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Homelessness is a process and not an event. It is our collective failure to address the root cause: the inadequate medical treatment of addiction and mental health. Until properly addressed, we will never help these very expensive subsets of homeless people.

Currently many homeless and seriously ill people use hospital ERs as a way to have a roof over their heads and a warm meal. Single individuals can generate  $500,000 to $1 million a year in healthcare expenses. Five percent of our Medicaid or Quest population consume more than 50 percent of the budget.

Estimates show we will spend nearly $2 billion over five years treating mental illness and addiction. These funds do not appear in many of the statistics generated by the state or city and county and are ultimately paid by our taxes.

The Hawaii State Hospital has a well documented bed shortage and it will be years before a new facility will be constructed. In-patient care at our state’s main facilities, including  Hina Mauka and Salvation Army, have constant wait lists. Patients present daily to emergency rooms and regular doctors offices asking for help and immediate referral for treatment, only to be turned away often for months. Ultimately this cycles leads to the streets of our state exposure to more addiction and easy access to drugs, alcohol and meth.

The good news is that the necessary funds to treat both issues, in most cases, already exist in the medical system through Medicaid and medQUEST.

The unfortunate and ultimately more costly news is that we are not allocating them appropriately. Until we invest in the services to truly treat and not just paper over the conditions, the crisis level for access and availability of services will only increase. Here are some ideas to bring change:

1) Create a medical task force representing the addiction community, psychiatry, psychology, substance abuse and private primary care physicians across the state. Currently efforts by the state and City and County of Honolulu have nearly excluded these professionals. It’s time to recognize and embrace the role of the entire medical community in working in concert with itself.

2) Create a methamphetamine task force. Hawaii Drug Court still has 90 percent of all lab tests come up positive for meth. We’re now into our third generation of meth users. It is not unusual to have a 60-year-old parent, 35- to 40-year-old grown child and a teenage meth user in the same family. We must reeducate the people of Hawaii about this drug that is unfortunately destroying families daily.

3) Create a legislative priority to address funding for inpatient and outpatient treatment. Wait lists at all treatment facilities exceed demand. A patient seeking treatment should be able to begin within 24 hours of diagnosis, plus transition to clean sober living with ongoing outpatient counseling for a minimum of one year.

4) Support development of multiple illness models. The very severe chronically ill need more comprehensive medical attention that includes integrated care between behavioral health and physical medical services at one setting such as in-residential. Investing in an integrated care model would save lives, respond to suffering and reduce millions and millions of dollars spent for emergency care.

People who have mild to moderate abuse issues can’t access treatment services. By training primary care services for screening and brief interventions, many people would not develop a more chronic addiction.  Training and protocols are needed for primary care to understand and treat mild abuse.

Some people need a little extra care to become healthy and functioning. For those, case management, peer mentoring and coordinated treatment with housing can make a lasting difference.

5) Open comprehensive addiction and mental health resource centers on each island. Primary care doctors and healthcare providers need one central resource to direct patients and families to available care. A central database of providers trained and willing to provide immediate access to care is essential when resources are limited. The Governor’s Task Force on Behavioral Health Integration supports this concept which is working in other states.

6) Increase educational options for substance abuse counselors, case managers and social workers specifically trained to work with the homeless. The University of Hawaii and Hawaii Pacific University should open additional class space in social work and psychology that includes specialized substance abuse and community mental health training.

7) Rethink the method for choosing housing. Housing First works best with immediate, broad integration of mental health and substance abuse treatment from day one. The new Silicon Valley Triage Tool is an innovative and validated screening process to determine the likelihood of hospital, ER, prison or other expensive alternatives to housing. It identifies individuals for whom the solution of housing costs less than the revolving social costs of homelessness.

8) Apply for a “1115 waiver” from the federal government to make housing a healthcare necessity as part of the Medicaid program for those with addiction and substance abuse. One of the key barriers to expanding supportive housing services, in addition to the capital investments needs, is the significant lack of funding for services that are delivered in the housing.

And that’s what the 1115 waiver would do.  It would recognize that those services have significant health outcomes, while dollars invested would have multiples of savings for the health care system. This will allow the state to access further funds from the federal government  that will be integrated within the healthcare delivery system to be spent on housing the chronically ill with home based services verses recurrent hospitalizations. It provides the opportunity for a “macro” look into the cost of homelessness.

9) We must comprehensively evaluate how all financial resources are being allocated. Many nonprofit organizations work tirelessly helping the homeless. But some organizations are getting more return than others on the investment of public funds. We need to measure it.

10) Give the Homeless a voice. Recipients of outreach know what’s working. Let’s independently survey them.

11) The Department of Human Services and  MedQuest must continue to work with healthcare contractors and insurance carriers which administer programs providing care to Hawaii’s Quest and Medicaid patients. All healthcare contractors are required to provide case managers, often registered nurses, for the most challenging patients. Many are homeless. Others have complex health needs including mental illness and substance abuse. We are missing early opportunities to address the chronic, serious health conditions before they spiral out of control and lead to homelessness. Currently it often takes two to three months before a case manager is assigned to a patient.

12) Seek advice from all communities. Beginning in January 2017, create an Innovation Forum where Hawaii residents are enlisted to help create solutions. Helping the homeless in Kaneohe may be different than in Lihue, Kihei or Hilo.

We must change our attitudes from negative to helpful. When we see the homeless as someone who needs medical attention for an untreated medical disease, we as a community can make a difference.

The bottom line:

It is time to begin addressing the root cause before homelessness in our state before it begins. We must reach every family and resident to understand their roles in preventing the conditions that lead to homelessness.

I believe we will succeed in addressing this crises if we begin to broaden the process and responsibility by creating new strategies involving the entire state. This does not mean starting over or abandoning the current processes that are working.

I believe people in Hawaii genuinely and sincerely care about our homeless.