahi.

And this patient needed medications to manage the pain and distress from cancer pressing on his brain.

That is different from a psychotropic medication. It's different than trying to treat a mental illness. That is palliative care. That is different. So GDR, as it comes in the context of people who are dying or end of life, that's a totally different conversation.

I think it's important also, we heard that, sometimes family members come and wanna visit their loved one. We know that in incarceration, family members aren't able to do this. They aren't able to come be with their loved ones as they're declining. And so I appreciate that you all are welcoming family members to be there. We understand that you have to balance, you know, noise and disruption to other people, but this is what we actually want to see happen.

We wanna see families be able to be with their loved ones at this time. I think the fact that there's only been four admissions in four years is something that's telling for us as a state agency. I think I'm very excited to hear that you all are going to be accepting some referrals. I think the quote in the CBS News article is that they would not, so this is exciting and forward motion, and I'm very grateful for it.

It is the case that, you know, sometimes it is totally unforeseen someone gets diagnosed with a terminal condition, and we don't have much time to act, But, that is the rare exception.

We did refer someone to Leahi. This was the gentleman who I shared about who was 62 years old with two forms of cancer and a feeding tube. And, because the process took so long for him to be considered and accepted, he died before he made it to the community. And so part of what this bill offers are those time frames and that coordination between agencies to get Medicaid moving beforehand.

I know that Bob Merce and Cory Reinke have been working very hard on issues like advanced care directives and power of attorney actually coordinating these cases.

So if you have specific questions, they would be the best people to answer it.

Tim, actually, that's a really good segue. Any further questions from the screen? Bob, can you come up? Because, again, have you heard that there's... You had 60% progress in

So we have had people placed, yes, including at Leahi and at other nursing homes in Hawaii.

Okay. Maybe, Bob, can you speak to the, experience and maybe that success rate? Because that's actually pretty stunning that you guys are able to get sixty percent placed at all.

Right. About a year ago, a year and a half ago, I was called by a family member and asked if I could help with somebody who was dying in prison and, help get them out. And I've done this over the the course of thirteen years. I've been working, with with the department. And usually, they just send me referrals and they say, here are the people.

Can you get them out? I go and interview them, find out what what their situation is, and do my best. And I got some out and some I didn't, and some died in there. But this was a recent one about a year ago, and I knew from talking to the family that Corey was working with this family and I didn't want to intervene and get things mixed up. So I called him and I said, I've been asked, I wanted to try and help this person.

He said, well, me too. And we started talking, and then he said, why don't we work together? And so I said, that's a great idea. So we've been working together ever since. And it's it's in my view, an absolutely great partnership.

I'm I'm I'm... Corey's a great partner to work with. And, it... It's just been it's been really, really good. And I'm glad, Gene, DuMello allows him to do this and work with me, because I think we're a good team.

We have gone to nursing homes. We've gone to hospitals. And we are sort of carrying the message out there that these are these are people in our community. These are part part of our family. I mean, you can't just segregate people and say, oh, there's incarcerated population.

Corey's done a wonderful job of addressing the, the fact that, a lot of times we have trouble with people with the sex offense, you know, conviction. And Corey has just been very dramatic in telling them, look, you know, you don't want this person in here because you have a sex offender... They're a sex offender. We we grant parole to sex offenders all the time. They're out in the community.

They're probably in the grocery store. They're probably in your hospital and maybe in your nursing home. But you don't know it because they're on parole and they have a relatively low recidivism rate. So we've been trying to, you know, address these stereotypes and convince people to to take, take these these people.

And Bob, can you speak to the assistance of helping with legal documentation, power of attorneys, guardians, and

and that's the That is that is a problem. Okay. The... But the the problem is the documents. The problem is finding the family members who are willing to serve as a surrogate for the patient.

We have only had, we have one... Two people, I think, right now that we we can't get out because we can't find any family members. But that's all. And and we... I mean, we've we've talked to them.

If I had a private investigator working for me, I could probably do a better job. But we're we're really trying to find these these family members. And one, for years, they tried to find a family member they couldn't. I got lucky. I called him on the phone and we, you know, we we got him involved. And

So what what is the alternative if there's no family member? It is a guardian.

Then it's a guardianship. And you can't do... I looked into it. You can't do an emergency guardianship because it just doesn't find... Not having a family member doesn't really meet the emergency, you know, criteria.

So that that that would be the only one. But, we we are now trying at this point to, reach out to the faith community because we believe there are people there who, really care about these people and that part of their faith would be that they would be willing to step up and and just say, I will... If the... If this person wants me to be the surrogate decision maker for them, I'd be happy to do it. It's a responsible position.

That's kind of an innovative, idea. But, FAMM is out... Actually helping, helping us with that. And they have some contacts here. And so we're we're actively doing that right now.

But that... That's a problem, but it's a relatively small part of the problem.

What is the larger problem from your perspective?

The larger problem, if if I... Yeah. Here... Here's the way I I would I would look at it. The number...

I think one of the big problems is Medicaid. I've heard over and over and over again that Medicaid reimbursement is simply not enough to take care of these people. They're high acuity people. They need a lot of specialized care, and we don't wanna take them. I heard this from the Queen's Medical Center.

Corey and I have met several times with the chief medical officer at at Queen's, to try and help him because he called me and said, you know, I've got this guy from the prison over here, and I... He's in an acute care bed. He's been here for months, and I can't get him out. Can can you find a place for him? And that started a dialogue with, with, you know, with Queen's.

And and they said, you know, for example, they said, look, we have no problem placing people who are private pay. They're in acute care bed. You know, they're they're ready to be discharged to a lower... Lower level of care. No.

If they're private pay, no problem. If they're if they're Medicaid, big problem. And Leahi has told us the same thing that, you know, that that that Medicaid is is really a a problem. And and and so I don't know what we can do about that except, decide whether there's enhancements that can be, paid to take care of these higher acute acuity patients. And I I know that, Tyrus Leffler is here.

He has taken people from the, state hospital into his his private facility and is caring for them now. I believe he's getting some sort of an enhancement. And it's working out as a sort of a proof of concept that we, you know, the private sector can play an important role in this. But, there's a point I wanna stress that, I was not aware of when I started out on this this journey, in the last year or so.

The real problem, one of the real problems is not that we don't have enough long term care beds.

It's that we don't have the people to staff those beds. That is critically important. And when Corey and I met with, we had a long meeting with the, Maluhia staff, and they said, look, we'd love to take some of these people, but we we don't have the staff to do it. And I've talked... Had long talks with the administrator of the...

Of Leahi, and she said the same thing. We don't... We just don't have the staff to take these people. So I began looking into it. And and and and every year, the, Department of Health sends out a questionnaire to all the nursing homes and hospitals and and said, we we wanna collect data.

And part of what we wanna know is how many beds do you have? How many beds are staffed? And the, table 16, the licensed long it's called licensed long term care beds, not staffed or set up as of 12/31/2024 for, Leahi Hospital, 155 licensed beds and a 114 staff beds, and not staff bed, 41 at Leahi. And at Maluhia, it's 38 and that's 79 beds according to according to the Department of Health that said they are not staffed.

And the reasons are not enough money because they're asked to specify why you have these empty beds.

So that that is, that is a big problem. It's a problem statewide because and this may come as a surprise to you. In... According to this this, utilization report by the Department of Health in... On Hawaii County, 30% of their licensed beds, 30% were not staffed.

Honolulu, 24%. Kauai, 28%. Maui, 9%. So those are tremendous numbers of of beds that are that are are are not staffed. 41% of Leahi's beds were not, staffed.

38% of Maluhia's were not staffed. And what happens when they aren't staffed is that patients come into the emergency room. They they get treated and they end up in an acute care bed for a certain amount of time. Then they settle down and they they get better and you wanna discharge them. We had a a a gentleman this year, who on January 3 was viciously beaten up at at at Halawa.

And he... I mean, they kicked him. They beat him. They broke all the bones in his face. And he ended up on...

I think it was January 3 at at, Queen's. And he was going to die, everyone thought, but they put him on a ventilator and eventually he recovered. He started making progress. He started wiggling his toes. And so we had conferences, Zoom conferences with Corey and myself and the medical staff of the prison and and Queen's saying, what are we gonna do with this guy?

Nobody wants to take him because he he was a sex offender, number 1. And number 2, he was, had a criminal justice record. And so that... Those are the kinds of problems that that we have, be... And because Leahi wouldn't take him and they would...

They called twenty twenty or 30 nursing homes. Nobody nobody wanted him. So those... That's that's one of the problems. But what's important to remember about that is that from January to...

He came out maybe June or something, we've not been paroled to Queen's of all places. And Queen's then moved him to Kuakini where they rent this space from Kuakini and and as a long term care facility. And that's, I think, where he is today. And hopefully, he's getting better at making some improvement. But he he was he was in Queen's for almost six months in an acute care bed when he didn't need to be there because he had improved.

And and there had to be a guard with him all of that time, twenty four seven. So what does that do to the staffing of the department? But let's look at that picture even bigger. These are the statistics I think you need that are that are really important.

Okay. I'm gonna let you wrap up on this because I wanna be mindful of the time and then we have... So you can wrap up with those statistics and then I wanna... We need to close this with any final questions from any of the members and then we'll wrap it in, like, five minutes.

Okay. You wanna go right now?

No. No. No. You can finish your thought. I don't want...

That's it. I finished my thought.

Okay. But you... I was waiting for these statistics.

What? Oh, okay. Okay. You're you're saying it? Yeah.

Right. Yeah. You built it up. This is all according to the Department of Health utilization, report for 2024. And the 2025 is coming.

I talked to the woman who does this at department of probably... Maybe it's out now or... But maybe within a week or two. Statewide in 2024, three thousand one hundred and twenty three people were stuck in acute care beds and those people accumulated sixty thousand eight hundred and seventy six patient days in an acute care bed when they did not need to be there.

While acute care costs vary by hospital and room type, the Kaiser Family Foundation news reported that the average daily rate for an inpatient hospital bed in Hawaii in 2024 was $3,500. At that rate, the total cost of those sixty thousand days of delayed patient discharge amount to an astounding $230,000,000 $213,000,000 So that is really what the problem that we're looking at.

And I think the solution is going to be that number 1, we need to utilize Leahi better and Mauna Kea better, and we need to get the the private sector involved as well. We can't rely on one or the other. I have a few other questions if you give me time when we come back, but, thank you.

Any final questions from any of the... So go ahead.

Well, for, Sean. Okay.

I think at this point, we've had a lot of... We've covered a lot of ground.

It's 10:30. What I'd like to do is... Any final questions for Mr., Mr. Merce?

Well, what I heard you say, if you could just confirm this, is that we... I mean, any state... The state run, care facilities Yeah. Need to get budget appropriations to recruit and retain nursing staff. Is that what

is... It's statewide that has

to happen. Statewide.

Right. It has to happen. The other... I mean, look at 30 or 40% on every island.

So this $200,000,000 that you mentioned going to hospital care when they could have been served, that $200,000,000, that would be at least the the amount that we should be prepared to invest in recruiting and retaining I

don't know who can make that exact

thing, but, you know, rough. Yeah. Money that's going out. Right? Objectives.

Right? But I just... If I could say about about, I was involved in... At least if there were four people in Leahi, I I helped get three of those four people in. And two...

And so I don't know which... Who Sean is talking about or, but, two two of the people that was... One was a woman with a brain tumor, a terrible brain tumor, glioblastoma. We got her in there, and she died there. And she was the most wonderful patient.

And and the Queen's... And and the the Leahi staff were so wonderful. They they went to the administration and said, we love this lady. You know? She's dying.

She wants to go to the beach. She wants to put her feet in the sand. Can we come in on our day off and get permission to take her to the beach on our day off? That's the kind of care that they're willing to give. And she died there and she wasn't psychologically deficient in any way.

She was she was a wonderful sweet person and it's a shame that she died. She had a wonderful family, and she had good doctors at at Queen's. And and and it's just just... I I don't know where... There was nothing wrong with her psychologically for sure.

Another woman, she had both of her legs amputated, at the knee... Just below, below the knee, from diabetes. We got her in into into Leahi. It was perfect because there's a dialysis place right right nearby. Sometimes they...

She didn't have a surrogate, so they called me and said, would you, you know, ride down with her? And and and that's fine. And so, you know, she... And there's nothing wrong with her psychologically. We had, and I think maybe the one person that they're, concerned about, another one might have been not, not a not a compassionate release, but, but a a probationer that might have been there.

I'm not sure. Because when we talked to Leahi about have you had problems in the past, we we we... They were obvious. Some of them were really confused about compassionate release versus a probation. So I hope this helps frame the problem.

Thank you. Any last questions? We have Ms. Crane here. We've covered a lot of ground. I wanna give any last questions to Ms. Crane before we wrap up.

Any last question? Alright. So, again, we've we've covered a lot of ground. I think that there's a lot that needs to be dived into for making sure that we have workforce shortage. You know, that there's broader problems.

Right? There's the workforce issues. There's Medicaid reimbursement. There is lots of things. I think that we need to dive a little bit deeper and understand.

So, Mr. Sonata, I think it's really important that we decouple or really understand is this the GDR problem with the compassionate release population or is it with the broader population that you're talking about that have been... There have been efforts to to to place more. And so if that... If we need to make that clear, it's... That's not...

If there's not an overlapping population there. And I think for future moving towards the legislation, I think the fact that we have been closed, that there's been a lot of conversations that I hope that there continue to be conversations amongst the stakeholders and also with the lawmakers who are gonna be coming on board because, clearly, this is a fruitful area that we can make sure we codify some best practices, that Hawaii is not gonna be the only state that's...

Doesn't have a a formalized statute and that this can actually help us improve the system as a whole. And so I encourage all of the community stakeholders to to work on that. I wanna acknowledge that, you know, it's gonna be more than just Leahi.

Right? Leahi, there there are other, nursing facilities and inroads have been made through the work that Bob and Corey have done together. But we may have more facilities hopefully coming online as well. We should look to what the state hospital is doing, to see if that is, any of the partners that they're also, contracting with could also be potential, places for compassionate release, clients, patients as well. With that, I think, again, we've covered a lot of ground.

There's a lot of work to do, and I know that the 2027 Legislature is going in between and following up on a lot of this work. Alright. On that note, we are adjourned.