Caring for Vulnerable Patients With Complex Needs

In 1855, Alexander Liholiho ‘Iolani became King Kamehameha IV at age 20. On April 7, 1855, the young king gave a renowned speech on a subject that he felt “in comparison ... all others sink into insignificance.” He urged, “Our acts are in vain unless we can stay the wasting hand that is destroying our people. I feel a heavy and special responsibility resting upon me in this matter, but it is one in which you all must share.”

This quote underscores The Queen’s Health System’s enduring commitment to its mission, one that aligns with the vision of the system’s founders, King Kamehameha IV and Queen Emma. It serves as a poignant reminder that their aspirations remain relevant today: Despite the passage of time, Native Hawaiians still experience lower life expectancy compared to other ethnic groups, emphasizing the need to address persistent health inequities. The work of The Queen’s Health System’s Native Hawaiian Health department is dedicated to improving the health and well-being of Native Hawaiians in honor of the health system’s founders.

The Queen’s Health System is a nonprofit healthcare organization with a rich history of caring for the people of Hawaii. It consists of four hospitals and more than 70 preventive, specialty healthcare facilities and labs throughout the Pacific region. The health system’s 10-year aspirational goals include:

• To extend the life expectancy and a life well lived of Native Hawaiians.
• To close the gap in life expectancy in half within the decade.
• To become a lifetime partner, improving the health and well-being of all those served.

Execution of Kahua Ola: Supporting Transformational Change The Kahua Ola framework is foundational to the health system’s 10-year aspirational goals and its Kahua Ola Strategic Plan. The framework was adapted from “the Hawaiian worldview,” a holistic paradigm that provides a Hawaiian perspective on health and well-being that is multidimensional and honors ancestral wisdom. It provides a basis for unity, harmony and balance for good health versus illness. The Hawaiian worldview definition can be found in the February 2020 issue of the Journal of Indigenous Voices in Social Work.

Why is the Native Hawaiian Health Strategic Plan Kahua Ola so important? The COVID-19 pandemic all but erased slight improvements in the gap in life expectancy for Native Hawaiians, which is now seven years shorter than Hawaii’s other major racial and ethnic groups. The U.S. Department of Health and Human Services Office of Minority Health reports that leading causes of death among Hawaiians are cancer, heart disease, stroke and diabetes. The 2023 Centers for Disease Control and Prevention’s Pregnancy Mortality Surveillance System reported that the highest pregnancy-related mortality ratio in the U.S. was among Native Hawaiians and other Pacific Islanders at 62.8 deaths per 100,000 live births. These maternal deaths were due to cardiovascular conditions, infection/sepsis, cardiomyopathy, hemorrhage, embolism, hypertension and stroke.

In addition, the 2021 Healthcare Association of Hawaii Community Health Needs Assessment identified five significant health needs affected by the COVID-19 pandemic in Hawaii: financial security, food security, mental health, housing, and trust and equitable access. Other studies, including the 2023 U.S. Census Bureau’s American Community Survey, indicate Native Hawaiian communities often face challenges in accessing healthcare due to factors such as geographical remoteness, cultural preferences, housing instability and transportation difficulties.

These health disparities indicate the importance and urgency for Queen’s Health System to meet its founders’ mission. Native Hawaiian Health is integral to providing culturally safe and responsive, high-quality health services to Native Hawaiians. In 2023, The Queen’s Health System received federal designation as a Native Hawaiian health center. The health system currently serves just over 110,000 Native Hawaiians, representing 38% of the approximately 289,776 Native Hawaiians in Hawaii.

By 2030, Queen’s Health System aims to increase the number of Native Hawaiians served to 145,000, or 50% of all Native Hawaiians residing in Hawaii. Organizationally, Native Hawaiian Health has systemwide oversight and kuleana (responsibility) to implement the healthcare strategy for attaining this Queen’s Health System aspirational goal: Reduce in half the seven-year Native Hawaiian lifespan gap and increase their quality of life by 2030. The Kahua Ola strategy continues to evolve and achieves this aspirational goal by addressing the health disparities and health equity challenges described above.

Key Lessons Learned Since Kahua Ola Strategic Plan 1.0 was approved in June 2019 (fiscal year 2020), there have been many valuable learnings through the collection of quantitative, qualitative and anecdotal data and lessons from the Kahua Ola implementation. One of the most notable learnings is that Native Hawaiians across the pae ‘āina (island group) still face barriers to accessing care and have limited access to culturally responsive and safe care. This is particularly true for those experiencing patient related or geographic factors such as poverty, poor health literacy, lack of social support, other social determinants of health or rural isolation.

Moreover, the health system has learned that there are many factors within Queen’s Health System that contribute to or exacerbate patient factors and limit the organization’s ability to provide access to care or to adequately engage Native Hawaiians in care. These system barriers (lack of financial resources and data collection challenges specific to Native Hawaiians) have posed challenges in the scalability, speed, development, expansion and sustainability of Kahua Ola programs and activities to support strategic plan execution. Financial resources alone are not sufficient to solve resistance in scalability that continue to slow spending, hiring or resource allocation. True integration of Kahua Ola across Queen’s Health System is needed to address gaps and ensure healthcare system transformation is possible.

Primary Care Behavioral Health Integration Program One example of this integration already underway is the Queens North Hawai‘i Community Hospital’s Kahu a Ola (to shepherd to good health) program, a primary care behavioral health integration program launched in February 2019. The program provides integrated behavioral health services, chronic disease management, care coordination and community navigation through a culturally responsive lens within primary care at Queens North Hawai‘i Community Hospital.

From its inception, the Kahu a Ola Program has supported Native Hawaiian patients with one or more of the following chronic diseases: Type 2 diabetes, hypertension or obesity. The program offers an array of services based on patient preference, including unique engagement activities such as nutrition and food preparation classes, hula, walk programs, and diverse webinars and in-person classes. As of the third quarter of fiscal year 2024, 142 patients were enrolled.?

Stephany Nihipali Vaioleti, JD, FACHE, is president, Queen’s North Hawai’i Community Hospital, Waimea (Kamuela), Hawaii. Darlena Chadwick, RN, FACHE, is executive vice president/COO, The Queen’s Health System, Kapolei, Hawaii.

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