The ongoing COVID-19 pandemic has opened conversations about improving behavioral health across the nation, and the importance of creating robust, communicative systems of care. In Hawaii, the state’s unique geography and cultural demographics have led to the development of a diverse network of behavioral health services. State of Reform spoke with some of the organizations offering these services about improving access to behavioral health care in the state.
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In Hawaii, people experiencing mental health crises or are seeking mental health and substance use disorder services can utilize Hawaii CARES, which offers a free 24/7, statewide call center. Hawaii CARES also works with partners in the criminal justice system and homelessness sector to provide access to behavioral health services for underserved communities.
One of the barriers to behavioral health care, according to Hawaii CARES Clinical Director Dr. Leocadia Conlon, is the amount of time it may take for a person to gain admission into a substance use disorder treatment facility program. To help mitigate this problem, Hawaii CARES refers callers to a bed stabilization program, where people can stay while waiting to enter a facility. Bed stabilization programs are also available to help individuals in mental health crisis avoid hospitalization.
Hawaii CARES can refer clients to services under the Department of Health’s by dispatching a crisis mobile outreach, where a crisis therapist will meet a client in the community and try to help them resolve the crisis in the “least restrictive setting.”
All of these programs require constant communication with different agencies around the state. Dr. Conlon explained that this communication and collaboration is necessary to maintain programs that can best serve the complex behavioral health needs of the community.
“There’s a lot of co-occurrence between mental health and substance use. So that’s one of the reasons why it’s so important to collaborate. It’s complex. A lot of these individuals also come from high-risk situations. They have unstable or unsafe housing. So you know, getting them into a stable place where they do have long term housing wrapping them around to those types of services. That’s why it’s so important.”
An important part of building a robust system of care is ensuring that people—particularly Native Hawaiians and other historically underserved communities—will feel comfortable within the system. Furthermore, systems of care can vary from island to island. Dr. Hannah Preston-Pita, CEO of the Big Island Substance Abuse Council (BISAC), said the pandemic has taken a particular toll on Big Island residents who live in more rural areas.
“When you think about ‘large,’ you think about a metropolitan area where there’s a lot more resources and it’s completely the opposite [on the Big Island]. Prior to COVID, [there was a] lack of resources, lack of providers here to provide the services, just access to care [in general] because of geographical issues and transportation to and from treatment. And then you add COVID … so the closures really impacted all agencies and we had to pivot to figure out a workaround, as to how we would continue to treat clients.”
While telehealth has helped reduce BISAC’s no-show rates for some health appointments, other issues persist, such as building trust in the health care system, according to Dr. Preston-Pita.
“It’s just a part of the culture. Asian, Native Hawaiian culture is [that] they’re not trusting the system … But what they’re trying to do is make sure that they’re able to triage for other [behavioral health] needs … It may take years before it becomes a well-oiled machine, and everybody is trusting the process but I think that’s what I see as an issue here on this island.”
Incorporating triage is key to Hawaii CARES, according to Dr. Conlon. Call operators (called care coordinator associates) triage calls for those who are actively suicidal or have had suicidal ideation, mental health crisis, or those callers who are not in crisis but need connection to services such as mental health or substance use disorder services, keeping in mind that the person’s needs may change throughout the call.
Dr. Conlon says there is still work to be done in Hawaii’s behavioral health systems. Like most places, more funding is needed for programs and treatment centers that could help increase capacity and reduce wait times. This is especially relevant for people covered by managed care organizations, according to Dr. Preston-Pita. Approximately 75%-80% of the clients at BISAC are currently under Medicaid.