Annual Report to the Legislature Summarizing Yearly Data on Forensic Patients at Hawai‘i State Hospital FY 2017

Prepared by: DoH Adult Mental Health Div, Hawaii State Hospital, December, 2017

EXECUTIVE SUMMARY

In accordance with Hawai‘i Revised Statutes (HRS) §334-16, the Department of Health (DOH) submits this report to the 2018 Hawai‘i State Legislature summarizing annual data on forensic patients served by the Hawai‘i State Hospital (HSH). All data, unless otherwise noted, is for fiscal year 2017 (FY 2017) and in comparison with FY 2016. Key terms and definitions may be found after the table of contents.

HSH forensic utilization remained strong in FY 2017. An emerging concern is the persistent and significant level of utilization by individuals ordered to HSH for temporary hospitalization due to conditional release violations, suggesting a need to bolster community-based treatment and supervision programs and reduce re-hospitalizations.

In FY 2017, HSH admissions and discharges decreased slightly from the prior fiscal year, but were still the second highest in the past decade, suggesting that high levels of HSH forensic utilization will likely continue. Commitment from the criminal courts continues to be the only admissions to HSH. Discharges outpaced admissions by +10, reversing the problematic trend of the previous three fiscal years where admissions exceeded discharges. 

HSH beds are augmented by DOH contracts with Kāhi Mōhala Behavioral Health (Kāhi Mōhala or KMBH) and Correct Care Recovery Solutions (Correct Care). DOH contracted 46 beds at Kāhi Mōhala costing approximately $13 million. To serve individuals who cannot be safely treated at HSH due to intractable dangerous behaviors, DOH contracted up to four beds at Correct Care’s secure forensic facility in South Carolina.

Admissions with the legal status of unfit to proceed continued to be the most frequent commitment category, involving 58% of FY 2017 admissions. A subset of unfit admissions involve Act 53, passed in 2011 by the Hawaiʻi State Legislature, which limited the duration of mental health commitment for individuals found unfit to proceed and charged with non-violent petty misdemeanor or misdemeanor offenses to 60 and 120 days, respectively. During FY 2017, commitments under Act 53 decreased slightly (-5%), but remained nearly one-third of all unfit to proceed admissions. Admissions involving up to 120-day commitments for misdemeanor offenses continued to increase (+50%; 14 to 21). 

The number of individuals found fit to stand trial after hospitalization and discharged from HSH decreased by -12% (84 to 74) and constituted 22% of all HSH discharges in FY 2017. 

Across the state, most counties and courts committed fewer patients to HSH in FY 2017, resulting in a -9% decline in overall admissions. The exceptions to this downward trend were increases from O‘ahu (Honolulu) family court (+73%, 11 to 19) and the Hawai‘i circuit court (+29%, 21 to 27). Similar to the prior fiscal year, more than half (51%) of all admissions in FY 2017 came from the circuit courts. 

Circuit courts generally oversee felony charges, and correspondingly, 53% of admissions (n=169) involved felonies as the most severe charge—a 10% decline from the prior year (187 to 169). In fact, the decrease in admissions with Felony A (-23%, 26 to 20) and Felony B (-17%, 46 to 38) exceeded the average decline in admissions (-9%). However, Felony C continued to be the most common grade of offense (35%, n=111) among admissions, followed by misdemeanors (27%, n=85) and petty misdemeanors (20%, n=64).

Analysis of the categories of the underlying crimes charged against forensic patients active during FY 2017 revealed that property crimes (§708, 44%) were slightly more common than offenses against persons (§707, 41%). Sexual offenses were relatively rare (§707 Part V, 4%) and 22% of patients were charged with crimes against neither persons nor property. Most individuals had charges in only one category (73%), while more than one-fourth (27%) were charged in crimes in multiple categories. 

Despite the -9% decline in admissions, hospital utilization as measured by total inpatient days continued to be strong, increasing by +1%. Similar to FY 2016, almost three-fourths of inpatient days were attributable to individuals admitted as unfit to proceed (46%) and temporarily hospitalized for conditional release violations (27%). 

For individuals discharged in FY 2017, the average length of stay (LOS) was 7 months, a decrease of 1.5 months from the previous fiscal year. Patients discharged as conditionally released (§704-415) continued to have the highest total and average (approximately 9 months) LOS of discharged patients. Further analysis revealed that 80% of individuals discharged on conditional release were originally admitted as temporary hospitalizations for violating terms of conditional release (§704-413(1)), with an average stay of 7.5 months, ranging from 2 days to almost 4 years. 

Using the last day of the fiscal year to provide a snapshot of the patients currently in the hospital, the largest percentage of patients held the legal status of unfit to proceed (37%, n=92). However, individuals acquitted and committed (“not guilty by reason of insanity,” or NGRI) constituted 21% of the population and individuals previously acquitted but violated conditional release represented 29% of the population. Together, this NGRI cohort of legal statuses (acquitted and committed, CR violations) equated to 50% of patients active on June 30, 2017. 

Measuring the gross LOS of patients hospitalized at HSH at the end of the fiscal year captures the length of an active hospitalization episode, particularly for those who require long-term treatment and are not readily discharged. Collectively, the 53 individuals with the legal status of NGRI on the last day of FY 2017 spent 405 years at HSH and contracted beds since their respective admissions. The 74 individuals with CR violations accumulated another 242 years. By contrast, the 92 individuals currently unfit to proceed constituted the largest group, but amassed only 56 years. 

After a steady decline in staff assaults by patients, HSH saw an increase in FY 2017 of total patient-to-staff assaults—both assaults with physical contact and attempted assaults. While HSH includes attempted assaults (i.e., no physical contact) in its aggression data, not all hospitals do so. Analysis of data revealed that just 10% of active patients (55 of 532) were responsible for all assaults on staff. In fact, more than one-fourth were attributable to 3 highly-assaultive patients. 

Although the number of staff assaults (physical contact) were the second highest in the past five years, the number and proportion of injuries resulting from the assaults was a little lower than expected (44%, range from 41% to 57%). Injuries requiring outside medical intervention were also lower in number and proportion (13%, range from 12% to 25%). This suggests that efforts to mitigate harm from assaults may have reduced the number and severity of injuries relative to the number of assaults. HSH takes all assaults seriously, be it committed or attempted, and continues to take steps to ensure the safety of staff and patients, such as enhanced staff training, adequate staffing levels, analysis of assault events, implementation of a proactive patient engagement program, driver partitions in patient transport vehicles, and security personnel presence on hospital units.

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