Advocates are again raising concerns about how the economic crisis is affecting mental-health programs in the Islands, but this time are eying Hawai'i State Hospital, which faces a $1.7 million budget shortfall and could see layoffs in the coming fiscal year.

The population at the state psychiatric hospital in Kane'ohe was at 168 last month, down from 192 a year earlier — a decrease attributable in part to more aggressive efforts to place people who are ready back into the community. Though advocates applaud that work, they question how recent big cuts to mental-health services are affecting patients and say the state should be doing more to monitor the situation.

Some also worry that worsening budget woes will hurt progress made at the state hospital since it emerged from federal oversight in 2004. The hospital has so far averted major funding cuts, though it has decreased spending by cutting back on overtime and costs for utilities, food and medicine, said hospital administrator Mark Fridovich.

Despite the measures, the hospital still faces a $1.7 million shortfall this fiscal year.

And the coming fiscal year brings the potential for more bad news: A proposed state House budget would cut 48 positions — at least 15 of which are filled — from the hospital's 639 allocated slots. Under the proposal, the hospital would get about $52 million in fiscal years 2010 and 2011, a reduction of about $4.2 million from this fiscal year.

The Hawai'i State Hospital is the only public institution in the Islands for the mentally ill. About 99 percent of its patients are referrals from criminal courts, Fridovich said, and their charges can range from not following the terms of their release to violent crimes. In fiscal year 2007, the hospital saw 226 new patients, about half of whom were from O'ahu. About 40 percent of the admissions were for felonies, figures show.

Fridovich said the reductions to mental-health services and proposed cuts to the state hospital are concerning, but Health Department officials have also maintained that the safety net for the mentally ill is still intact and that the cuts are not endangering public safety.

"This is a challenging time for many people and programs," Fridovich said, in an e-mailed response to questions from The Advertiser. "Of course we are concerned and we are also confident that we will be able to address the challenges which we face."

DEEP CUTS ALREADY

Discussions about how the state hospital is managing in these tough times come as mental-health services statewide have seen deep cuts because of the fiscal crisis. Advocates say they're most worried about how discharged patients from the state hospital will fare once they get back into the community.

They particularly point to cuts to case-management programs, which are designed to ensure mental-health clients outside of institutions are seeing a therapist if they need to or are staying on their medications. In January, the Adult Mental Health Division capped reimbursable case-management hours per client at 3.5 hours a month (from three hours a day), while also cutting services to those with private insurance.

Then, this month, AMHD told service providers statewide it had run out of money for a slew of contracted services — ranging from case management to crisis outreach — and in many cases won't be able to pay organizations for their work until the new fiscal year starts in July. Providers say the lag in payments could leave thousands of clients without some critical services, and could also spur more layoffs.

It could also force some agencies to go out of business.

"Our big concern has been the capping of case-management hours. It's just huge," said Mike Durant, president for the Hawai'i chapter of the National Alliance on Mental Illness, an advocacy group. "What's going to happen when people get out of the state hospital and are not monitored as carefully?"

Ku'ulei Kiliona, a member of the Hawai'i State Council on Mental Health, said the case of Tittleman Fauatea is an extreme example of what can happen when someone falls through the cracks. Fauatea, 25, who has a history of mental illness, has been indicted in the stabbing death last month of Wai'anae High School teacher Asa Yamashita. Yamashita's killing came three months after Fauatea was taken from the state hospital to serve a six-day sentence at O'ahu Community Correctional, which he left on Nov. 29.

The Health Department has said the hospital had a court order to release Fauatea to OCCC.

Kiliona said the case should have the public worried about what mental-health cuts mean to them.

"It's a trickle-down effect," she said.

GROWING DEMAND

The number of people statewide receiving community-based mental-health services has skyrocketed in recent years — thanks largely to public outcries in the 1990s over the condition of the mental-health system and the state hospital.

About 16,000 people in the Islands get mental-health services through organizations that have contracts with the state, compared with a little more than 5,200 in fiscal year 2003, state figures show.

The state spent more than a decade bolstering community-based mental-health programs following a 1991 lawsuit filed by the U.S. Justice Department's civil rights branch over conditions at the state hospital.

The lawsuit spurred a consent decree that kicked off 15 years of federal oversight into the state's delivery of mental-health services and treatment. Federal oversight of the state's mental-health plan ended in 2006, though oversight of the Kane'ohe facility was lifted two years earlier. Since then, there have been few problems raised with the state hospital, which has achieved national accreditation for patient safety goals.

Accreditation inspectors last visited the hospital in December and noted no major issues.

In 2007, some lawmakers did raise concerns about the number of assaults on staff members at the hospital. Legislators said the hospital was understaffed and overcrowded after the institution was forced to release about 50 workers to address a $6.5 million deficit. At the time, 201 patients were at the facility.

That year, the hospital recorded 179 assaults on staff, down slightly from 187 in 2006.

Last year, there were 150 assaults.

And in the first two months of this year, there were 23 assaults.

The assaults do not always include physical contact, and officials said most of the victims did not require treatment.

State Sen. Clayton Hee, D-23rd, (Kane'ohe, Kahuku), toured the state hospital following the concern about assaults. He said last week that it appears the issue has improved significantly.

But he added that budget cuts could chip away at some of that progress. "The mentally ill, like the incarcerated, have not been high on the budget" priority lists, said Hee, whose district includes the hospital. "In tough times like these, they experience even deeper cuts, which have more profound ramifications."