A deepening clash between state lawmakers, community providers and the state Department of Health is putting renewed scrutiny on how Hawaii handles defendants with serious mental illness — and whether gaps in the system are fueling a costly “revolving door” between jail, the Hawaii State Hospital and the streets.

At the center of the debate is House Bill 2505, which would streamline assisted community treatment, or ACT, and clarify that community mental health outpatient programs can prepare court certificates required to place someone in treatment.

But lawmakers say the bill also exposes a larger problem: Even when defendants are repeatedly found unfit to stand trial, few are being placed into court-ordered treatment.

HB 2505 aims to address part of the breakdown by clarifying that community mental health outpatient programs that agree to provide services under an ACT order may prepare the required certificate for the court.

State Rep. Adrian Tam (D, Waikiki), who introduced the bill, said current law largely limits that authority to advanced practice registered nurses, referred to as APRNs, on crisis teams, and the measure would speed access to care by allowing community mental health outpatient programs to prepare the required certificates as well.

Tam said the goal is to connect people to help as quickly as possible, particularly those who are not in a mental state to seek treatment on their own or lack a guardian to do so, and to avoid placing the responsibility solely on psychiatrists and APRNs amid an ongoing health care worker shortage.

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Data provided by the department show that from July 1, 2024, to Sept. 30, 2025, there were 298 admissions to the state hospital in which a defendant’s fitness to proceed remained unresolved. All were screened for involuntary hospitalization, and assisted community treatment was evaluated concurrently.

Only five defendants were found to meet criteria for involuntary hospitalization: five petitions were filed, four granted and one was withdrawn. No ACT petitions were filed during that period.

For Senate Judiciary Chair Karl Rhoads (D, Nuuanu- Pauoa-Pacific Heights), the fact that four involuntary hospitalization petitions were filed and zero ACT petitions were submitted is a “completely unbelievable” figure — and a disconnect he finds alarming.

Under the law, when a defendant is found unfit to proceed, DOH must evaluate whether the person qualifies for involuntary hospitalization or assisted community treatment and file a petition if criteria are met. If the person does not qualify, or if a petition is denied, the state hospital must discharge them with voluntary outpatient referrals.

Rhoads said DOH told lawmakers the low number of ACT petitions was tied to limited resources — that with more staff to file petitions and more placement options, more individuals might be found eligible.

He called that rationale inappropriate, saying clinical eligibility should not hinge on bed availability. Instead, he said he would support a clear request for additional staff and funding rather than allowing resource shortages to shape medical decisions.

DOH assessment process

Under Act 26, which mandates rapid competency evaluations for low-level, nonviolent defendants and diversion to treatment if found unfit, defendants may be held up to 14 days for evaluation, though the average stay is eight days or less. DOH said that is sufficient when patients engage in care, but those who decline treatment are more likely to return.

DOH told the Honolulu Star-Advertiser it is working to improve the assessment process and that, when appropriate, an attending psychiatrist may order a long-acting injection, coordinate community care and file an ACT petition.

Because ACT is outpatient- based, capacity and staffing constraints largely fall on community providers responsible for enforcing court- ordered treatment. From a policy standpoint, requiring coordination with an outpatient provider — including a psychiatrist or prescribing APRN — to file an ACT petition is intended to create a clinical bridge from inpatient care at the state hospital to community treatment.

In determining “imminent dangerousness” — defined as likely within 45 days — clinicians assess suicidal risk, risk to others, past violence, criminal history, admission history and current mental status. Involuntary hospitalization, the department explained, is reserved for patients actively exhibiting unsafe behavior who require a secure setting.

House Health and Human Services Chair Della Au Belatti (D, Makiki- Punchbowl- Papakolea) questioned whether that threshold is being applied too narrowly.

She acknowledged that civil commitment standards must protect individual rights, but said the practical result may be that intervention comes only after someone has deteriorated further.

Belatti said some believe that unless a person poses an immediate danger to themselves or others, they should be free to refuse treatment — a stance she said can conflict with community concerns about leaving severely ill people untreated on the streets. She added that some individuals appear competent to decline care but repeatedly refuse services and cycle back into crisis, which adds concerns about how state hospital clinicians interpret the legal standard when determining eligibility for ACT.

“When they’re left to their own devices, they become threats to themselves,” she said. “We have doctors in the state hospital who are saying these individuals don’t qualify for ACT when we believe they are … Is it going to take one of these people to assault someone, have a serious crime on their hands, and then, clearly, they’re harmful to others?”

Belatti said the law was intended to allow structured treatment in the community before individuals reach that point — but only if the eligibility standard is applied in a way that permits earlier intervention.

The ‘revolving door’

Community providers say the consequences of that gap play out daily on the ground.

Institute for Human Services Community Relations Manager Angie Knight said the organization has been tracking what she calls Act 26’s “revolving door,” in which low-level defendants sent to the state hospital for competency evaluations have their cases dismissed if found unfit.

“There has been very little, if any, people found eligible for court-mandated treatment, which different stakeholders are confused by,” she said. “Some people have over 50 counts of being unfit to proceed with criminal meetings, yet they don’t meet eligibility for their evaluation.”

As a result, individuals cycle back into the community untreated.

“They get picked up, they get discharged. No treatment has been initiated. They get picked up again, they get discharged again, and they’re in this loop, because nothing has changed,” Knight said. “That’s where the revolving door happens.”

Knight described one client who had “upwards of 20” — possibly even 30 — police encounters before a court-ordered treatment petition was granted. Repeated citations and police contacts often become part of the evidence used to show danger to self or others.”

Belatti said lawmakers have been “tinkering with assisted community treatment” for roughly a decade, and there’s big frustration over implementation.

“I think what’s frustrating is that we’ve invested a lot of money and time and effort. There’s a lot of laws on the books, and it’s like, ‘All right, you’re equipped with what we need, now implement,’” she said. “What’s the plan? What are you doing in the HSH? What are you doing to make sure people are getting your programs? There seems to be a lot of foot dragging at the Department of Health — what are you folks doing?”

In a Dec. 5, 2025, letter to lawmakers, DOH outlined budget-neutral steps to reduce repeat admissions. Because many patients lose Medicaid coverage under the federal Institution for Mental Diseases exclusion, the department is working with Community Care Services and Med-QUEST to speed reenrollment or grant presumptive eligibility before discharge. It is also exploring alternatives to hospitalization for some nonviolent defendants, allowing more time for substance withdrawal before initial hearings and adding outpatient versus inpatient recommendations to fitness reports.

To address delays in court-ordered treatment, DOH said it wants to partner with the state Judiciary to expedite ACT hearings and strengthen community supports, including a dedicated ACT team and streamlined petition forms in coordination with the state Department of the Attorney General.

The Judiciary, while taking no position on HB 2505 overall, opposed a provision requiring ACT petitions to be heard within five days, explaining that the proposal conflicts with the existing 10-day statutory deadline and does not provide enough time to appoint and prepare a guardian ad litem, recommending current timelines remain in place.

Clarification needed

Separately, DOH told the Star-Advertiser that statutory clarification in HB 2505 is necessary. Allowing either a community outpatient provider or the inpatient treatment team to prepare the required certificate and file an ACT petition would clarify responsibilities and improve the clinical hand-off from HSH to community- based care, supporting treatment in the least restrictive setting.

Rhoads agreed with DOH that resources are part of the problem. The goal of assisted community treatment, he said, is not to institutionalize people but to intervene in the least restrictive way possible. Still, community-based placements require staffing and support — including psychiatrists and other providers — and cannot function without funding. While those settings are less costly than long-term hospitalization at the state hospital, they still require meaningful investment.

However, he said the deeper issue is prioritization, expressing frustration that in nearly two decades in office, DOH has never made assisted community treatment a central focus, despite its importance to both individual health and overall community safety.

“It’s pretty clear at this point that schizophrenia is a progressive disease, and the longer you wait to treat it the first time, the worse it gets, and the harder it is to treat,” Rhoads said, adding that intervention could prevent long-term deterioration.

Knight agreed, noting that once treatment is in place, many clients stabilize.

“We’ve seen stability gained,” she said. “(HB 2505) doesn’t fix all, but it does make it easier to work with clients … This bill helps put a spotlight on the gap between the criminal court and the family court. There is currently a need for greater collaboration between the two.”