The state Department of Health says it plans a more effective way to deliver care to its most severely mentally ill patients. Critics contend the plan could throw DOH's Adult Mental Health Division into chaos, overwhelm the system and pose a risk to patients and the public.

"You're talking about pedophiles, murderers, people who mutilate themselves," said Poka Laenui, executive director of the Wai'anae Coast Community Mental Health Center, the state's only private, nonprofit community mental-health center and one of the agencies affected by the change.

"These are people who can be a danger to themselves and to others."

The state, however, says the changes will mean better service for the patients.

All service-provider contracts will be terminated for a treatment model that has managed the care of the state's most severely mentally ill patients since 2003. The change will affect hundreds of such patients in Hawai'i, and could influence the care of thousands of other case-managed patients.

DOH said it will continue treatment for affected patients throughout a 90-day transition ending Aug. 31, after which those patients will be treated under a Community Based Case Management, or CBCM, protocol.

DOH believes the decision to terminate what's known as Assertive Community Treatment, or ACT, contracts will allow it to better serve its community-based case-managed patients. The plan is to incorporate the current 425 severely mentally ill ACT patients into the CBCM protocol, which serves some 4,970 patients.

Plus, the change will allow the department to devote nearly $2 million more a year to CBCM patients that it had previously spent on duplicated costs associated with its ACT contracts.

ACT, a team-based approach to managing mental healthcare, was designed on the Mainland in the 1970s in response to the widespread closing of psychiatric hospitals. The concept was introduced to Hawai'i as a way to deal with adult mental-health patients with high service needs.

UNHAPPY WITH ACT

DOH has funded the ACT model through three treatment service providers — the Wai'anae Coast Community Mental Health Center, Care Hawaii and Helping Hands — that serve O'ahu, the Big Island and Maui.

However, state Health Department director Chiyome Fukino hasn't been satisfied with the results.

"ACT is a specific program that has not worked well here," Fukino said. "Over the past two years, despite ongoing training efforts, providers have been unable to provide ACT services as outlined in their contracts.

"The providers are doing Community Based Case Management, but are billing for ACT services, which are paid at a higher rate. DOH is unable to bill Medicaid for ACT services because they aren't being done."

ACT has the highest level of services, according to Laenui in Wai'anae. His center has some 40 ACT clients. The next level of services is CBCM, of which Laenui's center has about 350 clients.

The difference between the two programs is largely one of management style.

The CBCM model uses a case manager. ACT's approach relies on a multidisciplinary team of specialists (psychiatrist, nurses, social workers and others) to determine the client's needs.

The case manager's job is to negotiate appropriate services on behalf of the client.

"But in both ACT and CBCM you have seriously mentally ill folks," Laenui said. "Many have court records; they've been through the criminal system."

The Wai'anae center not only will lose its ACT contract on Aug. 31, but because of a contractual dispute it will lose its CBCM contract at the end of this month. Laenui said it is unwise to move ACT patients into CBCM programs, and he questioned the state's planned 90-day transition program.

POLICY SHIFT CRITICIZED

"It will be difficult," Laenui said of what he believes is a mistaken DOH policy shift. "I've looked at the numbers and the available spaces for people who are doing CBCM work. And you place (our) ACT clients ... and our 350 CBCM clients into the available spaces, and you have an excess of at least 200 or more clients who will not be serviced."

But Michelle Hill, the Health Department's deputy director for Behavioral Health, disagreed. For one thing, she said, there has been no policy shift. That's because she contends her division hasn't been getting its ACT services in the first place.

"What we have discovered upon monitoring all the ACT providers is that we have not been able to achieve the true ACT service," Hill said. "What we're finding instead is that they have actually been delivering is more consistent with CBCM."

Thus, she said, it makes more sense to focus on the CBCM services and do away with ACT.

"We are doing what we think will be a better model that is driven by each consumer's need because, actually, more versatility is allowed under CBCM," she said.

Hill said the decision to terminate ACT contracts was not an overnight decision. She said her division has worked to minimize disruptions to patients and providers, and that the three months it has allowed to transition patients and providers should be more than adequate to ensure the patients' continued recovery.

Furthermore, she said, the process can be done so that patients can remain in their current locations with providers from the same community.

"We want to ensure that individuals who benefit from our array of mental-health services know that we are really trying to assure that they get the appropriate level of care at any given point in time," she said. "That is our focus."