‘Ke Ku‘una Na‘au’: Focusing on Complex Care for Native Hawaiians
Native Hawaiians are overrepresented as the largest ethnic group experiencing homelessness in Hawaii. The Queen's Medical Center in Honolulu has focused on addressing the social disparities experienced by the highest-risk Native Hawaiian patients with a transition-of-care model that starts in hospital inpatient settings.
Daniel Cheng, M.D., M.P.H., medical director of the Queen's Medical Center Emergency Department, noted that the homelessness problem started getting really bad following the 2008 recession, and that in the emergency department, providers realized they were seeing the same population of people over and over again. In 2016, he looked at utilization data from their electronic medical records and found that just 3 percent of the population was using about 60 percent of the resources. “It really just blew my mind,” he said.
Cheng was speaking during a webinar put on by the National Center for Complex Health and Social Needs, an initiative of the Camden Coalition of Healthcare Providers in New Jersey.
He described how he took the EHR utilization data to HMSA, the largest private health insurance company in Hawaii and a large Medicaid insurer at that time, as well as to the CEO of Queen’s Health System, and they agreed something needed to be done. In 2017, Queen’s Health System decided to initiate a program focused on these issues. In 2018 they got a CMS grant to focus specifically on social and mental health. They established the Queen’s Care Coalition to provide post-discharge navigation services by community health workers to high-need, high-cost patients, many of whom are experiencing homelessness. One arm of the coalition works specifically with Native Hawaiian patients.
Kehau Puou, who works as a navigator, said the program’s name uses the Hawaiian phrase “Ke Ku‘una Na‘au, which has a connotation of laying down a fishing net, or “putting one's mind and heart at ease.” She noted that the considerable health disparities and shorter life expectancy for Native Hawaiians “clearly define the historical trauma endured by people due to displacement and colonization.” Puou said the navigators in the program engage with patients in the hospital, form relationships, and help them transition back to the community. They help make connections with family, community-based organizations, primary care and housing support.
Tiffany Mukai, a project coordinator and social worker at Queen's Medical Center, said that most of the referrals come from inpatient hospital staff, who identify patients who may benefit from navigation support. Patients meet criteria for the program by self-identifying as Native Hawaiian and having social determinants of health need, such as housing instability, financial instability, and by being at high risk for readmission.
There are five navigators on the team, as well as a social worker and a community nurse clinician. “The goal is to meet patients at bedside prior to discharge to start the engagement process and develop rapport,” Mukai said. Navigation is provided for 30 to 90 days — it is short-term and high-intensity. The navigators have a caseload of 10 people each, so they're able to provide at least weekly and sometimes daily check-ins and follow-ups with patients. They assist patients’ referrals to community resources — everything from housing to food to clothes to financial benefits. They also connect patients to community support such as insurance care coordinators and mental health case managers.
The social worker provides clinical supervision to the navigators in areas of behavioral health and substance use issues. “The role of the community nurse clinician is to provide medication management, disease education and wound care. This often happens at the beach, at bus stops, in parks — wherever the patient is,” Mukai explained. The core values of the program are harm reduction and cultural sensitivity. And the key to success is the navigators’ relationships with patients and strong relationships with community partners, she added. “Each month we meet with federally qualified health centers to discuss the highest utilizers of hospital services who are connected with their clinics. We develop care plans and share recommendations on how to best support these high-risk individuals.”
Since the inception of the program, of the 210 patients who were homeless or unsheltered, 46 percent of them were off the streets after their graduation. In comparison, according to a recent HUD study, the national average for successful placement in any type of housing from street outreach was 33.4 percent in 2019.
In terms of hospital outcomes, there was a 50 percent decrease in emergency room visits comparing six months prior to participation in the program and six months post-graduation. Additionally, there was a 23 percent decrease in length of stay in the hospital, and approximately 50 percent decrease in the 30-day readmission rates.
Across the Queens Care Coalition, there has been a 55 percent decrease in hospital admissions, and a 50 percent decrease in ambulance transports when comparing numbers six months prior and six months post-graduation. There is a consistent decrease in utilization correlated with navigation services. Mukai noted that Queen's Medical Center is the only hospital in the state that has this type of intense inpatient/outpatient navigation support, not only in terms of readmission rates and utilization, but also in improving patient's quality of lives, by getting them off the streets and stabilizing them medically. “We have shown that this model of navigation works. The navigator serves as a bridge between the hospital and the community, and is also an interpreter of sorts, who helps patients understand the complexities of the healthcare system.”
Cheng closed by talking about the financial sustainability of the effort. There are five health insurers in Hawaii that provide Medicaid services. They get paid more per person by CMS if they prevent hospitalizations as well as ER visits, he added. “When those insurers shared total cost of care data, it ended up being about $40,000 to $50,000 of savings per patient from this program,” he said. “That was a huge turning point in this program because this allowed the incentives to align,” he said. “Obviously we all want to do what’s best for the patients, but there are some real bottom-line issues for these insurers, and now we can align their financial incentives with our goals, and it was a fairly easy step from there to writing some memorandums of agreement and contractual agreements to create some value-based payments to extend this a few years and get some more data. Any savings to Medicaid is a savings to the state coffers, so aligning incentives in different ways is a crucial part of providing more resources to create financial stability.”
Cheng noted that the 2008 recession led to a housing crisis a few years later. Although Hawaii has not suffered as badly as other states from a health perspective from COVID-19, the state’s unemployment rate soared above 30 percent. “Looking back at 2014, three or four years after the great recession, our state really had a significant amount of impact, so one of the things we're looking at, moving beyond 2021, is to see what kind of recession impact 2020 is going to have for our population.”
