TABLE OF CONTENTS
I. Opening
A. Pali Momi Medical Center
B. Executive Summary
C. Background and Scope
D. Partners
E. Methodology

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II. Statewide Assessment
A. COVID-19 Impacts
B. 2021 CHNA Priorities
Financial Security
Food Security
Mental Health
Housing
Trust & Equitable accessC. Significant Health Needs
D. Unique Populations
Geographic
Healthy Women and Healthy Keiki

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III. Addressing Health Priorities
A. A Shared Kuleana for Community HealthB. Developing Strategies to Address Priorities
C. Policy Opportunities
D. Pali Momi Medical Center’s Selected Health Priorities
E. Evaluation of Prior 2020-2022 Implementation Strategy Activities

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IV. Conclusion
A. Mahalo from the Research Team
B. Acknowledgments

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V. AppendicesA. Appendix A - Shared Kuleana Strategies
B. Appendix B - Statewide Healthcare Facilities
C. Appendix C - Steering Committee
D. Appendix D - Community Advisory Council
E. Appendix E - Community Meetings
F. Appendix F - Key Informants
G. Appendix G - UH Partnership

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1

I.

Opening
A. Pali Momi Medical Center

Pali Momi is pleased to present its 2022 Community Health Needs Assessment, which was adopted
by Pali Momi’s Board of Directors, on May18, 2022. This CHNA report was developed incollaboration with other nonprofit hospitals in Hawai‘i under the leadership of the Healthcare
Association of Hawai‘i. Note: The research team conducted much of its work during 2021 andtherefore this document refers to the 2021 CHNA and 2021 Priorities throughout. However, Pali
Momi’s CHNA was completed in 2022 and therefore was adopted as Pali Momi’s 2022 CHNA.
About Pali Momi Medical CenterIn the early 1980s, Dr. Joseph “Joe” Nishimoto returned to Hawai‘i from the mainland topractice medicine in ʻAiea and Pearl City. As the community grew, he envisioned a local, stateof-the-art hospital so Leeward families would not have to drive into town for medical care. The
road to achieving that vision spanned eight years and took the efforts of many.
Pali Momi opened on July 31, 1989. Since its opening, the hospital has delivered many medical
firsts for Central and West O‘ahu, including: The first interventional cardiac catheterization unit to detect and treat heart disease.
 First retina center in Hawai‘i.
 Minimally invasive surgical technology featuring the da Vinci robot-aided system.
 A comprehensive women’s center.
 Hawai‘i’s only team triage approach to emergency medicine.
 A complete bariatric surgery program.
 The most advanced diagnostic imaging technology available.
Today, Pali Momi continues to provide award-winning care to thousands of patients each year. Pali
Momi has been recognized by the American Heart Association and American Stroke Association
for its stroke care program. The Bariatric Surgery Program offers complete patient care, lifestyletransition and support, and has received Metabolic and Bariatric Surgery Accreditation and isrecognized as a Quality Improvement Program Accredited Center, a joint program of the American
College of Surgeons and the American Society for Metabolic and Bariatric Surgery. With morethan 1,200 employees and 400 physicians, Pali Momi is fully accredited by The Joint Commission,
an independent nonprofit organization that certifies health care organizations and programs in the
United States.
Hawai‘i Pacific Health
Hawai‘i Pacific Health (HPH) is a not-for-profit health care network of hospitals, clinics,
physicians and care providers dedicated to the mission of improving the health and well-being of
the people of Hawai‘i and the Pacific Region. Anchored by its four hospitals—Kapi‘olani Medical
Center for Women & Children, Pali Momi Medical Center, Straub Clinic Medical Center andWilcox Medical Center—HPH includes more than 50 convenient locations and service sites
statewide. As the state’s largest health care provider, Hawai‘i Pacific Health’s network of doctors
3and specialists provide a distinctive model of coordinated care. Its not-for-profit mission means all
earnings are reinvested into improving medical equipment and facilities, as well as invested inresearch, education, training, and charity care for under-served people within the island
community.
Community Served by Pali Momi Medical Center
Pali Momi serves the health needs of residents in Central and West O‘ahu, as well as patients fromall across O‘ahu. Therefore, the island of O‘ahu, which comprises the County of Honolulu, willserve as the unit of analysis for this CHNA.
In 2020, O‘ahu had a population of 1,016,508. Children under 18 made up 21.1% of the island’s
population and adults over 65 made up 17.8 % of the population.1
The largest single race group in Oahu is Asian (52.1%), followed by White (18.4%), Native
Hawaiian/Other Pacific Islander (7.6%), Hispanic or Latino (7.1%), Black/African American(1.9%), and American Indian/Alaska Native (.05%). At 18.5% Japanese make up the majority of
the Asian population on Oahu. 15.6% of O‘ahu’s population is multi-racial, with 67.5%
identifying as any part Asian, and 32.5% identifying as any part White. While 7.6% of Oahu
residents are Native Hawaiian/Other Pacific Islander only, a total of 18.7% are all or part Native
Hawaiian/Other Pacific Islander.2O‘ahu residents are relatively well educated compared the rest of the US population, with 92.4%
of O‘ahu residents age 25 and older achieving a high school degree or higher (compared to 88.5%
for the US) and 35.7% achieving a bachelor’s degree or higher (compared to 32.9% for the US). 3
The 2019 median household income on O‘ahu ($87,722) was relatively high compared to the US
overall ($64,994). 9.1% of O‘ahu’s population lived below poverty level, compared to 12.8% of
the total U.S. population. American Indian/Alaska Native (21.7%), Native Hawaiian/Other PacificIslander (21.1%) populations had the highest poverty rates. 4
It is important to note, however, that federal definitions of poverty are not geographically adjusted,
so the data may not adequately reflect the proportion of residents who struggle to provide forthemselves due to the high cost of living across the state of Hawai‘i.
The Asset Limited, Income Constrained, Employed (ALICE) Report may provide a more accurate
picture of economic hardship and survival in accordance with Hawai‘i’s relatively high cost ofliving, dominance of low wage jobs, lack of affordable housing, and gaps in public assistance. Thismeasure, developed by the United Way, provides estimates for those who live above the Federal
Poverty Level but still struggle financially. The ALICE population is working, but they are
typically just one major crisis (loss of job, health emergency, etc.) away from being at an increased
risk for long term problems such as loss of housing or chronic health concerns. 5
1 U.S. Census Bureau, 2020 American Community Survey, 5-Year Estimates
2 U.S. Census Bureau, American Community Survey, 2020 Estimates
3 U.S. Census Bureau, American Community Survey, 2020 Estimates
4 U.S. Census Bureau, American Community Survey, 2020 Estimates

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Hawai‘i United Way ALICE Report, 20204

According to the 2020 Hawai‘i ALICE Report, while 8% of O‘ahu households met Federal Poverty
Level guidelines for financial hardship in 2018, a total of 40% were ALICE and below. Families
with children headed by a single parent were even more likely to meet ALICE criteria. In 2018, of
the 13,877 single female headed households with children on O‘ahu, 78% (10,821 households)
met ALICE criteria, as did 51% of the 3,582 single male headed households with children (1,833
households). This is compared to just 29% of the 63,259 married households with children who
were ALICE or below (18,198 households). 86% of the 9,864 households consisting of individuals
under the age of 25 met ALICE criteria in 2018.
Native American/Alaska Native (60%), Native Hawaiian (54%), Black (52%), and Hispanic (50%)
households were more likely to meet ALICE criteria than White (36%), Asian (37%) households.

5B. Executive Summary
The research team has had the opportunity to engage with over 200 people across our island home
who care deeply about our Hawaiʻi. Social workers, teachers, farmers, doctors, policy advocates,
mothers and fathers, sons and daughters, survivors, students, and healthcare providers all asked toshare their thoughts on and for the communities where they live, the clients they serve, and thepeople they love.
With a charge of updating the 2018 Community Health Needs Assessment (CHNA) and adding
the lens of the pandemic effects on the social determinants of health, the 2021 CHNA researchteam sought out a wide range of perspectives to understand the unique and Significant Health
Needs facing Hawaiʻi’s communities.
Strategies to collect input included: 82 key informant interviews, 18 community meetings, threeexpert panel webinars, four small focus groups, a literature review of CHNA reports from various
U.S. markets, and a review of publicly available secondary data. The importance of a sharedkuleana - responsibility - of healthcare working together with community and government toaddress social determinants of health was an important theme throughout the process. A library ofcommunity-based organizations and programs working to address social determinants of health
was updated from 2018 and is included as Appendix A.
With the endorsement that the Statewide Priorities from 2018 were all still relevant and should
remain as Significant Health Needs, several of the social determinants were consistently identified
by key informants, experts at the University of Hawaiʻi Thompson School of Social Work & Public
Health, and community groups as being even more critical in 2021, due in large part to thepandemic experience. These Significant Health Needs were in existence before the pandemic, with
the COVID-19 experience exposing the urgency of addressing these basic needs. While the social
determinants of health, by their very nature, are interdependent and must be viewed holistically,
the “once in 100 years” COVID-19 physical and societal impacts require focused efforts. The
Significant Health Needs that have been identified as a 2021 priority are:6

Each of these Significant Health Needs and 2021 Priorities is described in great detail in the pagesof this report, with discussions of how they manifested during the pandemic, how communities
strived to deal with them, and recommended Best Practices derived from that learning. These Best
Practices are identified as opportunities for hospitals to be part of addressing the 2021 Priorities.
In addition to the Best Practices, this report includes Possible Strategies for consideration byhospitals wishing to identify actionable steps in addressing the 2021 Priorities, as well as Policy
Opportunities. The research team recognizes that many hospitals are already individuallydeploying some of these strategies, advocating for these policy changes, and/or participating incommunity initiatives for collective action. Indeed, all are integral parts of the communities inwhich they operate; and, by virtue of this involvement, work for the betterment of theircommunities. Voices heard throughout this assessment believe that greater collaboration will resultin greater impact, and they are hopeful that some of these strategies and opportunities will lendthemselves to that spirit of collaboration. (Please see Sections III-B and III-C, Addressing HealthPriorities.)7

Several themes emerged across discussions of the 2021 Priorities and Significant Health Needs
and warrant highlighting here. All have important implications for future planning:● The rapid adoption of telehealth was one of the silver linings of COVID-19.
● The need for resilience and building resilient citizens is one of the lessons of COVID-19.
● An important investment needed now is in community health workers; trained people ofthe community, working in their same community.
● To better prepare for future public health crises, hospitals must get out into communities
and build relationships. This is key to building trust in healthcare and assuring equitable
access.
● For policy change, advocates and organizers around upstream determinants need for thestrong voice of Hawaiʻi’s hospitals to be heard.

C. Background and Scope
In 2010, the Patient Protection and Affordable Care Act of 2010 (referred to as “ACA” or“Obamacare”)1 amended the Internal Revenue Code (IRC) by adding a requirement that taxexempt hospitals complete a Community Health Needs Assessment (CHNA) at least once every
three years for each of its facilities. 2021 marks the fourth CHNA that the Health care Associationof Hawaiʻi (“HAH”) has conducted on behalf of its member hospitals with prior CHNA’s
conducted in 2013, 2015, and 2018.
The requirement to conduct a CHNA is intended to ensure that hospitals receiving tax benefits arein turn providing benefits to the communities they serve. The CHNA seeks to ensure
understanding of the Significant Health Needs facing a hospital’s community, which is paired with
an implementation strategy following that CNHA that identifies how the hospital intends toaddress Significant Health Needs.2
In 2018, the CHNA research and drafting was led by Islander Institute, “a local, civic enterpriseworking to bring about positive social, economic, and political change in Hawaiʻi by partneringwith individuals, communities, organizations, and networks committed to island values,”
together with their subcontractor Hawaiʻi Public Health Institute (HIPHI).

Internal Revenue Service. “Community Health Needs Assessments for Charitable Hospital
Organizations - Section 501(r)(3),” available athttps://www.irs.gov/charities-non-profits/community-health-needs-assessment-for-charitable-hospitalorg anizations-section-501r3 (referred to as “IRS Section 501(r)(3) Overview”).
2
IRS Section 501(r)(3) Overview.
1

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The 2018 process critically re-centered the work of the CHNA around community-driven
definitions of “health” based upon the HAH stated commitment to “engaging in deep andtransformative relationships with local communities to address the social determinants of healthand increase access to high quality of care.”3 Understanding criticism of CHNA processes acrossthe country that lacked a connection to community voices and understanding social determinantsof health, Islander Institute laid the foundation that the “CHNA is meant to be a substantial step
forward in addressing the root causes of health. It is a resource to be shared with all of Hawaiʻifor the creation of new strategies and partnerships.” 4
It is with that foundation that HAH sought a research partner to update the 2018 CHNA for 2021.
Ward Research built a team to engage meaningfully with community members, organizations,organizers, leaders, and those involved in both direct healthcare and in addressing upstream social
determinants that significantly impact health outcomes. The Ward Team intends that this 2021
CHNA be read as building upon and updating, not replacing or reimagining, the important work
done in 2018.

“How do we build systems that build upon trust,community relevance, cultural relevance- to do that successfully in people’s vulnerable spaces and times, in a
way that is trustworthy and delivering the right information, at theright time, in the right way.”
Social Work Educator342018 CHNA, HAH, page 9.
2018 CHNA, HAH, page 10.

9The CHNA should… 5…lift up and listen tocommunity voice;engage with andlearn from community

26 CFR Part 1§1.501(r)-3(b)(6)(i)(C) - the CHNA…must include…A description of
how the hospital facility solicited and took into account input received
from persons who represent the broad interests of the community it
serves§1.501(r)-3(b)(1)(iii) - In assessing the health needs of the community, solicit
and take into account input received from persons who represent the broadinterests of that community, including those with special knowledge of orexpertise in public health§1.501(r)-3(b)(5)(ii) - …a hospital facility may solicit and take into account
input received from a broad range of persons located in or serving its
community…aim tounderstand people
with the greatest
needs§1.501(r)-3(b)(3) - In defining the community it serves… a hospital facility
may not define its community to exclude medically underserved, lowincome, or minority populations who live in the geographic areas fromwhich the hospital facility draws its patients§1.501(r)-3(b)(5)(i)(B) - …a hospital facility must solicit and take into
account input received from…Members of medically underserved,
low-income, and minority populations in the community served by thehospital facility, or individuals or organizations serving or representing theinterests of such populations

5…refocus on
upstream causes ofhealth

§1.501(r)-3(b)(4) - For these purposes, the health needs of acommunity…may include, for example, the need to address financial andother barriers to accessing care, to prevent illness, to ensure adequate
nutrition, or to address social, behavioral, and environmental factors that
influence health in the community…foster dialogue andhelp
hospitals forge
partnerships andtake action§1.501(r)-3(b)(1)(v) - Make the CHNA report widely available tothe public§1.501(r)-3(b)(4) - To assess the health needs of the community…ahospital facility must…identify resources (such as organizations, facilities,
and programs in the community, including those of the hospital facility)
potentially available to address those health needs

Table from 2018 CHNA with information adapted from IRS, Additional Requirements for Charitable Hospitals.

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D. Partners
Healthcare Association of Hawaiʻi (HAH)
HAH has been the leading voice of healthcare in Hawaii since 1939. Its 170 member organizations
encompass acute care hospitals, skilled nursing facilities, assisted living facilities, Type II adultresidential care homes, Medicare-certified home health agencies, and hospices. Additional
members include home infusion/pharmacies, case management firms, air and ground ambulance
providers, the Blood Bank of Hawaii, dialysis providers, and more. In a time of unprecedentedchange in healthcare, HAH is committed to working with providers across the continuum of care
toward a healthcare system that offers the best possible quality of care to the people of Hawaiʻi.
University of Hawaiʻi Thompson School of Social Work & Public Health
From the start, it was clear that the CHNA process would benefit from the involvement of the
University of Hawaiʻi (UH). The UH Thompson School of Social Work & Public Health’s vision
is “achieving social justice and health equity for the people of Hawaiʻi and citizens in a changing
world.” They hosted panel discussions around the emerging priorities with faculty topic area
experts and have followed the work on the CHNA with great interest and hopes of futurecollaboration.
Ward Research
Ward Research is a Hawaiʻi-based market research firm specializing in both qualitative andquantitative research, with a wide range of public and private sector partners. Ward Research has
worked with Hawaiʻi’s healthcare systems for decades in supporting public health policy,
understanding client experiences, evaluating existing programs in meeting client needs andfocusing on health and human service needs.
Solutions Pacific
Solutions Pacific is a community-based planning company working to support the collaborationof community, industry, and government. Its Team seeks to develop meaningful relationships
between organizations serving communities needs and Hawaiʻi’s communities with a particularfocus on Native Hawaiian and other traditionally vulnerable and under-served communities,
including Pacific Islander, immigrant communities, and those experiencing houselessess.

“Partnering with outside resources builds community trust, communicates to hospitals what
the community needs are, strengthens the supports that exist outside of the hospital,and develops relationships with outside resources so that patients can access them sooner
and seamlessly.”
Hospital Social Worker

11E. Methodology
26 CFR §1.501(r)(3) requires that the CHNA process ensures that perspectives from “medicallyunderserved, low-income, and minority populations in the community served by the hospital
facility, or individuals or organizations serving or representing the interests of such populations”
are meaningfully incorporated into the final assessment and implementation plans. The following
were identified as critical sub-populations to engage, often representing underserved populations,to ensure voices from a wide range of community perspectives:
Ethnic Communities●●●

Native Hawaiian
Pacific Islanders(especially
COFA)
Filipino

Geographic Regions●●●

Rural Oʻahu
Kauaʻi, Maui Nui, andHawaiʻi Island
Homestead communities

Vulnerable Populations
●
●
●
●
●
●

Homeless households
Developmentally disabled
persons
ALICE families
Kūpuna6
Persons with mental healthneeds
Domestic violence survivors

The Ward Team had prepared itself for potential participant fatigue given strong participation in2018 and significant demands on time and resources due to COVID-19. However, community
organizers and participants seemed eager to offer their perspectives, often honed through a lens
impacted by COVID-19. Input was gathered through a range of methods, including community
meetings, key informant interviews, and small groups.
Community Meetings
Organizations throughout the state, called "community connectors," helped to reach individuals
from key communities for group talk story sessions. These organizations were invaluable partners,
each trusted and recognized within their target communities, and willing both to provide input
from their own work as well as create space and encourage their clients, partners, staff, andstakeholders to participate. Each meeting focused on both a geographic region and either an ethnic
community or a vulnerable population.
COVID-19 presented unique challenges in engaging with Hawaiʻi’s difficult to reach communities
while remaining safe. Most organizations continued to have virtual gatherings or one-to-one
services in lieu of gatherings spaces, making it difficult to bring out voices typically not heard.
However, community groups were eager to provide an opportunity to share their experiences andlift up the voices of their clients and the communities they serve.
The Ward Team was able to join existing meetings of organizations both in person and virtually,gather in smaller groups, and host virtual events that provided resources to community
organizations to help them with computer access and training. When appropriate and safe,
6

Kupuna is the Hawaiian word for a “senior”, with kūpuna as the plural form.

12community meetings were conducted in the spaces where members of that community areaccustomed to gathering, and refreshments were provided to encourage a relaxed environment.
Whether virtually or in person, meetings were generally approximately 90 minutes and included
anywhere from 3 to 20 participants. Participants were primarily members of focus subpopulations
or social workers and other community service providers doing frontline work with thosecommunities. Facilitators from different islands would lead the group in an organic discussion
beginning with the 2018 priorities and discussing top priorities that were similar to or different
from today, understanding the impact of COVID-19, and teasing out opportunities for Hawaiʻi
hospitals to be a partner in addressing the community health needs identified both at theoperational as well as the systemic level.
The Ward Team sought out a diversity of perspectives, including: geographic through having atleast one meeting on each island; a mixture of those that participated in 2018 and those that did
not; multiple different ethnic communities; and various vulnerable populations with unique healthneeds. Community meetings were conducted in various locations, from agricultural plots in Kunia,Oʻahu to youth residential facilities in Kailua, Oʻahu, and nonprofit offices in Līhuʻe, Kauaʻi.
Every effort was made to ensure that Limited-English Proficient (LEP) and otherly-abledindividuals were supported through interpretation, culturally appropriate facilitation, and graphic
representations of the 2018 priorities. Participants were assured that their comments would beanonymous and their identity not included. In situations with especially vulnerable populations
such as foreign-born folks or survivors of intimate partner violence, facilitators refrained fromrecording the meetings if the participants were uncomfortable.
Participants generally took some time to become comfortable, opening up as others sharedexperiences with the healthcare system.7 On many occasions, participants became emotional andexpressed distress or anger over how they and their ‘ohana were treated. This honesty seemedindicative of feeling safe and encouraged others to similarly share passionate perspectives.
Discussions frequently included exploration of systemic racism, language bias, and discrimination
based on substance abuse or sheltered status.
Each in their own ways, community meetings began with an opening of space and recognition of
the place hosting the discussion. Discussion of the 2018 priorities helped to orient the discussion.
The three subsections of Foundation, Community, and Healthcare provided a framework forunderstanding the various upstream determinants and downstream impacts.
“Foundational” elements are the furthest upstream determinants of health. Starting there allowed
for a broader snapshot of the lived experiences of the participants. Housing and financial security
were resounding themes among nearly every group. “Community” generally revealed

Generally, this report refers to the “healthcare system” as the collective organizations and people, whose primary
intent is to promote, restore or maintain health, typically through a more clinical setting such as hospitals and healthcenters. The “healthcare continuum” is used to reference the broader collective of organizations and people, who are
involved in impacting the health of a person or community through a continuum of care, such as social work, skilled
nursing, in-home care, non-clinical healthcare, and impacting upstream social determinants of health.
7

13uniquenesses of different regional experiences. Response to sense of place, for example, wassignificantly different on the island of Hawaiʻi versus in urban Honolulu.
“Healthcare” generally focused on the importance of trust in the healthcare system andaccessibility of care. Most participants were comfortable enough to express both frustrations aswell as positive experiences. To ensure all were heard, facilitators tried to conclude discussions
by asking each participant: 1. What is the biggest obstacle to being healthy for you or yourcommunity?, and 2. If you could give one piece of advice to hospital administrators about serving
your community, what would it be? The substantive suggestions from the community offered
recommendations for how to develop trust, which was widely recognized as a key component in
the ability for hospitals to meaningfully address the Significant Health Needs identified.
Key Informant Interviews
The Ward Team conducted 80 key informant interviews with individuals in key stakeholder
positions able to provide input and insight on behalf of a target population. These tended to beorganizational leaders serving stakeholder communities versus members of those actual
populations that joined community meetings. Interviews were typically one on one between aninterviewer and a key informant, lasting anywhere from 45 to 90 minutes.
Interviews included representation from a wide variety of stakeholder groups, including; all of thesponsoring Hawaiʻi hospitals, Federally Qualified Health Centers (FQHCs), Native Hawaiian
health centers, community clinics, community-based organizations doing health-related work,community-based organizations working in the areas of upstream determinants, community-basedorganizations specializing in working with particular subpopulations, recognized community
leaders in hard to reach communities, and many that were referred as critical experts or community
leaders throughout the CNHA process.
Discussions began with a review of the 2018 Statewide Priorities to assess current relevance,
identifying where notable progress had been made, or ground had been lost, and asking if anything
was found to be missing from the Priorities. The next set of questions addressed the influence of
the COVID-19 pandemic on those priorities, asked participants to think about any fracture points
in the system which had been illuminated by the pandemic, and sought to identify the short- andlong-term impacts anticipated. Lastly, the perceived role of hospitals in addressing these healthneeds was discussed, with a particular interest in exploring aspects of building trust in thehealthcare system and identifying actionable steps hospitals might take.
Key informant interviews were critical in capturing both the systemic as well as specific needs
and opportunities for implementing best practices. Often interviewees were the key to unlocking
critical dialogue with other parts of their communities of need. In many cases, the key informants
participated in 2018 and offered valuable continuity perspectives. In all instances, informants
offered generous input and unique viewpoints from direct and critical experiences. Appendix E
includes the list of 2021 key informants, as well as the discussion outline used in the interviews.

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UH PartnershipAs the community health needs assessment process began, three key areas started to emerge asthemes for a greater level of need and priority: housing, food security, and mental health needs.
The Ward Team put together a series of opportunities to engage at different levels around each
topic, entitled “Impacts of COVID-19 on the Social Determinants of Health”. (See Appendix F
for a listing of the panel members and topics covered.) The Ward Team partnered with the
University of Hawaiʻi, Thompson School of Social Work & Public Health, to host three separate
panel presentations featuring faculty topic area experts. Co-moderated by Interim Dean Tetine
Sentell, Ph.D., and a member of Team Ward and attended by interested members of the Steering
Committee and the Community Advisory Committee (CAC), the discussions elicited richsystemwide input around these three priorities.
Held virtually on Zoom, attendees were encouraged to send questions in advance and/or put
questions into the chat. The sessions began with a brief synopsis of CHNA learning to date on the
topic area, introductions and brief presentations by each of the panelists, and subsequentdiscussion and Q&A. Dialogue around intersectionality explored how each priority integrates andworks together for positive and negative health outcomes.
Small Groups
The Ward Team also held a series of private small group meetings with key leaders in three ofthese areas (food security, mental health, and housing). (Note that two of these necessitatedadditional one-on-one interviews, rather than small groups, given scheduling difficulties and thedesire to speak with key individuals). These interviews followed the completion of most of the
key informant interviews and community meetings and benefitted from that learning to date. The
focus of discussion was around identifying COVID-19 adaptation strategies that worked and howthat learning can be carried forward and built upon. Much of this discussion has augmented theBest Practice strategies highlighted in this report.
Secondary Data Compilation
Given the crucial secondary data collected in the 2018 CHNA, the Ward Team committed to
updating that data to create trend information for this and future CHNA efforts. The secondary
data included in the body of this report represents information relative to the four priority areas.
Data related to the continuing Significant Health Needs are provided in a separate addendum tothe report. It is important to note that while the data were updated, much of the “new” information
is from 2019 or earlier, i.e., pre-pandemic, given the reporting lag. That data has been included,
but caution is advised, as 2020 data forward may provide a different picture.
Literature Review
A literature review was conducted as part of the CHNA, reviewing four reports from other U.S.
markets, as identified in the RFP and recommended by members of the Steering Committee. The
review concentrated on best practices, particularly related to the prioritization process, and wasshared with the Committee early in the assessment. This review resulted in the development ofHoʻolōkahi, the iterative process used by Team Ward, the Steering Committee, and theCommunity Advisory Committee.

15

Steering Committee
In 2018, the Steering Committee included hospital representatives, government agencies, andcommunity members. In 2021, the process included a Steering Committee (composed ofrepresentatives from the hospitals) and a Community Advisory Committee (of other key
stakeholders). Most Steering Committee members participated in key informant interviews toprovide their perspectives on the current priorities and COVID-19 and its impacts. Members were
extremely supportive in identifying community-based partners and organizations to reach out toand engage with to encourage participation. Through monthly meetings, members provided
insight and feedback on the assessment progress, especially attentive to ensuring a wide range ofperspectives was being included and community member voices from traditionally
underrepresented populations were heard. Members are included in Appendix C.
Community Advisory Committee (CAC)
In 2021, the Community Advisory Committee (CAC) was composed of community leaders
serving various target communities. CAC members were especially generous with their time,
input, and expertise throughout the process. In addition to being key informants, they also
participated in meetings during the last phase of the assessment and report and helped to makecritical connections where there were gaps, ensure that things were ground-truthed with what theysaw in their communities, and provided input as to how the priorities could be helpful both within
the clinical and community-based contexts.
Finally, the CAC helped develop the final priorities and ensure that the Significant Health Needs,
2021 priorities, and COVID-19 all work together to paint the current picture of the community
health needs. The rich input of this assessment, and the recommendation for future partnership
opportunities, owe much to the invaluable input and support of the CAC members. Members areincluded in Appendix D.

“The opportunity that is ahead of us is to take what community has been doing, what
the healthcare systems have been doing,
and how we have both responded and have had to partner to respond to COVID.
Community health workers are where we can use their expertise and our connectedness tocommunity as the way that we move forward together.”
CAC Member

16Prioritization Process
In response to inquiries from a few members of the Steering Committee, the Ward Teamdeveloped a prioritization process influenced by a traditional Delphi Method structured for
Hawaiʻi and HAH. The central premise is a structured and iterative communication technique tointegrate the input of experts towards a consensus.
The process that emerged was Hoʻolōkahi, “to bring into unison”. With the 2018 priorities as abasis, the Ward Team synthesized input from all sources and proposed prioritization options for
feedback to the Steering Committee and CAC. The Ward Team guided this process by presenting
progressive prioritizations for feedback, integrated input, refined the prioritization, and presented
it again for feedback until agreed upon.

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2021 Community Health Needs Assessment
Page 1II.

Statewide Assessment
A. COVID-19 Impacts

In early 2020, the world became aware of a highly contagious and rapidly spreading acute diseasecaused by the novel coronavirus SARS-CoV2 (COVID-19), with various short- and long-term
symptoms ranging from asymptomatic to death.8 By March 2020, the State of Hawaiʻi joined therest of the United States in declaring an emergency due to the COVID-19 pandemic. Throughout
the next 22-months and ongoing as of the writing of this report, the pandemic has touched nearly
every single part of life in Hawaiʻi.
Hawaiʻi health care systems have faced significant and ongoing strain, requiring HAH to request
the support of hundreds of U.S. Federal Emergency Management Agency (FEMA) nurses
throughout 2021 and causing one hospital to declare an emergency in August 2021. Non-emergent
operations were canceled and postponed. Guests were strictly limited, even at the end of life.
Emergency response capacity building measures were implemented including field clinics and onsite tent operations.
For almost a year, before COVID-19 vaccinations were made available to the greater generalpublic, progressively restrictive limitations were placed at both the state and local levels tomanage viral spread through person-to-person interactions and mitigate the devastating impactsof the virus, which had disproportionately negatively impacts on Native Hawaiians, PacificIslander, seniors, and vulnerable populations with underlying health conditions. Ongoing healthcare needs transitioned nearly completely virtual where possible, as did much of life. However,many routine screenings and health maintenance visits were missed; ramifications that may not
be fully appreciated for years to come.
Many businesses closed, travel in and out of the state was constricted for periods, unemployment
rose to over 20%, schools were closed, and the federal government passed significant resources tohelp pay for the immediate health, community, and economic impacts on communities across theUnited States. Despite the significant impacts, the health-driven approach is largely believed tohave saved hundreds if not thousands of lives, with just over 1,000 Hawaiʻi residents having losttheir lives due to COVID-19 as of the writing of this report. States that took less precautionary
measures saw death per 100,000 people at nearly ten times the rate of Hawaiʻi.9
The impact that COVID-19 has had and continues to have will take years to be fully understoodand measured. Most of the Significant Health Needs identified in 2018 were discussed as having
been exacerbated and exposed by COVID-19. In some cases, such as financial insecurity andmental health, COVID-19 introduced new and consequential stressors. Pre-existing inequities
8

World Health Organization.
Becker’s Hospital Review, describing the New York Times “Latest Map and Case Count” as of January 6, 2022.
See: https://www.beckershospitalreview.com/public-health/us-coronavirus-deaths-by-state-july-1.html.
918

were exposed and put marginalized communities further at risk.10 Many participants caution thatthese needs preexisted the COVID-19 pandemic. In many instances, participants described
COVID-19 as shining a light on pre-existing fractures in our community foundations. Indeed,blaming COVID-19 for many of these chronic needs facing Hawaiʻi's communities would be amisunderstanding of those impacts.
Many community participants even identified silver linings. This devastating event has allowed
Hawaiʻi to take a closer look at these needs that were long ignored, overlooked, or not profoundly
understood before COVID-19. The last 20 months have forced all sectors and segments of life tosee plainly many of the fracture points. The calls to reject a "return to normal" have been
deafening. Community-based organizations have put forward visions forwhat Hawai’i can transform to as a post-pandemic world becomes a reality.
Although we have yet to see what will manifest, there have been significant “opportunity seeds”
sown into the soil if only we water and nurture them. Needed resources coming in from the federal
government have allowed the funding of long-overdue pilots and community-bas concepts. While
it is unsure in the long run how these programs will be supported after the federal funding is
exhausted, it has provided a unique opportunity to try the programs and determine what does anddoes not work.
Meaningful advancements have been made in digital and virtual engagement. Though this reportwill discuss some of that impact on those communities left behind, this event has forced systems
to propel forward in ways that they have been trudging along for decades, with information
technology professionals slowly pulling out their hair, hoping the rest of us will catch on. Perhaps
the most exciting are the partnerships that have been born between community systems, acrosssectors, between government agencies, and interconnecting siloed efforts that have the potential
to carry the future forward.
Throughout this report, COVID-19 impacts are uniquely discussed through each of the Significant
Health Needs and 2021 priorities will be discussed in the relevant sections.

“What we know is that most of those risks are rooted in social determinants of health. And I
love that very broadly, early on, we look at - how do we engage as a community to takeresponsibility for building stronger and more resilient communities that support individuals, sothey do not end up experiencing the worst of the possible outcomes.”
Social Work Educator

For further exploration of how COVID-19 layered with pre-existing health inequities, see “COVID-19 In Hawaiʻi:
Addressing Health Equity in Diverse Populations” (March 2021), published by the Department of Health inpartnership with the Native Hawaiian and Pacific Islander Hawaiʻi COVID-19 Response Recovery Resiliency Teamand the University of Hawaiʻi published, available at:https://hawaiicovid19.com/wp-content/uploads/2021/03/COVID-19-Race-Ethnicity-Equity-Report1019

B. 2021 Priorities
The IRS explains that to “assess the health needs of its community, a hospital facility must identify
the Significant Health Needs of the community. It must also prioritize those health needs, as wellas identify resources potentially available to address them.” 11 Hospital facilities may decide
whether a health need is significant by evaluating any of the information gathered or known about
its community.
In 2018, the CHNA process identified 11 Priorities across 3 Goals. Each priority continued tomaintain importance in 2021, and they are now called “Significant Health Needs.” From those
Significant Health Needs, the 2021 CHNA identified 5 Priorities. Aside from some changes inwording, the Significant Health Needs remain the same. Given the prioritization framework, thestructure by goal was not maintained. The graphic below cross-walks the changes from 2018
Priorities (left in orange) to 2021 Priorities and Significant Health Needs (right in blue).

11

IRS Community Health Needs Assessment for Charitable Hospital Organizations - Section 501(r)(3).

20

Roots - Significant Health Needs. Across all input methods, there was a resounding message thatthe 2018 priorities continued to be “Significant Health Needs” requiring attention. In someinstances, participants reflected that progress had been made since 2018 but reiterated that more
was needed to be done before it could be indicated as addressed.
Stream - 2021 Priorities. These five needs were elevated as the 2021 Priorities. They are pervasiveneeds that, when unaddressed, are barriers to healthy communities and, as water, demonstrate
fundamental values interconnecting communities and healthcare systems and nourishing thepositive outcomes. Wai in Hawaiian means water, waiwai means wealth, illustrating full andhealthful communities when they have the water they need to thrive.
Branches - Strategy Concepts. Potential strategies for hospitals and communities to partner inconnecting upstream social determinants of health to positive outcomes.
Leaves - Positive Health Outcomes. Comprise the positive health outcomes that can be achieved
within communities as the Significant Health Needs and 2021 Priorities are addressed and help tostrengthen the resilience of Hawaiʻi’s communities.

21

With the endorsement that the Statewide Priorities from 2018 were all still relevant and should
remain as Significant Health Needs, several of the social determinants were consistently identified
by key informants, experts at the UH Thompson School of Social Work & Public Health, andcommunity groups as being even more important in 2021, due in large part to the pandemic
experience. These Significant Health Needs were in existence prior to the pandemic, with the
COVID-19 experience highlighting the need to address these needs with greater urgency. While
the social determinants of health, by their very nature, are interdependent and must be viewed
holistically, the “once in 100 years” COVID-19 physical and societal impacts require focused
efforts. The Significant Health Needs elevated to 2021 Priorities include:

The increase in calls to Aloha United Way’s 211 referral service corroborates several of the needs
highlighted above, as the graph below illustrates. Calls to 211 related to housing increased almost
150% in 2020 over 2019, with dramatic increases in those related to healthcare, food, utilities, andfinancial assistance noted, as well.
2019 vs 2020 Comparison of Total Monthly Calls Processed by AUW 211

Hawaii Data Collaborative
https://www.hawaiidata.org/news/2021/3/3/partnering-to-build-robust-211-data-resource

22

Similarly, calls to Hawaiʻi CARES, the crisis hotline staffed by trained counselors, fielded 46,598
more calls in 2020 than in 2019. The volume of calls fell off in 2021 but still far exceeds 2019
levels.

23

All Hawaiʻi CARES Calls
85,327

92,258138,856

29,908

2018

2019

2020

2021

The sections that follow discuss each of these elevated priority areas in greater detail, providing
relevant secondary data to help build out the picture of each, valuable insights from community
leaders, lived experiences of community members, best practices of healthcare programs thatmight prove a template for others, and the direct words of many of those that participated in thisprocess. This report seeks to identify the priorities, understand and contextualize them, andidentify potential strategies to address them.
Truly understanding these priorities will require direct investigation through continued andexpanded outreach to community partners and often underrepresented communities. Addressing
them meaningfully will require working hand in hand with the leaders of each of these uniquecommunities and ongoing investment into the necessary competencies.
Community leaders throughout this assessment encouraged a greater level of self-efficacy thanperhaps is typically acknowledged collectively. A self-efficacy that knows that we do have thetools, the knowledge, and the passion to take on these critical priorities with our community
partners beyond healthcare. Acknowledging the intersectionality of many of the Significant Health
Needs may provide a pathway towards stronger resiliency by understanding that social
determinants of health can be impacted by the resources and talent of those already here in ourcommunity, both within healthcare and beyond.

“There are long term impacts for ﬁnancial insecurity. Folks who are struggling to keep housing
over their heads, or still not returning to work, that income insecurity has
stretched out longer than we imagined.
Many parents have lost their jobs. So their children didn’t go to college. When we look at our
graduating class of 2020 and 2021, the decision-making for their parents and for themselveson whether they pursued a career, college, or post-secondary education, will impact thewealth of that family generationally.”
Community Foundation Leader

24

FINANCIAL SECURITY
The Secondary Data Story
Note: Much of the data available at the time of report preparation is pre-pandemic.
Experts in the field all agree that, when data are available, the picture will be evenmore critical.
Financial Hardship
While many of Hawaiʻi’s households have been severely impacted by the 2020 COVID-19
pandemic, understanding the economic environment before the pandemic paints a picture of aslowly recovering state, but one still in financially dire straits. Hawaiʻi’s financially struggling
families found it difficult to afford basic needs such as housing, food, childcare, healthcare,transportation, taxes, and, as seen from the pandemic, technology. The high cost of living in
Hawaiʻi outweighs their salary, which often leads to being forced to make difficult choices fortheir ʻohana. The struggle of local families to survive on low-income, job instability, and limitedaccess to build any financial cushion has caused many to fall into the ALICE category. Although
only one indicator, financial stability is interconnected with community health through access andother barriers.
ALICE is defined as Asset Limited, Income Constrained, Employed households that earn morethan the Federal Poverty Level (FPL) but less than the basic cost of living for the county (theALICE Threshold). ALICE workers are an essential part of our society, from teacher assistants tohealth aides to hairstylists to sales clerks. These are residents who are employed but do not earnenough to provide basic needs for their families.
When you factor in ALICE with the poverty level, Hawaiʻi was reported to have 148,771 ALICE
households (33%) and nearly 9% (more than 41,619 people) living in poverty in 2018. Hawai‘iCounty (48%) continued to lead other counties in the proportion of ALICE households and thoseliving below the federal poverty level. Estimates for 2020 are that ALICE households comprised
59% of Hawaii’s households post-shutdown, a shocking 17-point increase.

“I worry that we are hearing a lot about ‘budgeting’ for families. The reality is that the mathdoesn't work out for basic budgeting right now. It is a community responsibility, not an
individual responsibility.”
Youth Policy Advocate

25Source:https://www.hawaiidata.org/news/2020/6/19/fifty-nine-percent-of-hawaii-households-estimated-to-experience-significantfinanci al-hardship-by-the-end-of-2020

2013-17USHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

14.6%

10.3%

17.4%

10.0%

9.1%

9.1%

13.4%

9.4%

15.6%

9.3%

8.3%

8.1%

POVERTY

2015-19

Percentage of people living below the federal poverty level (FPL).
(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates,2017 (Data: 2015-19). Source: U.S. Census, American Community Survey 5-year
estimates, 2019

2013
2014

INSUFFICIENT
LIQUID ASSETS

36.8%

N/A

37.0%

33.5%

30.7%

30.5%

36.9%

N/A

36.6%

32.9%

30.4%

29.3%

Percentage of households without sufficient liquid assets to subsist at the poverty level for three months in the absenceof income.
(Data: 2013). Source: Prosperity Now Estimates Using Survey of Income and Program Participation and American
Community Survey, 2018
(Data: 2014). Source: https://scorecard.prosperitynow.org/data-by-issue#finance/localoutcome/liquid-asset-poverty-rate

2015
2018

ALICE +
POVERTY

N/A

48%

55%

51%

46%

43%

N/A

42%

48%

42%

40%

44%

Percentage of households Asset Limited, Income Constrained, and Employed with incomes above FPL but not high enoughto afford a basic household budget + the %age of households below FPL = households struggling to afford basic necessities.
(Data: 2015). Source: United Way, ALICE: A Study Of Financial Hardship in Hawaiʻi, 2017
(Data: 2018). Source: Alice Threshold, 2007-2018.American Community Survey, 20072018 https://www.unitedforalice.org/state-overview/Hawaii

26

2013-17
2015-19

CASH PUBLICASSISTANCEUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

2.6%

3.4%

4.4%

3.1%

3.3%

3.1%

2.4%

2.9%

3.9%

2.4%

2.9%

1.9%

Percentage of households receiving general assistance and/or Temporary Assistance to Needy Families (TANF).
(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017
Data: 2015-19). Source: Hawaii Health Matters, U.S. Census, American Community Survey 5-year estimates, 2021

Unemployment
The state’s unemployment rate remains high at 6.4%, compared to 4.6% nationally. In May 2020,
the state’s unemployment rate jumped to a peak of 21.9%. State mandates to curb the pandemic
forced many local businesses to limit social interaction between the staff and business patrons.
Businesses were faced with implementing social distancing measures by changing and scaling
back operations, reducing business hours, and reducing staff.

2019
2020
2021

UNEMPLOY- MENTUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

3.3%

2.8%

3.5%

2.7%

2.6%

2.8%

7.7%

15.2%

13.5%

23.2%

13.6%

20.2%

4.6%

6.4%

6.3%

8.1%

5.9%

8.4%

Civilians, 16 years of age and over, who are unemployed as a percent of the civilian labor force.
(Data: 2019). Source: Hawaiʻi Health Matters, US Bureau of Labor Statistics, 2019
(Data: 2020). Source: Hawaiʻi Health Matters, US Bureau of Labor Statistics, 2020
(Data: 2021). Source: Hawaiʻi Health Matters, US Bureau of Labor Statistics, 2021

“People just can’t aﬀord to live here.”Foundation Executive

Community voices shared the tremendous exacerbation of the financial strains upon all families,
but especially those already struggling before the pandemic. Significant financial resources havepoured into the state to deal with immediate impacts; however, community organizers expressed
concerns over how their communities would fare as those state and county emergency relief
programs draw to a close and families are left in a financial position that was already worsening
before the pandemic and has been since compounded.
27

One of the areas of relief was Unemployment
Insurance (UI), which provided some relief to over
564,972 residents from March 18, 2020, to January 7,
202212. However, the system was not prepared tohandle the tremendous volume, and residents reported
waiting months for benefits, spending hours every dayon the phone trying to get through to provide
information to staff. A number of organizers talked
about the stress this added to the stressors already onfamilies. There were some residents unable to receive
benefits at all.
Immigrant and COFA13 migrant communities
repeatedly discussed barriers to accessing UI, withmany families never receiving financial assistance.
Members of these communities were often filling
essential worker jobs or had to take such positions
because they were unable to access UI, and thus theyand their families were further exposed to the spread of
COVID-19. COFA communities across the state came
together to support their families with food, quarantine
housing, support in navigating programs, and all
aspects of critical support systems. However,often, this work was done as volunteers with limited resources. The few paid positions were parttime or on-call and tended to focus on translation services alone rather than care coordination andhelping to support community members to navigate processes. Those without access to family
members or community leaders to assist them were often left behind.

“One of the reasons we formed the task force is that we would be left behind if we didn’t.
COVID exposed the health disparities. And we stood up to do something about it.”
COFA Community Leader

State of Hawaiʻi, Unemployment Weekly Updates, available at:
http://dbedt.hawaii.gov/economic/unemployment-2021-ui_state_2022/.
13
COFA refers to the Compact of Free Association between the United States and these countries. COFA
communities includes those from the Federated States of Micronesia, the Republic of the Marshall Islands, and theRepublic of Palau.
12

28

29

FOOD SECURITY
Recent natural disasters have shown just how vulnerable we are as a state, especially in rural areasand islands with varying periodic barge deliveries. It is estimated that 85-90% of Hawaiʻi’s foodis imported14, proving the necessity to be more sustainable in order to face future threats. Thispriority seeks to understand and address both hunger and related food insecurity as well as foodsystems and pathways that can be strengthened for greater economic, ecological, and sustainable
resiliency.
The Secondary Data Story
Note: Much of the data available at the time of report preparation is
pre-pandemic. Experts in the field all agree that, when data are available, thepicture will be even more critical.
Access to Food
Despite federal stimulus payments and programs to assist in rent and food, residents still faceddifficulty in providing basic needs. According to Feeding America data from 2019, 162,220
residents face hunger, with 54,700 of them children. In 2019, prior to the pandemic, 11.5% of
Hawaiʻi households were food insecure, meaning there was difficulty in providing good, healthy
food to their ohana because of a lack of money. 13.1% of Hawaiʻi County households were foodinsecure, as compared to 9.8 percent in Kauaʻi County.
Data from the Accountable Health Communities Hawaiʻi Project shows food sitting atop the listof needs reported by individuals screened across practice sites at five Oʻahu facilities: The Queen’s
Medical Center - Punchbowl and Queen’s Medical Center - West Oʻahu, Kalihi-Pālama HealthCenter, University Health Partners (Family Medicine Clinic), and Waiʻanae Coast Comprehensive
Health Center. Note that data spans pre-pandemic through October 2021.

“There are Medicare gaps among our Seniors, where they make a little too much income toqualify for Medicaid, so they make food versus medicine choices and don’t get the treatment
they need or use the hospital for care services.”
Government Leader, Maui Nui

Office of Planning, DBEDT, State of Hawaiʻi, “Increased Food Security and Food Self-Sufficiency Strategy”(October 2012).
1430

While the pandemic exposed policy gaps for those most affected and with the least resources, some
programs have been beneficial, such as the federally sponsored Supplemental Nutrition Assistance
Program (SNAP). The State Department of Human Services reported that Hawaiʻi had a total of
189,956 SNAP recipients in September 2021, which is down from the pandemic-era peak of
206,226 in July 2021 but higher than a pre-pandemic total of 152,252 in February 2020. 32.7% ofhouseholds receiving SNAP benefits have children.

31Prior to the pandemic, while the percentage of the statewide population that is classified as foodinsecure had fallen from 13.7% in 2014 to 11.5% in 2019, the proportion of food insecureindividuals who qualified for SNAP benefits fell correspondingly from 57.0% to 48.0%.

2014

US

HAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

N/A

13.7%

13.1%

13.1%

13.0%

12.8%

N/A

11.5%

13.1%

10.3%

10.5%

9.8%

FOOD INSECURITY
2019

Feeding America accounts for poverty, unemployment, and median income to project the number of “foodinsecure” individuals.
(Data: 2014). Source: Hawaiʻi Community Foundation, Hunger in Hawaiʻi; Feeding America, Map the Meal Gap,
2016 (Data: 2019). Source: Feeding America, Map the Meal Gap, 2020

https://map.feedingamerica.org/county/2019/overall/hawaii

2014
2019

FOOD INSECURE,% SNAP ELIGIBLE

N/A

57.0%

75.0%

65.0%

54.0%

66.0%

N/A

48.0%

65.0%

52.0%

48.0%

56.0%

Feeding America identified “food insecure” individuals who live below 200% FPL and are eligible for government
benefits. (Data: 2014). Source: Hawaiʻi Community Foundation, Hunger in Hawaiʻi; Feeding America, Map the Meal Gap,
2016 (Data: 2019). Source: Feeding America, Map the Meal Gap, 2020
https://map.feedingamerica.org/county/2019/overall/hawaii

2014
2019

FOOD INSECURE,% NOT SNAPELIGIBLE

N/A

43.0%

25.0%

35.0%

46.0%

34.0%

N/A

52.0%

35.0%

48.0%

52.0%

44.0%

Feeding America identified “food insecure” individuals who live above 200% FPL and are disqualified fromgovernment benefits.
(Data: 2014). Source: Hawaiʻi Community Foundation, Hunger in Hawaiʻi; Feeding America, Map the Meal Gap,
2016 (Data: 2019). Source: Feeding America, Map the Meal Gap, 2020
https://map.feedingamerica.org/county/2019/overall/hawaii“When our State was considering closing schools due to COVID, the conversation quickly
shifted to the kids that get their only meals from school. How would they eat?
That was a lesson in the many fracture points prior to the pandemic.”
Education Policy Organizer

32

33

Access to Healthy Food
In 2018, this was one of the 11 identified priorities, andthere was robust discussion around access to healthy,
locally grown, sustainable food. In 2021, with over a year ofsomefamilies not being able to access food at all, the importanceof both individual and household level food security andcommunitywide food security became heightened. Some
community members expressed concerns around backslidingof keiki15 nutrition and interruptions to farmers markets.
With so much of Hawaiʻi’s food supply reliant uponoverseas and inter-island transport by ocean barges and/or
container ships, the State Emergency Operations Plan notesthat the hub-and-spoke model of Hawai'i's shipping network,
the vulnerability of island ports and harbors, and theminimal logistics system for distribution of commodities has
rendered problematic the development of a large andsustainable warehousing system with sufficient capacity tomeet surges in demand and/or withstand long impacts orinterruptions. There is an estimated 5-7 days of food supply
in-state, and a disruption to the supply chain would have analmost immediate impact on the population.16 Community
participants in a number of rural areas noted that there weregrocery stores in their communities during the pandemic
that completely shut down due to supply chain issues.
These vulnerabilities are one reason that decades-long calls
for investments in greater agriculture participation to
support food security both as a normal course and especiallyin times of impact have grown. Countless articles over the
past two years have discussed opportunities for investing thethousands of agriculturally zoned lands across the paeʻāina
into agriculture, supporting local farmers, and making foodsecurity accessible on a household level through foodgardens and other neighborhood solutions. Organizations
like ʻĀina Aloha Economic Futures have put forward
visions for how to rebuild towards a circular economy withrestorative and regenerative economies with investment inlocal food security as a pillar.17

15

Keiki is the Hawaiian word for child or children
State of Hawaiʻi, Emergency Management Agency, “Emergency Operations Plan” (November 2019), available
at: https://dod.hawaii.gov/hiema/files/2020/02/Hawaii-State-EOP-Fall-2019-Published.pdf.
17
See: https://www.ainaalohafutures.com/.
16

34

Efforts like the Food Pantry, a no waste, healthy food resource using online ordering, helped toempower communities to come together. Community organizations played critical roles in helping
to mitigate food insecurity in a wide range of ways. These grassroots partnerships coordinated anddistributed local produce from local farms to families in need. While these community efforts
proved effective, a University of Hawaiʻi, College of Social Sciences study completed in March
2021, “Addressing Hunger and Food Insecurity among Hawaiʻi’s Families,” observed several
barriers that should be addressed:
●
●
●
●
●

A lack of public awareness of available services
Shame about needing to use food services
Transportation (some food distributions are drive-up only)
Difficulty receiving benefits without a stable address
Lack of a coordinated plan statewide for addressing food insecurity

Despite the challenges, food distributions provided an opportunity for many non-profit programs
to connect with their communities. Outreach was paired with wellness checks, vaccination access,checking in for intimate partner violence, assessments for in-home health services, and enrollment
in SNAP benefits for those that were eligible. The industry coordination created mesh networks
to meet broad communities while minimizing overlap. Those networks built important trust
connections that may allow an even deeper ability to reach people where they are and support theirhealth needs.
Greater opportunity exists to make families aware of resources available to them. Programs suchas “Da Bux” helps to lower the cost of healthy food for SNAP eligible households and makehealthy food more accessible. Building of gardens at affordable housing projects, where people
are living and gathering, was an investment some organizations and counties made during the
pandemic to help families to access healthy food right at their own homes - vegetables, fruit
trees, herbs - with success at multi-family properties were enough families indicated in advancethey were interested and would help care for a food garden if provided the opportunity.

“Many people have diabetes because of their unhealthy diet, where the only food that was
fresh was ﬁsh or breadfruit. Everything else was canned - we did not grow up eating fruits andvegetables. You buy the food that is gonna feed your entire household.
It’s a matter of survival.”
COFA Community Leader, Maui

35

MENTAL & BEHAVIORAL HEALTHThe Secondary Data Story
Note: Much of the data available at the time of report preparation is
pre-pandemic. Experts in the field all agree that, when data are available,
the picture will be even more critical.
Severe Mental Illness and Addiction
In 2018, 10.3% of adults in Hawaiʻi lived with a mental health illness. This included residents who
experienced stress, depression, and emotional problems which lasted for more than 14 days during
the past month. While the national figure had decreased from 2016 (15.0% to 13.0%), Hawaiʻi’s
population continued to see a moderate increase across the state. At 13.4%, Hawaiʻi County wasslightly higher than the national average of (13.0%), while Honolulu County had the greatest
percentage point increase of 2.5 points (from 8.5% to 11.0%).

2016
2018

FREQUENT
MENTAL
DISTRESSUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

15.0%

9.6%

11.7%

10.2%

8.5%

9.4%

13.0%

10.3%

13.4%

11.8%

11.0%

11.5%

Percentage of adults who stated that their mental health, which includes stress, depression, and problems withemotions, was not good for 14 or more of the past 30 days.
(Data: 2016). Source: Hawaiʻi Health Matters, County Health Rankings,
2018 (Data: 2018). Source: Hawaiʻi Health Matters, County Health
Rankings, 2020

As stress and other emotional issues increased, substance abuse has increased, as well. Locally,
heavy alcohol usage continues to outpace the national level, 8.3% and 6.5%, respectively. Maui
County saw the highest percentage at 11.9% reporting heavy alcohol consumption, whereas
Hawaiʻi County decreased to 9.3%.

2016
2019

HEAVY
DRINKINGUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

6.5%

7.9%

11.6%

7.9%

7.4%

9.7%

6.5%

8.3%

9.3%

11.9%

7.4%

8.9%

Percentage of adults who reported having more than two drinks per day on average (for men) or more than one drink
per day on average (for women).
(Data: 2016). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS,
2017 (Data: 2019). Source: Hawaiʻi Health Matters, Hawaiʻi DOH
BRFSS, 2021

36

Mortality rates from drug overdoses have escalated both nationally and locally. While the overall
overdose rate in Hawai'i is lower than the nationwide figure, it nevertheless still presents anongoing and significant challenge for the state. The City and County of Honolulu (16.3%) and
Kaua'i County (16.2%) reported the highest overdose rates, while Hawai'i County (10.8%) had thelowest.

2014-162017-19DRUG
OVERDOSE
DEATHS(per 100,000)

US

HAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

16.9

12.1

10.9

12.8

12.2

12.1

21.0

15.4

10.8

15.8

16.3

16.2

Death rate per 100,000 population due to drug poisoning (accidental or
intentional) (Data: 2014-16). Source: Hawaiʻi Health Matters, County Health
Rankings, 2018 (Data: 2017-19). Source: Hawaiʻi Health Matters, County Health
Rankings, 2021

Suicide is an overwhelming problem in modern society. The daily stresses, addiction, and despair
have led to the steady rise in adult suicides from 12.9 to 14.8 per 100,000 Hawaiʻi residents since
it was last reported in 2019. Kauaʻi had the highest rate increase, from 14.6 to 22.0 suicides per
100,000 people.

2013-152017-19SUICIDE
DEATH
RATE (perUS

HAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

13.3

12.9

20.4

15.9

10.3

14.6

13.9

14.8

21.4

18.4

10.7

22.0

100,000)
Age-adjusted death rate due to suicide (ICD-10 codes *U03, X60-X84, Y87.0).
(Data: 2013-15). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Vital Statistics,
2017 (Data: 2017-19). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Vital
Statistics, 2021

“Mental health will be the next great crisis.”
LGBTQIA Community Advocate, Oʻahu
A current public messaging campaign from a Native American community simply, but effectively
demonstrates the connections between upstream determinants of health and suicidal ideations. One
ad states that people thing Suicide Preventon looks simply like a number for a hotline. Although
important, it goes on to state that Suicide Prevention is actually: food security,
37

affordable housing, youth suicide prevention courses, peer norm activities, affordble healthcare,housing stabilizatoin policies, destigmatizing mental illnesses, community engagement activities,
strengthening household financial security, increasing access and decreasing stigma to mental
health care, parenting skills and family relationship programs, and family acceptance ofindividuals who identify as LGBTQIA+.
Among those interviewed, there was overwhelming agreement thatthe mental and behavioral health challenges that existed in Hawaiʻi
before the pandemic have only been exacerbated by the COVID-19
experience. Some hypothesized that it is in mental health where thegreatest cracks in the system have long existed, with past cutbacks instate funding and a dearth of providers resulting in nowhere to send
those screened and identified as needing assistance. Rebuilding themental health system infrastructure was identified as criticallynecessary by a number of key informants.
Looking to the future, there is great concern about the long-term
mental and behavioral health impacts of the pandemic experience,
impacts that perhaps cannot yet be appreciated. The isolation andlack of social interaction on the part of school children, who may
slow in social and academic development, likely will result in
behavioral problems that manifest down the road. Kūpuna havesuffered from limited social interaction, closure of senior daycares,
and limited contact with their families. The stresses on families ofparents working from home (if not laid off from their jobs),
attending to their school-aged children struggling with distancelearning, trying to manage financial needs, and dealing withhealthcare challenges all will take a toll. Domestic violence andsexual abuse reports have increased. Reporting of child abuse cases
declined dramatically when schools were closed, experts indicated,
as schools were a primary source of identification.

“The COVID impact on mental and behavioral health will be long-lasting.
We don’t have a mental health hospital, no crisis center, etc.
We don’t have the safety net to address the issues on hand now, and more will come.”
Mental and Behavioral Health Service Provider, Oʻahu
Overall, communities across the state saw a decrease in the accessibility to mental healthresources. Providers and patients alike shared an overall decrease in appointment availability,
resulting in lengthy delays for patients needing to access mental health providers in thecommunity. As appointments transitioned to telehealth, patients without access to a phone orcomputer, or with anxiety around use and lack of privacy at home, were negatively impacted.
38

Although a challenge for many, the growth of telehealth increased access for many as well.
Community providers moved counseling sessions to video, breaking down geographic barriers.
Whereas a family might have needed to bring their child across an island for counseling, forexample – if transportation and time permitted – this barrier was now removed. Without
geographic barriers, experts related that some services available on the U.S. continent could beremotely accessed, helping to address the shortage of providers available in Hawaiʻi.
Telemedicine also has the potential to help address the shortage of mental health professionals in
Hawaiʻi, because providers can be anywhere. It is believed by mental health experts that the moveto telehealth can be combined with in-person services as we emerge from the pandemic; that it
will be one of the lasting positive impacts of the COVID-19 experience on mental health.

“I think there’s been a change in the lens, the paradigms through which wesee some of these mental health issues. It’s a trauma-informed lens.
It’s a recognition that these are not broken people.
WE are not broken people.
We are people who have had particular sets of experiences that have been
extraordinary, and our responses are actually normative in the sense that this isexactly what you would expect under such incredible circumstances.
Culturally and historically across time, these are events that have created ways of
relating and understanding our world. And sometimes our coping strategies
become potential barriers. And it becomes important to recognize the impactsof these traumas and the impacts and the consequences of thesetraumas.
And recognize them rather than as abnormal reactions; instead, incredibly
normal reactions to extraordinary circumstances.”
Behavioral Health Educator

39

HOUSING
Note: Much of the data available at the time of report preparation is
pre-pandemic. Experts in the field all agree that, when data are
available, the picture painted will be even more critical.
The Secondary Data Story
Income, Home ownership, housing supply
According to the 2020 U.S. Census, 41.1% of Hawaiʻi residents (about 2 in 5) live in renteroccupied housing units; the City and County of Honolulu registered the highest among all counties,
at 43.8%. The pandemic has brought more individuals to rethink their current living conditions,from living in the congested urban core to living in a less dense or even rural area. Low interest
rates and the ability to work remotely have made Hawaiʻi’s housing market even more competitive
among local and out-of-state buyers, often purchasing above market price.
The U.S. Census American Community Survey’s 5-year estimate for 2015-2019 reported the
median housing unit value in Hawaiʻi was $615,300, while nationally, it was $217,500. A recent
study from Title Guaranty Hawaiʻi reported that in May 2021, the median sales price for a singlefamily home on Oahu was $980,000, and it has since exceeded $1,000,000.
In partnership with the counties, the State of Hawaiʻi performs a housing gap study every three
years. The need for housing at all income levels has steadily increased yearly since the study began.
The most recent study in 2019 demonstrates that over 65,000 housing units are needed statewide
to address housing needs by 2025. Housing is built at a rate of only a few thousand units per year.
While just over half of those units are needed for families earning 80% or below the annual medianincome, considered low to moderate-income, it is clear that this is not a problem simply for lowincome families.
Housing stability has an important upstream impact on mental and physical health. Instability andpoor housing conditions lead to greater stress, increased exposure to unhealthy environments, andless access to healthy food options. A recent study illustrated that “poverty and poor housing
together are implicated in high rates of chronic diseases. Studies show a correlation of housing
conditions with asthma, diabetes, high blood pressure and stroke, heart disease, and anxiety anddepression. This is borne out by data for Hawai'i showing the disproportionate prevalence of these
conditions among low-income households.”18

Good Health Depends On Decent Housing, Hawai‘i Budget and Policy Center (December 2021), available at:https://static1.squarespace.com/static/5ef66d594879125d04f91774/t/61cbb9d2e388e752f5626375/1640741331194/
Health+%26+Housing+Handout.pdf
1840

2013-17
2015-19

MEDIAN
HOUSEHOLD
INCOMEUSHAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty$57,652$74,923$56,395$72,762$80,078$72,330$62,843$81,275$62,409$80,948$85,857$83,554Median household income. Household income is defined as the sum of money received over a calendar year by all
household members 15 years and older.
(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates,2017 (Data: 2015-19). Source: U.S. Census, American Community Survey 5-year
estimates, 2019

2018
2021

HOMEOWNERSHIP

56.0%

49.4%

52.0%

44.7%

50.0%

46.4%

56.2%

49.8%

53.6%

45.5%

50.1%

46.2%

Percentage of all housing units (i.e. occupied and unoccupied) that are occupied by homeowners.
(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates,2017 (Data: 2015-19). Source: U.S. Census, American Community Survey 5-year
estimates, 20192013-17
2015-19

MEDIAN
HOUSING
VALUE$193,500$563,900$316,000$569,100$626,400$520,100$217,500$615,300$350,000$633,500$678,200$570,700

Median housing unit value.
(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates,2017 (Data: 2015-19). Source: U.S. Census, American Community Survey 5-year
estimates, 20192013-17
2015-19

VACANT
HOUSING
UNITS

12.2%

14.9%

22.3%

24.6%

10.1%

26.3%

12.1%

15.3%

20.9%

25.5%

10.8%

26.9%

Percentage of total housing units that are vacant(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates,2017 (Data: 2015-19). Source: U.S. Census, American Community Survey 5-year
estimates, 20192010-142013-17

SEVERE
HOUSING
PROBLEMS

18.8%

27.8%

26.9%

32.2%

27.3%

26.6%

18.0%

26.7%

22.8%

28.6%

27.5%

23.4%

Percentage of households with at least one of the following four housing problems: overcrowding, high housing costs, lackof kitchen, or lack of plumbing facilities.
(Data: 2010-14). Source: Hawaiʻi Health Matters, County Health Rankings,
2018 (Data: 2013-17). Source: Hawaiʻi Health Matters, County Health
Rankings, 2021

41

“Housing is out of reach even for middle income working families.
There has to be a major shift on housing - it is connected to everything.
Soon, we will have no choice but to move away.”
Native Hawaiian Organization and Policy Leader

Nearly every key informant interview and community meeting included discussion on the need for
housing, even where represented communities or organizations were not necessarily focused on
housing. Some of the less obvious examples of the impact that were shared include:● Domestic violence organizations talked about the lack of a place to go being a primarybarrier in most survivors fleeing abusive households.
● Both Maui and Kauaʻi service providers shared a regular return of housing choice vouchers(Section 8) and other housing subsidies due to the inability to find a unit to rent, despite
being able to pay market rent with the voucher.
● Overcrowded housing conditions for many families contributed to rapid and widespread
COVID-19 impacts. Many low-income households were financially unable to afford tostop working or work remotely. These same families often struggled with being able tosafely distance or quarantine within their home from family members when exposed to
COVID-19. These compounding factors were identified as contributing to thedisproportionate rate of death among Pacific Islander communities due to COVID-19.
● Hospitals reported holding patients who are homeless longer than medically necessary,
unable to discharge because of lack of housing and no place to safely recover; adding tocapacity issues at hospitals during COVID-19 surges.
● Every homeless provider discussed lack of housing as the most significant barrier inaddressing houselessness. On Oʻahu alone, hundreds of individuals are considered"housing ready" and cannot even find rooms in a shared home or dorm-like dwelling torent, much less a private unit.
● While many seniors and their families wish to age in place, the lack of affordable senior
housing is a stated barrier for tens of thousands of local seniors. Senior housing and senior
daycare can provide needed companionship and social opportunities for seniors who often
face higher rates of depression, feelings of isolation, and suicide than the population.19“Four-Year Area Plan on Aging”, Honolulu Elderly Affairs Division (2019 - 2023), available at:https://www.elderlyaffairs.com/Portals/_AgencySite/docs/Area_Plan_2019-2023_FINAL_DRAFT_10-0119.pdf.
1942

“COVID-19 made Kauaʻi itself a desirable location for people around the country to retreat to.
This drove up housing prices and made purchasing a home almost unattainable forKauaʻi locals.
There is a perception that:ʻNo matter how hard you work or how many jobs you have, we just can’t get ahead.’”Hospital Administrator

Homelessness is an important and critically related element of the housing crisis. Homeless service
providers across the state indicated that while other issues impact houseless communities, there isno greater barrier to their having healthier lives than the lack of available, affordable, andaccessible housing. An estimated 25% of persons experiencing homelessness on O‘ahu live witha mental health problem, 28% live with a physical or developmental disability, and 17% aresurvivors of domestic violence, 4% of whom are actively fleeing.20 These challenges further
demonstrate the layered relationships between the 2021 Priorities and the importance ofinterconnected approaches.
Housing First models have been successfully implemented in Hawaiʻi and demonstrate positive
health outcomes by high likelihood of staying housed, decreased use of drugs and emergent care,and increases in social engagement. Additionally, the direct healthcare benefit includes anestimated healthcare cost savings of $6,197 per client per month, representing a 76% decrease inhealthcare costs after housing placement.21
Both national and local reports repeatedly
demonstrate that the cost of addressing impacts of homelessness far exceed the cost of providing
stable, permanent, supportive housing for those experiencing homelessness.22
Recently, Medicaid has added Community Integration Services (CIS) as eligible for coverage. This
includes providing housing support services with the goals: “(1) Support the member’s transition
to housing; (2) Increase long-term stability in housing in the community; and (3) Avoid
future periods of homelessness and institutionalization for members.” 23 Two homeless service
agencies have become or are in the process of becoming enrolled providers.
Going into the pandemic, in January 2020, the Point-in-Time Count performed by Partners in Careidentified 6,458 individuals as homeless, with 3,650 of these unsheltered. Hawaiʻi’s homeless rate
leads the nation in dramatic numbers, at 45.5 per 10,000 (HI) vs. 17.3 (nation).

2020 O‘ahu Point in Time Count, Partners in Care (2020), available at:https://static1.squarespace.com/static/5db76f1aadbeba4fb77280f1/t/5efa984a8ae4f774863509e8/1593481306526/PI
C+2020+PIT+Count+Report+Final.pdf
21
Hawaiʻi Pathways Project, State of Hawaiʻi, see: https://homelessness.hawaii.gov/housing/.
22
Good Health Depends On Decent Housing, Hawai‘i Budget and Policy Center (December 2021).
23
Medicaid Community Integration Services, Homelessness Initiative, see: http://homelessness.hawaii.gov/cis/.
20

43

Many of the unsheltered individuals face major health issues caused by exposure to the elements
and safety issues.

2016
2020

HOUSELESS(per 10,000)

US

HAWAIʻI

Hawaiʻi
CountyMaui
CountyC&C ofHonoluluKauaʻiCounty

18.3

55.4

70.2

69.2

49.8

61.4

17.3

45.5

39.7

47.2

45.4

58.8

Rate of homelessness per 10,000 population.
(Data: 2016). Source: Hawaiʻi Health Matters, Hawaiʻi Dept. of Human Services, 2017. National figure from2015. (Data: 2020). Source: Hawaiʻi Health Matters, Hawaiʻi Dept. of Human Services, 2020. National figure
from 2019.

A sample of specific strategies recommended for potential hospital partnership included:● Participate in workforce housing for hospital employees to provide affordable housing
options, make existing inventory available to other families, and● Support the integration of housing services into hospital programs now that it is aneligible Medicaid reimbursable expense● Develop care coordinator relationships that create a “hand-off” from the hospital to thesocial service providers upon discharge● Support existing street outreach programs that seek to meet people where they are“I think that we have not yet seen the worst of what is coming for youth homelessness.
When the moratorium ends, they will lose housing.
It is hard for youth that were in job training programs that were shut down.
The youth are no longer getting ahead, just treading water.”
Youth Homeless Service Provider, Oʻahu

44

TRUST & EQUITABLE ACCESS“Trust and access should really just be the theme for the entire report.”
Community Organizer, Hawaiʻi Island

Both community members and hospitals highlighted various forms of access issues throughout theassessment process. Underserved communities are often so because there are barriers to accessing,understanding, or being aware of those services and offerings. Focusing on equitable accessbecomes an opportunity for hospitals to meet people where they are, apply trauma-informed careprinciples, and help build meaningful relationships with those communities. In doing so, trust canbe built, or in some cases rebuilt, to allow communities to try to gain meaningful access and better
address the population's needs.
Investments into building systems that will increase access to healthcare can also have a leveraging
effect to increase access beyond healthcare and in support of addressing upstream determinants.
For example, as will be discussed in more detail in Section III. B., hospitals’ inclusion ofcommunity health workers can help people navigate the healthcare system and also be connected
to existing services, programs, and organizations.
Throughout the assessment, community organizers emphasized their interest in supporting
connectivity between hospitals and community service providers. Hospitals can be seen as animportant entry point to existing services and programs beyond healthcare. Developing andimproving direct relationships to support warm handoffs during discharge can help to makemeaningful progress in increasing access beyond healthcare.
When discussing access to medical care or the broader healthcare system with neighbor island,
rural, marginalized ethnic populations or kūpuna, consistent themes emerged around the following
areas of systemic barriers:●●●●

Transportation
Language Access
Cultural Competence
Stigma & Bias

●
●
●
●

SafetyDigital Literacy & Access
Insurance
Trust

45

Transportation
While for some, the ability to work remotely and engage with telehealth has had a positive impact
in increasing access, there are several ways in which transportation is a persistent barrier tohealthcare for large portions of our community. The first is the proximity of clinics or hospitals tothe populations that they serve and the viability of public transportation in relation to those places.
Respondents on neighbor islands and rural areas of Oʻahu told stories of being discharged fromthe ER in the middle of the night and having no way to return home because they did not have avehicle or a ride. Others talked about the difficulty of taking large chunks of time off from work
to travel by bus to an appointment; making it less likely for them to keep up with recommended
visits.

“If you are on Molokaʻi, then your options have gone backwards. You have to get on a verysmall plane. No available ﬂights. If you use a wheelchair on Molokaʻi, they hoist you up on aforklift. Also, if you need nursing care, they have to ship you oﬀ island.”
Kūpuna Care Provider, Maui
Among Neighbor island residents, Lāna‘i and Molokaʻi respondents were especially vocal
concerning the lack of specialists or routine care that they could access on-island. One registerednurse on Lāna’i told the story of her own fight with breast cancer during the pandemic and needing
to arrange flights during the inter-island travel ban or take a ferry to Maui. For those serving
kūpuna on Molokaʻi, the consensus was that one could not age safely on-island due to the lack ofcomplete care needs.
“I got breast cancer - I had a problem, needed to have radiation daily.
I had to change providers so that I could go to Maui instead of Oʻahu, so that I could go by boatand not ﬂy during the COVID restrictions. The ferries were only running two days a week, so I
had to stay on Maui for my treatment. I had a place to stay with friends andaccess to a car - but not everyone has those things.”
Lānaʻi Caregiver
On Kauaʻi, the lack of residential treatment facilities means that those who get care are typicallycovered by insurance to travel to and stay on Oʻahu. Far more don’t receive care, especially if it isdifficult to find options with keiki care. Domestic violence survivors in an off-island programtalked about how not having a place to go on Kauaʻi was a significant factor in their not leaving
their abusive situation earlier.

46

“Language barrier is the top, number one. At the hospitals when you’re visiting your doctor, a
lot of interpreters don’t know what the doctor said, and it might be because the interpreter
does not understand the medical terminology.
During COVID, when you had to get tested or you had to get the vaccine, everybody had to go
online and pre-register. Well, not everybody has access and internet. And on top of that, they
don’t understand the questions because they are all in English.
We helped. We just told people - give me your information and we will sign you up.”
Kūpuna Care Provider, Maui

Language Access
Despite 18% of Hawaiʻi residents being foreign-born, accounting for approximately 255,499
people,24 many of the Limited English Proficiency (LEP) communities that were interviewed forthis survey felt that language access was the most significant barrier to receiving adequate care.
Language access can be interpreted as shorthand for “culturally-competent, linguisticallyappropriate care”. The stories that immigrant participants often regaled were of extreme confusion
concerning diagnosis, decision-making, and outpatient care.
One Chuukese community leader and interpreter told a harrowing story of having to tell her auntthat her uncle was terminally ill because she was the only Chuukese interpreter available. Others
commented on the challenges that arose due to lack of understanding of cultural protocols by
medical staff. The importance of language and cultural representation among medical staff can beillustrated by one Thai farmer who participated in a community meeting; despite living in Kunia
he would travel, by bus, into Kalihi to visit Kōkua Kalihi Valley where he could be seen by a Thai
doctor.
Cultural CompetenceCommunity members pointed to the State Department of Health, Office of Health Equity as animportant resource that was shut down and is perhaps now being revived. They also pointed to
the Pacific Islander community liaison position developed by the City & County of Honolulu as
an example of progress for government institutions seeking to build relationships with
community groups.
“They look up your name and they hear your accent, and they know you Micronesian, so they
don’t rush to take care of you.”
Chuukese participants, KKV, Oʻahu
New American Economy, “Immigrants and Migrants in Hawaiʻi: Essential Contributors to the State’s
Workforce and Economy” (2021), available at:https://research.newamericaneconomy.org/wp-content/uploads/sites/2/2021/05/NAE_Hawaii_V7_FINAL.pd
24

47

Stigma & Bias
In conversations with Native Hawaiian, COFA status, housing
insecure, and former or current drug users, the issue of stigma wasreiterated often. The feeling that care was being withheld or thatthey were being intentionally ignored by providers was common.
For the Micronesian and houseless population, several participants
asserted that they were receiving subpar care because the provider
knew they didn’t have medical insurance. Such biases and feelingsof exclusion work in both directions, creating a barrier forindividuals to want to access care, even when it is desperately
needed.
Behavioral health patients, as well as providers, sang a common
refrain of clients receiving lower quality care due to judgments
about addiction or mental health. The belief was that the stigma
exists on the policy level as well, where resources, programs, andespecially facilities are grossly lacking to provide the kind of care these populations need.

“One time I went to the hospital after my boyfriend bashed my head with a ﬁshing rod. He told
them it was an accident. The nurses knew me and knew he abused me, but I
overheard them saying - ʻdon’t worry, she’s just a chronic’.”
Domestic Violence Survivor

SafetyIn relationships with intimate partner violence, safety is a significant barrier to receiving any
medical care at all. Abusers isolate their partners, and keeping them from medical access is a formof maintaining control. When survivors do come into hospital settings, healthcare workers are notalways trained in trauma-informed care and do not recognize the situation. Even when they do,
and they find a way to privately offer assistance, without integrated services such as housing andsafety plans, survivors feel they cannot risk leaving.
Recommendations included requiring training on how to ask important questions, provide posters
in every exam room, bathroom, or other potential location. Collaboration with domestic violence
providers is an opportunity to create more warm handoffs for care, where there seems to be very
little currently. Housing support services, an eligible Medicaid expense, can also be of value here
to have within the hospital setting for these and other populations where housing support is a
critical element of the individual’s health needs.

48

“You can’t strengthen families if you don’t know whether their family is a safe family.
Kids living with families that are not safe do not have a healthy start at all.
How do you treat the whole person if you are leaving out a whole portion of their reality?”
Domestic Violence Service Provider

While the physical and sexual violence data still reflects data from 2013, it is important to pointout that Hawaiʻi’s percentages are much higher than those for the nation overall. Domestic
violence providers as well as hospital workers reported significant increases in intimate partner
violence. “Safer at Home” slogans didn’t apply to many people who were not safer at home butwere afraid to go to shelters, which were facing the same constraints as other shelters with the needto spread out, and where their kids might get exposed to COVID-19, there were less opportunities
to ask for help and develop safety plans, and courts were closed. Providers added services such as
texting, online chat, and participated in at-home food delivery in order to meet people where they
were and offer resources. One hospital worker indicated having patients that called 911 feigning
illness to the Emergency Department and privately ask for help.

“The pandemic did not turn people into abusers. Stress does not cause domestic violence. . . abusers that relish the power and control they have over their partner had more powerand control. Like exposing themselves to coronavirus and then [holding] that over theirpartners and threatening them.”
Domestic Violence Service Provider

2013

INTIMATE
PARTNERVIOLENCEPHYSICALUSHAWAIʻI

Hawaiʻi
County

8.6%

9.5%

11.5%

Maui
CountyC&C ofHonoluluKauaʻiCounty

14.3%

8.3%

10.7%

Percentage of adults who report they have ever been hit, slapped, kicked, or hurt in any way by a current or former
intimate partner.
(Data: 2013). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 2015

2013

INTIMATE
PARTNERVIOLENCE- SEXUAL

1.8%

3.6%

4.5%

5.5%

3.0%

3.8%

Percentage of adults who report they have ever experienced unwanted sex by a current or former intimate partner.
(Data: 2013). Source: Hawaiʻi Health Matters, Hawaiʻi DOH BRFSS, 201549

Technology
While COVID-19 has thrust many of us into new digital spaces, these spaces are not always
equitable. Across the state, broadband access is spotty, with rural populations suffering the mostand entire communities unable to regularly connect to internet service. The rise of telehealth has
broadened the barrier to care among folks without internet, a device, or the training to use one.
Many participants serving kūpuna commented on how difficult it was to support their patients inusing a device to make appointments, check their medical history, or keep up with public healthinformation. For rural populations they simply lacked consistent access to broadband or did nothave strong enough wifi to have multiple members of their household using it at the same time.
Still, among Micronesian and Marshallese populations, few had regular access to a device, and thesites they needed to use were not translated.
As stated above, underserved populations are typically underserved because there are systemic
barriers they consistently encounter. Although these challenges are entrenched, difficult to solve,
and require many years of focused work, there were several programs and initiatives shared as
making meaningful progress. Meeting people where they are, and tapping into the technology they
are using, is an important approach. For example, Honolulu County has created kiosks in grocery
stores to assist people with basic licensing and vehicle registration. Similar tools, or partneringwith existing ones, may be one way to utilize technology to bring healthcare into communities
where they are.
Many communities were delighted to see mobile and pop-up clinics coming to their neighborhood.
Project Vision, Healthy Mothers Healthy Babies, Kaiser, HPH which were referenced often as
excellent models, to be replicated and expanded. Progress was also made in addressing culturaland language barriers when Pacific Islander, Native Hawaiian, and Filipino COVID-19 coalitions
were brought together and started pushing for more contact tracer, in-language health information,and vaccination sites in their own communities.
Insurance
For 25 years COFA communities were unable to access Medicaid after being removed in 1996.
Although the state continued to cover the federal portion for a period, it was dramatically reduced
in 2009. One Marshallese physician at the time recalled, “we heard stories of people actually goinghome to die because they couldn’t get access to the health care they needed.”25 In December 2020,
Congress restored COFA migrants as eligible for Medicaid, impacting an estimated 25,000
Hawaiʻi residents, and efforts by community leaders to get their members enrolled are actively
underway. But getting funding for those positions has been a challenge as organizations are largely
left to grant processes.
In the meantime, damage has already been done to the COFA community and many community
members’ relationship with healthcare. For 25 years, many community members did not go to thedoctor at all, even for life-threatening issues, and saved what little money they could to try to“How Decades of Advocacy Helped to Restore Medicaid Access to Micronesian Migrants.” Honolulu Civil Beat
(December 2020), available at:https://www.civilbeat.org/2020/12/how-decades-of-advocacy-helped-restore-medicaid-access-to-micronesian-migra
nts/.
25

50

afford to pay out of pocket for care for their children. Being impacted by and having to pay for
healthcare needs has also worked to keep COFA communities in poverty. Trying to rebuild thoserelationships and habits will take time and concerted effort.
Trust
Many of these fractures in access and in social relationships and conditions as a whole work
together to create a lack of trust between communities and institutions, including hospitals. The
lack of trust in the healthcare system, combined with distrust of government, has made current
conditions ripe for misinformation and prevents many from engaging with providers, healtheducators, and others. While the root causes of this distrust may go back generations and isimportant to understand, it is instructive to focus on: a) how it currently manifests and b) what
actions are needed to rebuild trust.
Some examples of how this mistrust manifests that were shared in the course of the data collection
include screening rates far below target thresholds, delaying early intervention until acute care isneeded, and vaccine resistance.
Opinions on what is needed to build trust in the healthcare system, and specifically what hospitals
could do in this regard, were virtually unanimous. The key, they said, is outreach to the community,
building relationships now in preparation for the next crisis. Had the investment in these
relationships already been made, our pandemic experience might have been different, they thought.
By outreach, key informants and community members were talking about getting out into thecommunity, rather than waiting for the community to walk into the facility. The suggestions
centered around these themes are explored more below:●●●●

Utilize and invest in community health workers
Build cultural competencies
Develop greater collaboration and trust within the healthcare system
Address common/consistent messaging

Community Health Workers
The pandemic experience has underscored the need for increased investment in community healthworkers (CHW); persons of the community working in the community. The most successful efforts
in educating underserved communities have been those that identified and trained trusted people
in the target communities, sometimes going door-to-door to distribute flyers and encourage
vaccination and promote healthy behaviors. The CHW can aid community members in navigating
the complex healthcare system, provide health education, dispel myths, and meet people where
they are. Many examples of this were given and complimented, but in almost every instance, theposition had run out of funding and been terminated, had put the CHW on part-time or on-call, andthe work reverted back to volunteers.

51

“If they’re from that community, they will not only be trusted, but will be really vested in the
mission of improving those health outcomes.”
UH Faculty Professor — Nursing

At times, there was a disconnect in the definitions of community health workers. Communitybased key informants see them as “of the community, in the community”; well trained but notnecessarily requiring advanced education. Often, most effective because they are known to thecommunity in other capacities. Some seek CHW applicants with a solid educational background.
Adding to the confusion, some of the hospitals refer to medical social workers – often bilingual –in their Emergency Department as CHW. Clarity in the definition will be helpful to finding
common ground.
Further complicating the discussion is whether and how a licensing process and regulation mightwork and to what degree it may be needed as a possible pathway to insurance reimbursement which
would likely lead to better pay and job stability and security. Concerns are that this process andlicensing costs may leave many of those integrated with the community behind another barrier,creating further divisions.
CHWs are currently housed both in clinical and non-clinical settings. In some cases, status as parttime, temporary, or contractors create barriers in having consistent services available. Community
volunteers often help to fill similar roles. Perhaps more than any other single recommendation, theWard Team heard the value of investing in greater capacity in this area. Many hospitals alreadysupport CHWs in some way, and there seems to be great opportunity to work together with
community organizations to build additional capacity both within the hospital setting and within
the community setting while avoiding the risk of pulling critical community-based resources out.
One of the challenges identified by some of the hospitals is the lack of reimbursement for CHW
services. They identified the need for grants and health systems support, and endorsed the grant
recently secured by the Department of Health to augment training programs statewide.26
In
2018, Housing Services became eligible for Medicaid reimbursement. Hospitals may consider how
to invest in these services to support the financial costs of CHW services. Additionally, having theresources available within the hospital makes them available for housing support and coordination
with service providers as needed for domestic violence survivors and those experiencing
houselessness. Although some homeless service providers have pursued certification, navigating
the billable process is challenging for many non-profits and could be a partnership opportunity.
26

See:
https://governor.hawaii.gov/newsroom/doh-news-release-2-2-million-grant-to-augment-community-healthworkforc e-training-programs-statewide/52

“We put out a plea to folks to help us. We used CARES money to do medical services inhouse. We established contracts with every health plan on island to provide medicalcare. We became a credentialed Medicaid provider.”Homeless Services Provider

Building Cultural Competencies
When speaking about building trust, participants talked about developing cultural competencies
that go beyond staff training. Staff training certainly is a part of it, but to truly build that trust, theysaid, it needs to be operationalized. It needs to become part of the fabric of the organization,requiring a paradigm shift. An example during COVID-19 was the establishment ofisolation/quarantine (ISO/Q) facilities for households unable to isolate or quarantine at home.
Translation alone was not enough to make people comfortable to go to live in a place they did not
know. A major shift happened with the COFA community when providers within their community
were able to manage a ISO/Q hotel, helping to navigate people through the health system, making
the property welcoming and warm, and managing it in a way that was culturally appropriate forcommunity members to feel comfortable.

“When you take unique community needs to a large healthcare system, one that understands
operational protocols, we fall short. We continue to not understand each other because
there’s no one translating the ‘how’. It takes a special assertive role, like
cultural programmer, and we often don’t invest in those types of positions that help us todevelop processes and protocols to operationalize trust in the context of care setting.”
Hawaiʻi Hospital Representative

For some routinely underserved communities, such as the COFA population, leaders
commented that individuals were quick to abort care if they felt misunderstood or care camein a culturally inappropriate manner; these individuals would then be less likely to return tothat provider for any further services. While telephonic interpretation is often better thanpatients not being able to communicate at all with their provider, most participants felt that it
was grossly inadequate to: communicate clearly with the patient their care pathway; assist thepatient in making the appropriate decision for themselves; reduce the stress or concern present;
and understand or address unspoken cultural barriers or misunderstandings. There wasresounding support for increasing the number of bilingual medical social workers, medical
interpreters, and culturally-competent providers as the most meaningful way to address barriers
to care for LEP communities.

53

Greater Collaboration Within Healthcare and Beyond
An observation frequently mentioned in the key informant interviews was that greatercollaboration within the healthcare industry would help build trust and better serve communities.
They felt that competition within the healthcare industry
may sometimes prevent community advancement, delay
services, and ultimately further underserve marginalized
populations. This perceived competition was not limited
to the largest health systems, but was felt to permeate allparts of the healthcare industry – hospitals, urgent careclinics, FQHCs, primary care clinics, and eventuallypharmacy-based primary care delivery – all competing forthe same healthcare dollar. Greater collaboration would
result in greater impact on the patients they serve and,potentially, lower healthcare costs, they thought.
Looking to the broader healthcare continuum, nearly
every social service provider indicated that a warm handoff strategy would tremendously improve the working
relationship, trust, and patient care. While hospitals may
not be positioned to provide all aspects of care an
individual needs, establishing close referrals and hand-off
relationships can help ensure that care is received.

Consistent Messaging
Perhaps reflecting the challenges of communicating during a rapidly-changing pandemic, somethought that inconsistent messaging contributes to a distrust of the healthcare system. This can beseen by some as a failure to collaborate or as an example of the variety of “facts” available. An
important communication strategy in building community trust is sharing successes. As
recommendations from this assessment are implemented, reporting back and sharing thosemilestones as a direct result of engagement through the process helps to further reinforce the pilina- or relationships - that are built through processes such as these.

54

C. Significant Health Needs
The 2018 CHNA identified eleven (11) Priorities across three (3) goals. Throughout the processof research and input gathering for the 2021 CHNA, five (5) priorities emerged as have been
explored in depth above. However, the remaining 2018 Priorities were identified by community
members and leaders as remaining critical to address. These continued needs are referred to as the“Significant Health Needs” by the IRS in Section 501(r)(3). Below is a brief update of key themesfor each of the 11 Priorities from 2018. The table below provides brief themes and summaries
taken from the statewide interviews and community conversations regarding each of the 11
Significant Health Needs.
SIGNIFICANT HEALTH NEED

2021 SUMMARY

Address financial insecurity.
Create coordinated and systemic
opportunities for communities andfamilies to make good food andhousing realistically accessible,
develop workforce skills, create new
economic opportunities, build
financial assets, and reestablish
active lifestyles.

Respondents felt that financial insecurity had
increased dramatically. Housing prices are higher,
inflation has impacted the cost of household items,
and unemployment has touched many families.
The most financially vulnerable said thatunemployment and the Child Tax Credit had
helped them significantly but those with moremeans had little recourse, and many faced foodscarcity or eviction.

Work together for equity and justice.
Work alongside affected populations toaddress inequitable treatment andopportunity.

Most respondents commented that not much had
been done to shift systemic racism, gender
equity, income disparities, or bias, but they feltthat most people were now aware of the issues
that had been present all along. This narrative
shift and understanding was seen as the first step
towards addressing the issue. Discussions
highlighted that access, resources, andchallenges were not experienced equally by all
genders.

Strengthen safe families. Create theconditions and opportunities for families
to be healing forces for its own
members, including addressing financial
stress that will enable more healthy time
together.

Respondents largely commented that while
communities had, at times, grown stronger due to
COVID-19, families were less safe and under
greater strain than in 2018. Many highlighted theincrease in intimate partner violence and childabuse due to sheltering at home, doubling up
households, and the lack of resources or contact
with educators who could report abuse.

Prepare for emergencies. Mitigate
future health impacts by engaging
people, increasing understanding of theThis priority was seen as having made the mostprogress of the foundational goals. Folks largely
credited the collaboration of agencies and55

27

most vulnerable populations, building
food systems, and strengthening
relationships and community cohesion.

organizations that are traditionally siloed as thegenesis of this progress. COVID-19 caused suchan overwhelming emergency that traditional
stakeholders had to get out of their comfort zone
just to address basic needs of the community.

Build good food systems. Establish
access to nutritious food so that it isavailable to all.

The public is now aware of how many keiki andkūpuna are food insecure and Hawaiʻi’s relianceon imported foods. Many pointed to how folks
began growing their own food, the creation of foodhubs, and farmers’ markets as positive steps
forward. Increased usage of SNAP and “Da Bux”
program, which partners with grocers to provide
half off local produce, helped mitigate impacts.

Restore environment and sense ofplace. Better protect Hawaiʻi’s natural
resources, prepare adequately forclimate change, develop good design
and integration of the built
environment, and reduce the negativeenvironmental impacts of the visitor
industry.

Respondents commented that the biggest impact
they had seen on this issue was when Hawaiʻi shut
down tourism, and our natural spaces were given
room to heal. Many pointed to Hanauma Bay andother parks that were in better shape now. Most
did not feel the current reliance on tourism istenable or that enough is being done to mitigate
the harm that tourism and climate change ishaving on our state. Over 80% of respondents to a
2021 health and well-being survey indicated thehealth of the land and ocean was important to theirown well-being, with 63% of Native Hawaiians
stating it was extremely important.27

Nurture community identity andcohesiveness. Support community-led
efforts through shared activities andevents, active organizing around sharedpurposes, and instilling community pride
to foster greater trust and connectivity.

Two situations were regularly commented on withregard to this priority. The first was COVID-19 andhow organizations and neighbors banded together
to meet basic needs and support the mostvulnerable. The second was the efforts to protect
Mauna Kea, and the growth of a shared identityand purpose among some of the Native Hawaiian
population working together.

Invest in teenagers and healthy
starts. Invest in health and education at
the earliest stages of life. Support
school-based structures,
community-based activities, and youth
empowerment for pre-teens and teens.

Respondents were frequently distressed by thispriority, with some commenting that it had
regressed seriously in the last three years.
Concerns were raised about increase in childneglect and the need for more training to identify
signs. Teens no longer had access to their peers
or after-school programs. Teen vaping andsuicide rates rose. Access to early childhood careand

ʻImi Pono Hawaiʻi Well-Being Survey 2021, see: https://marzanoresearch.shinyapps.io/HawaiiDashboard2/.

56

support was similarly scarce and unreliable.
Outcomes for homeless youth and youth
identifying as LGBTQIA are especiallydisparate.28 Those that have 4+ childhood
traumas are 17 times more likely to experience
substance abuse.
Shift kūpuna care away from “sickcare.” Build a new paradigm of aging
so that healthy aging is available tomore. Combat the grave threats ofboredom, loneliness, purposelessness,inactivity, and other social andemotional hardships of aging.

Respondents commented that while muchattention was given to the needs of kūpuna andthings like “kūpuna shopping hours” were helpful;the lack of congregate, in-person activities,
closure of adult daycares and senior centers haddone serious damage to the population. Many
died in isolation without their family around them.

Strengthen trust in healthcare.
Rebuild and strengthen trust throughlistening, empathy, compassion, andtreating the whole person, while also
paying attention to the use of language
and cultural nuances.

Respondents commented that at the beginning of
the pandemic, some subpopulations had a lot oftrust in the healthcare system while othercommunities routinely felt bypassed or judged by
the healthcare system and providers. This was
exacerbated after the COVID-19 vaccine
mandates. Most respondents were wholly
distressed by the breakdown of trust andconcerned about effective strategies. Many
examples and invitations were highlighted to build
stronger relationships between hospitals andcommunity organizations.

Provide accessible, proactive
support for those with high needs.
Identify, develop, and strengthen
outreach, early intervention, freehealthcare services, mental health, andoral health for those who are struggling
with houselessness, mental illness, andaddiction.

Responses to this question varied greatly fromisland to island and among different ethnic,
linguistic, and marginalized communities. A few
common issues were: lack of mental healthresources, especially for youth or LEP individuals;
telehealth and mobile clinics were two innovations
that were universally seen as progress, but accessto broadband and/or familiarity with technology
were barriers; and the complexity of thehealthcare system was routinely noted as
especially difficult to overcome.

The inaugural Hawaiʻi Sexual and Gender Minority Health Report, produced by the State Department of Health,is an invaluable resource for a more in-depth exploration of health needs impacting this community. Available at:https://health.hawaii.gov/surveillance/files/2017/05/HawaiiSexualandGenderMinorityHealthReport.pdf.
28

57

“Patients are not only a body, but a person with emotions, spiritual beliefs, life experiences,
cultural identity, and social struggles.”Hospital Social Worker

D. Unique Populations
1. Geographic
Hawaiʻi County
Secondary data show Hawaiʻi County with many challenges in addition to the geographic
challenges brought by the distinct demographic differences of the West and East sides. Population
growth in Hawaiʻi County was among the highest for the state from 2010 to 2020, at 8.2%. At thesame time, data show Hawaiʻi County with the lowest median household income, highest
percentage of adults reporting frequent mental stress, and the second highest suicide rate (justslightly behind Kauaʻi). The teen birth rate is the highest in the state, and early/adequate prenatal
care for all women with a recent birth was the lowest. The proportion of single parent households
is the highest in the state. The challenges of rural health on Hawaiʻi’s largest island are currently
being examined by the State Rural Health Association; State Department of Health, Office ofPrimary Care and Rural Health; in conjunction with community partners.
On the positive side of the ledger, with the lowest median housing prices in the state, the homelessrate is lower than other counties, as is the percentage reporting severe housing issues(overcrowding, high housing costs, lack of a kitchen, lack of plumbing). A higher percentage of
Hawaiʻi County teens spend less than 2 hrs a day online in activities other than school-related,with the hope that they spend more time outside.
Kaua‘iPopulation growth in the past 10 years was the highest in the state, at 9.2%. This translates to an
additional 6,200 people on this relatively small island, and contributes to traffic and congestion
problems, escalating real estate prices, and housing challenges. The homeless rate on Kauaʻi is thehighest in the state, and service providers often cannot get families into housing even if they have
Section 8, Housing First, or other vouchers that will pay market rents (with the latter true on Maui,as well). At the same time as these indicators are showing challenges, many of Kauaʻi’s healthindicators are showing improvement, such as the percentage of adults who have had a routine
medical checkup in the prior 12 months (prior to the pandemic) and those saying . While cancer
prevalence is low, some cancer death rates also are among the lowest in the state.
Significantly, the incidence of breast cancer is the lowest in the state; and the death rate frombreast cancer is lowest. The same is true for lung cancer. This suggests that it isn’t lack of screeningthat results in low prevalence, given the relatively lower death rates, as well.
58

Given the relatively small population of Kauaʻi, the lack of facilities and health care/service
providers is a significant barrier, especially in the area of mental and behavioral health. Women
domestic violence survivors in residential treatment on Oʻahu who were from Kauaʻi indicatedthey would have gotten help earlier if there were resources and facilities on-island.
Maui County
The distinct characteristics of each of Maui County’s tri-island population mask some of thechallenges faced by residents. The map of areas of highest socioeconomic need in the state, forexample, does not highlight any ZIPCodes on Maui, but rather multiple areas of Molokaʻi. It is
likely the heterogeneity of Maui’s residential areas – defined by ZIPCodes – that masks this. The
median home prices are second only to Oʻahu, with a high vacancy rate (i.e. vacation rentals)
rivaling that of Kauaʻi. Both Maui and Kauaʻi residents find themselves struggling with rising realestate costs due to increased demand from population growth and second home prices paid byoutside buyers. The residual unemployment rate from the pandemic remains highest in Maui
County and financial stresses (among other factors) likely contribute to the highest percentages ofadults in the state reporting heavy drinking (two or more drinks per day) and intimate partner
violence, both physical and sexual.
At the same time, Maui County reflects the lowest percentage of adults who did not participate inany physical activity or exercise outside of work in the 30 days prior to the survey. The mortality
rate in the county is the lowest in the state. While cancer prevalence has fallen over the past several
years, as it has around the state, Maui County’s prevalence remains the highest, with certain cancer
death rates among the highest, as well. Coronary heart disease and congestive heart failure rates
are among the lowest.
“As goes Native Hawaiian health on Molokaʻi, so goes health on Molokaʻi”, given thatapproximately 6 out of 10 residents of Molokaʻi have Native Hawaiian ancestry. The chronic
conditions known to be overrepresented in the Native Hawaiian population all present challenges
to health on Molokaʻi. So, too, does household income below 200% of the federal poverty level,
which accounted for about 45% of the population before the pandemic. Subsistence farming,
hunting, and fishing contribute to the family dinner table and serve to maintain the culturalconnection to the ancestral way of life. The remoteness of Molokaʻi, combined with the populationof approximately 7500, leads to a dearth of services and facilities for healthcare (and other goods).
The people of Molokaʻi are extremely dependent on limited transportation services, especially forspecialty care, much of which is extremely inconvenient and can be costly for accompanying
caregivers.
City & County of Honolulu (Oʻahu)
As would be expected of an urban center, the stresses of long commute times, driving alone on along commute, and other urban lifestyle indicators are clear in the secondary data. Anotherexample is air quality, which is much worse on Oʻahu than on the Neighbor Islands. Insufficient
sleep, defined as 7 hours or less per 24-hour period, was much higher on Oʻahu (45% of adults,
contrasted to 38-40% on Neighbor Islands).
Certain health outcomes data, however, are generally better for residents of Oʻahu than for thoseon the Neighbor Islands, likely due to greater access to screening and preventive care. With59

breast cancer, for example, the incidence is the highest in the state yet the death rate from breast
cancer ranks among the lowest, which likely reflects greater access to care. The birth rate, which
has fallen on Oʻahu and almost everywhere in the past several years, remains the highest in thestate, while the teen birth rate is among the lowest. Data for teens show levels of fruit/vegetableconsumption and sufficient sleep to be lower on Oʻahu than on the Neighbor Islands. However,the percentage of teens reporting being bullied or cyberbullied is lowest on Oʻahu, as is thepercentage who reported at least one suicide attempt in the 12 months prior to being surveyed (aspart of the Hawaiʻi DOH Youth Risk Behavior Surveillance System). Levels of teen vaping andalcohol use are reportedly lowest on Oʻahu, as well. This data may be a reflection of the highest
median household income in the state and the proliferation of private schools on the island.
1. Healthy Women and Healthy Keiki
The old saying, it takes a village to raise a child can still be applied to modern society. However,in today’s society, it takes a community to raise a healthy child. Building special relationships
based on trust will open doors from a young age. From vaccinations to nutrition and fitness, byproviding the tools to help children develop a healthy foundation at a young age will support theirsocial emotional health to guide them to make responsible decisions. Furthermore, good nutritionand physical activity/exercise leads to self confidence.
Healthy Starts
The birth rate in the state and nationally has decreased since 2015. Hawai‘i’s birth rate decreased
to 11.9, while nationally the rate dropped to 11.6 per 1,000 total population in 2018. Unfortunately,
Hawai‘i had a higher rate of newborns at low birth weight than the national figure of 8.3%. Hawai‘iCounty accounted for the highest at 8.6%, with Honolulu and Kaua‘i at 8.5%.
While the proportion of birth mothers with adequate prenatal care during pregnancy has decreased
overall in the state (66.4% from 70.8%) and Honolulu County (63.4% from 72.7%) from 2013 to
2019, other counties saw a positive increase. Maui County saw the highest improvement from
67.3% to 83.1%, while Kaua‘i County remained the highest level of prenatal care delivered, at
91.7%. Teen pregnancy rates in the U.S and Hawai‘i have reflected a dramatic decrease from 2015.

2015
2018

BIRTH RATE
(per 1,000 total
population)US

HAWAI`I

Hawai`i
CountyMaui
CountyC&C ofHonoluluKaua`iCounty

12.4

12.9

12.1

11.5

13.3

12.4

11.6

11.9

11.1

10.9

12.4

10.4

The birth rate is an important measure of population health. The birth rate is usually the dominant factor in determining
the rate of population growth; however, it depends on both the level of fertility and the age structure of the population.
(Data: 2015). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Vital Statistics, 2017
(Data: 2018). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Vital Statistics, 2020

60

2015
2018

TEEN BIRTH
RATE (per1,000teen girls)

26.5

20.6

29.5

22.1

17.8

28.8

17.4

17.2

24.0

20.2

15.4

14.8

Rate of live births to resident mothers between the ages of 15 and 19 years.
(Data: 2015). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Vital Statistics, 2017; National figure from2013 (Data: 2018). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Vital Statistics, 2021; National figure
from 2013

2013
2019

EARLY/ADEQUATE
PRENATAL
CARE

66.8%

70.8%

59.6%

67.3%

72.7%

81.4%

66.8%

66.4%

60.9%

83.1%

63.4%

91.7%

Percentage of women with a recent birth who had adequate prenatal care according to the Adequacy of Prenatal
Care Utilization Index.
(Data: 2013). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Pregnancy Risk Assessment Monitoring System, 2017
(Data: 2019). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Pregnancy Risk Assessment Monitoring System, 2021. National
figure from 2011.

2013

MOTHERSMOKED
DURINGPREGNANCY

9.0%

4.3%

7.0%

2.1%

4.0%

7.3%

Percentage of births to mothers who smoked during their pregnancy.
(Data: 2013). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Vital Statistics, 2015

2013
2017

C-SECTION
BIRTHS

26.9%

25.6%

32.8%

29.7%

23.5%

28.4%

32.0%

25.9%

N/A

N/A

N/A

N/A

Percentage of births to resident mothers delivered by a cesarean delivery, or a C-section.
(Data: 2013). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Vital Statistics, 2015
(Data: 2017). Source: https://www.cdc.gov/nchs/pressroom/sosmap/cesarean_births/cesareans.html

2013-152016-18

EARLY
PRETERM
BIRTHS

1.5%

1.3%

1.4%

1.1%

1.3%

1.1%

1.2%

1.1%

1.2%

1.0%

1.1%

1.2%

Percentage of births to resident mothers in which the baby had 32 to 33 weeks of gestation.
(Data: 2013-15). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Vital Statistics,
2017 (Data: 2016-18). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Vital
Statistics, 20202013-152016-18LOW BIRTHWEIGHT

8.1%

8.3%

5.4%

4.6%

9.3%

4.7%

8.3%

8.2%

8.6%

7.9%

8.5%

8.5%

Percentage of births to resident mothers in which the newborn weighed less than 2,500 grams (5 pounds, 8 ounces).
(Data: 2013-15). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Vital Statistics,
2017 (Data: 2016-18). Source: Hawaiʻi Health Matters, Hawaiʻi DOH, Vital
Statistics, 2020

61

Food Security
Children experiencing food insecurity are more likely to experience developmental problems andperform poorly in school. The negative physiological and psychological impacts affect a child’s
behavioral and social development, which is likely to lead to future adverse health outcomes into
adulthood.
Going into the pandemic, fewer Hawai‘i students were eligible for the Free Lunch Program andthe percentage of children living below poverty level had improved. However, when the pandemic
closed public schools, meals were not provided to school aged children who depended on the daily
nutritious meals.
Many families have also lost financial stability during the pandemic. Most children come fromhouseholds where all parents are in the workforce. Overall, Hawai‘i (74.2%) and its counties had
more households with all parents holding down a job than was true nationally (71.5%), and, ofcourse, multiple jobs are often necessary to keep up with the cost of living. Kaua‘i County (82.9%)
had the highest among the counties; while, Honolulu was 72.9%.

2015-162019-20

STUDENTSELIGIBLE
FOR FREELUNCHUSHAWAI`I

Hawai`i
CountyMaui
CountyC&C ofHonoluluKaua`iCounty

42.6%

40.1%

58.3%

40.7%

36.1%

38.4%

41.2%

36.5%

53.9%

34.5%

32.6%

35.5%

Percentage of students eligible to participate in the Free Lunch Program under the National School Lunch Program.
(Data: 2015-16). Source: Hawaiʻi Health Matters, National Center for Education Statistics, 2018
(Data: 2019-20). Source: Hawaiʻi Health Matters, National Center for Education Statistics, 2020. State figure is from 2018-19.

2013-17
2015-19

CHILDREN
BELOW
POVERTY

20.3%

12.9%

23.7%

11.6%

11.2%

8.3%

18.5%

11.9%

22.9%

10.7%

10.1%

9.0%

Percentage of people under the age of 18 who are living below the federal poverty level.
(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates,2017 (Data: 2015-19). Source: U.S. Census, American Community Survey 5-year
estimates, 20192013-17
2015-19

PARENTS
WORKINGUSHAWAI`I

Hawai`i
CountyMaui
CountyC&C ofHonoluluKaua`iCounty

70.7%

73.4%

73.8%

79.1%

71.7%

81.5%

71.5%

74.2%

74.4%

77.8%

72.9%

82.9%

Percentage of households with children 6-17 years old and all parents in the family are in the workforce(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017
(Data: 2015-19). Source: U.S. Census, American Community Survey 5-year estimates, 201962

Stress
The percentage of children living in single parent households have remained steady since 2017.
Today, single-parent families make up a large segment among family households at almost threeout of ten. Overall, the state is below (28.7%) the national level (32.7%). However, three counties(Hawaiʻi, Kauaʻi and Maui) are near or above the national figure.

2013-17
2015-19SINGLE
PARENT
HOUSEHOLDSUSHAWAI`I

Hawai`i
CountyMaui
CountyC&C ofHonoluluKaua`iCounty

33.0%

29.1%

37.7%

33.8%

26.5%

30.9%

32.7%

28.7%

38.1%

32.5%

25.8%

32.9%

Percentage of children living in single-parent family households (with a male or female householder and no spousepresent) out of all children living in family households.
(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017
(Data: 2015-19). Source: U.S. Census, American Community Survey 5-year estimates, 2019

Health Insurance
Before the pandemic, the state had observed a slight improvement among children under the ageof 19 who were covered by health insurance.
Since the beginning of the pandemic, there’s been an increase of residents enrolled in Medicaid
coverage. Maui County (36%) had the highest portion of residents enrolled under Medicare since
March 2020. It was recently reported on Hawaii News Now (dated September 29, 2021) that halfof the children in Hawai‘i are covered under Medicaid.

2013-17
2015-19

CHILDREN
w/o HEALTH
INSURANCEUSHAWAI`I

Hawai`i
CountyMaui
CountyC&C ofHonoluluKaua`iCounty

5.7%

2.5%

2.7%

3.2%

2.4%

2.6%

5.1%

2.3%

2.6%

3.3%

2.0%

3.0%

Percentage of children under 19 years who do not have health insurance.
(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017
(Data: 2015-19). Source: U.S. Census, American Community Survey 5-year estimates, 201963

Asthma
Asthma is a common chronic disease among young children. While the rates for childhood asthma
are still relatively high (7.5%, state), it has improved since last reported (10.2%). Honolulu
observed the most improvement from 10.1% to 7.2%. However, Kaua‘i County saw a rise to12.5%, the highest among the counties.

2016
2019

CHILDREN
w/ASTHMAUSHAWAI`I

Hawai`i
CountyMaui
CountyC&C ofHonoluluKaua`iCounty

9.2%

10.2%

11.9%

10.0%

10.1%

8.2%

N/A

7.5%

6.9%

9.1%

7.2%

12.5%

Percentage of children under 18 years of age that currently haveasthma. (Data: 2016). Source: Hawaiʻi Health Matters, Hawaiʻi DOH
BRFSS, 2018 (Data: 2019). Source: Hawaiʻi Health Matters, Hawaiʻi DOH
BRFSS, 2021

Education
Before the pandemic, there was a slight improvement in early childhood education enrollment
among three- and four-year olds for Hawai‘i and three of its counties. Only Maui County had
experienced a downturn in enrollment, from 51.7% to 44.6%. The disruption in education causedby the pandemic prevented three- and four- year olds from being in a safe and nurturing
environment to support their learning and developmental years. Thus, many childcare workers
were faced with unemployment or termination as enrollment decreased or childcare centers closed.
Before the pandemic, national (48.3%) and state (48.0%) figures for early childhood education
enrollment remained stable and showed positive change.
Furthermore, daycare centers were shut down due to lack of workers or low student enrollment
due to low immunization rates among preschoolers. During the pandemic, many residents avoided
medical centers and doctor offices or lost health insurance coverage for their family because they
were unable to work. This meant immunization among 3- and 4-year olds were postponed orignored, for children who were about to start preschool or daycare. Thus, children were unable toenroll in daycare or preschool without the required immunization.

2013-17
2015-19EARLY
CHILDHOOD
EDUCATIONUSHAWAI`I

Hawai`i
CountyMaui
CountyC&C ofHonoluluKaua`iCounty

47.5%

47.6%

43.7%

51.7%

48.5%

35.8%

48.3%

48.0%

44.1%

44.6%

49.9%

41.8%

Percentage of three- and four- year olds enrolled in school (public or private).
(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates,2017 (Data: 2015-19). Source: U.S. Census, American Community Survey 5-year
estimates, 201964

Results of the Strive Hawai‘i (DOE) testing in 2021 showed a sobering 26% decrease in mathproficiency scores and a similar 20% drop in science scores. The disruption in in-classroom
teaching is proving to be problematic in a child’s early foundation for critical thinking and social
wellbeing. It will be particularly challenging to assess the needs of certain at-risk groups(homeless, Micronesians, Pacific Islanders, and Native Hawaiians), where many opted to keep
their children home rather than return back to the classroom for in-person learning.
Many students described to be at-risk were not equipped with a technological device nor internet
access to participate in online learning. Thus, chronic absenteeism was observed among
Micronesians (77%), English learners (72%), and among Pacific Islanders (55%). The Departmentof Education conducted a study amongst 90,000 students in grades 1 through 8. The study showedsimilar results to earlier studies, with a higher percentage of students who were performing below
their grade level.
Children Living with Disabilities
When schools shut down and distance learning took into effect, it proved challenging for parentsof school-aged children with disabilities and special needs. Daily routines utilizing specialized
occupational exercises and tools could not be followed at home.

2013-17
2015-19

CHILDREN
W/DISABILIT
Y<5 YRSUSHAWAI`I

Hawai`i
CountyMaui
CountyC&C ofHonoluluKaua`iCounty

0.8%

0.5%

0.3%

0.6%

0.6%

0.7%

0.7%

0.7%

0.8%

0.6%

0.7%

0.7%

Percentage of children less than 5 years old with any disability(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates, 2017
(Data: 2015-19). Source: U.S. Census, American Community Survey 5-year estimates, 20192013-17

2015-19

CHILDREN
W/DISABILITY
5-17 YRS

5.4%

3.7%

3.5%

4.1%

3.8%

2.9%

5.5%

3.9%

5.3%

3.7%

3.8%

1.7%

Percentage of children 5 to 17 years old with any disability(Data: 2013-17). Source: U.S. Census, American Community Survey 5-year estimates,2017 (Data: 2015-19). Source: U.S. Census, American Community Survey 5-year
estimates, 201965

TeensThe ongoing stress, fear, grief, and uncertainty created by the COVID-19 pandemic has impacted
everyone, but many children and teens have had an especially tough time coping with the
unknown. The social bonding in formative years has been severed due to school closures,
separation of friends, and canceled activities. Anxiety, stress and mental health challenges areheightened concerns that need immediate attention.
Obesity and Eating Disorders
During the pandemic, as parents found themselves with more things to do but with less time to doit, fast food meals became the quick solution. A CDC study released in September 2021 showedsignificant weight gain nationally among children and teens between the ages of 2 and 19. Before
the pandemic, child obesity levels were at 19%, increasing to 22% during the pandemic. Higher
obesity levels translate to higher respiratory problems, diabetes and high blood pressure at an
earlier age. And according to a recent report by the Robert Wood Johnson Foundation, the obesity
rate for preteens and teens in Hawai‘i ages 10 to 17 showed a significant increase from 11.1% in
2018-2019 to 15.5% in the years 2019-2020.
The prevalence of eating disorders continues to rise at a steady pace for Hawai‘i’s teens. While
Maui County showed a slight improvement at 23.4% from 22.4% in 2017, data from other counties
indicated an increase.

2013
2019

TEEN
EATINGDISORDERUSHAWAI`I

Hawai`i
CountyMaui
CountyC&C ofHonoluluKaua`iCounty

N/A

20.8%

18.1%

23.4%

21.0%

19.9%

N/A

21.5%

22.0%

22.4%

21.2%

22.3%

Percentage of public school students in grades 9-12 who went without eating for 24 hour or more, took diet pills,
powders, or liquids without a doctor's advice, or vomited or took laxatives to lose weight or keep from gaining weight in
the past 30 days.
(Data: 2013). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2017
(Data: 2019). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2021

66

Sufficient Sleep
Only one out of 4.5 Hawai‘i teens, on average, gets 8 or more hours of sleep per night. However,with the exception of Honolulu County (21.9%), the other counties reported a higher percentageof teens getting 8 or more hours of sleep on a school night than the national figure (22.1%).

2017
2019

TEEN
w/SUFFICIENT
SLEEP

US

HAWAI`I

Hawai`i
CountyMaui
CountyC&C ofHonoluluKaua`iCounty

27.3%

22.8%

26.6%

21.8%

22.2%

23.8%

22.1%

22.8%

25.7%

23.5%

21.9%

26.0%

Percentage of public school students in grades 9-12 who got 8 or more hours of sleep on an average school night.
(Data: 2017). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System,
2018 (Data: 2019). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance
System, 2021

OnlineOn the positive side, prior to the pandemic, data show that local teens were more likely to spend
less than 2 hours a day online (on activities other than school-related) than were their Mainland
counterparts.

2017
2019

TEEN <2 HOURSSCREEN TIMEUSHAWAI`I

Hawai`i
CountyMaui
CountyC&C ofHonoluluKaua`iCounty

58.3%

59.3%

61.3%

55.3%

59.2%

63.5%

53.9%

58.2%

63.8%

54.4%

57.4%

62.0%

Percentage of public school students in grades 9-12 who play video or computer games or use a computer forsomething that is not school related for two hours or less on an average school day.
(Data: 2017). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2018
(Data: 2019). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2021

67

Bullying and cyberbullying showed moderate signs of improvement, but remain a concern. In
2019, 17.0% of island teens reportedly experienced bullying; whereas, it was at 18.4% in 2017.

2017

US

HAWAI`I

Hawai`i
CountyMaui
CountyC&C ofHonoluluKaua`iCounty

20.2%

18.4%

21.3%

21.7%

17.1%

19.9%

19.5%

17.0%

20.7%

18.1%

15.8%

19.2%

TEEN BULLIED
2019

Percentage of public school students in grades 9-12 who were bullied on school property in the 12 months preceding
the survey.
(Data: 2017). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2018
(Data: 2019). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2021

2017
2019

TEEN
CYBERBULLIED

15.5%

14.6%

15.1%

16.4%

14.0%

16.1%

15.7%

13.1%

15.8%

14.0%

12.2%

14.5%

Percentage of public school students in grades 9-12 who were electronically bullied, including bullying through email,chat rooms, instant messaging, web sites, or texting, in the past 12 months.
(Data: 2017). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2018
(Data: 2019). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2021

SuicideA growing health concern is the increased numbers of teen suicide attempts in our island state. In
2019, the state surpassed the national figure, 3.2% versus 2.5%. In Hawai‘i County, 4.3% of their
public school teens reported a suicide attempt that required medical attention within the past year.
Maui County also reported a high percentage at 4.0%. While the U.S. overall reflected a decrease
from 2017 to 2019, Hawai‘i’s rates increased.

2017
2019

TEEN SUICIDEATTEMPTUSHAWAI`I

Hawai`i
CountyMaui
CountyC&C ofHonoluluKaua`iCounty

2.8%

2.4%

3.5%

3.1%

2.1%

3.4%

2.5%

3.2%

4.3%

4.0%

2.9%

3.0%

Percentage of public school students in grades 9-12 who reported at least one suicide attempt that required
medical attention in the past 12 months.
(Data: 2017). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2018
(Data: 2019). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2021

Trusted Adults and Role Models
Four out of five (79%) of Hawai‘i teens reported that they had an adult or teacher they could
confide in. However, when compared with data from 2017, these percentages have decreased in
all counties, except Kaua‘i, which remained the same.

68

2017
2019

TEEN
w/ADULT
THEY CANTALK TOUSHAWAI`I

Hawai`i
CountyMaui
CountyC&C ofHonoluluKaua`iCounty

N/A

81.9%

84.4%

81.7%

81.5%

81.3%

N/A

79.0%

78.7%

78.3%

79.0%

81.3%

Percentage of public school students in grades 9-12 who report they have an adult or teacher they can talk to about
things that are important to them.
(Data: 2017). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2018
(Data: 2019). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2021

VapingCurrently, teen vaping is on the rise, both nationally and locally. It is a major health concern as
numbers escalate for the state and each of the four counties. In 2017, Hawai‘i reported that 42.3%
of teens had tried vaping. Jumping to 2019, that number increased significantly to 48.3%. Threeout of the four counties surpassed the national rate of 50.1%; Maui County having the highest at
58.1%.

2017
2019

TEEN TRIED
VAPINGUSHAWAI`I

Hawai`i
CountyMaui
CountyC&C ofHonoluluKaua`iCounty

N/A

42.3%

49.6%

50.7%

39.0%

45.3%

50.1%

48.3%

56.5%

58.1%

44.5%

51.6%

Percentage of public school students in grades 9-12 who have ever tried an electronic vapor product (e.g. ecigarettes, vaping pens).
(Data: 2017). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2018
(Data: 2019). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2021

Alcohol
Alcohol use among teens showed improvement in 2019, with consumption across the Islands down
to 20.4% from 24.5%. This decrease can be seen in all four counties.

2017
2019

TEEN ALCOHOLUSEUSHAWAI`I

Hawai`i
CountyMaui
CountyC&C ofHonoluluKaua`iCounty

32.8%

24.5%

32.1%

32.8%

21.0%

30.1%

29.2%

20.4%

27.9%

27.7%

17.3%

24.3%

Percentage of public school students in grades 9-12 who had at least one drink of alcohol on at least one day in the past
30 days.
(Data: 2017). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2018
(Data: 2019). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2021

69

Teen Meth
Hawai‘i’s teen methamphetamine trial and usage is more than double the national rate, 4.5% and2.1% respectively. While Neighbor Island counties reflected decreases, the percentage of O‘ahu
teens reporting using “ice” at least once in their life increased slightly. Similarly, the percentageof teens who reported being offered drugs at school is higher than is reported nationally.
.

2018
2021

TEEN METH USEUSHAWAI`I

Hawai`i
CountyMaui
CountyC&C ofHonoluluKaua`iCounty

3.0%

4.8%

5.7%

6.2%

4.3%

5.4%

2.1%

4.5%

4.7%

4.6%

4.4%

5.3%

Percentage of public school students in grades 9-12 who have used methamphetamines (also called speed, crystal, crank,
or ice) one or more times during their life.
(Data: 2017). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2018
(Data: 2019). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2021

2018

OFFEREDDRUGS ATSCHOOL

21.7%

25.4%

26.8%

26.5%

25.3%

21.4%

Percentage of public school students in grades 9-12 who were offered, sold, or given illegal drugs on school property inthe past 12 months.
(Data: 2015). Source: Hawaiʻi Health Matters, Hawaiʻi DOH Youth Risk Behavior Surveillance System, 2016

“Our kids had a basic understanding of COVID but didn’t really realize how serious this disease
could be. They were seeing their family members passing away right and left, but their publichealth understanding was very limited, so they would go to work, even if they had exposure.
They also didn’t know that the eviction moratorium was in place.
We connected with a hospital to bring outreach workers to talk with our kids - that was great.
The kids asked a lot of questions, and it was super helpful.”
Youth Career Program Leader

702021 Community Health Needs Assessment
Page 69

III.

Addressing Health Priorities
A. A Shared Kuleana for Community Health

The 2018 baseline CHNA proposed an empowering framework of shared kuleana. The following
is an excerpt that is important to reassert, reestablish, and recommit towards.
“At some point in history, a model of healthcare was established that went thisway: It is up to the doctor to heal the patient, and it is up to the patient to comply
with the doctor’s orders. But even as our understanding of health grew to include
public health, prevention, and social determinants, our concept of responsibility
for health doesn’t seem to have kept pace. We are still primarily looking tohealthcare—now in the form of the healthcare industry—to drive theimprovement of health, now including community health. In turn, the industry
puts increasing onus on individuals to adopt “healthy lifestyles”—something thatmany in the community would say is essentially impossible for lack of a basic
foundation for health. Expectations are unrealistic on both sides of the equation.
Rather than pushing responsibility back and forth between individuals and thehealthcare system, it is more realistic and more consistent with Hawaiʻi values toengage one another and share kuleana throughout the entire healthcare
ecosystem.”
The HAH CHNA process has adopted the understanding of upstream social determinants asdirectly connected to health and healthy outcomes. Hawaiʻi’s hospitals, the health care ecosystem,and the broader community are capable of addressing these Significant Health Needs and the 2021
Priorities, and building a healthy Hawaiʻi. A Hawaiʻi that keeps its people safe, that provides
enriched environments for its keiki to thrive, that provides a home to every family that wants one,
where there is no stigma and discrimination, where healthcare meets people where they are, jobs
can provide a good quality of life, that lives up to is promise of celebrating diversity, that seeks toheal generational trauma, where sustainable food and quality education are accessible for all, andwhere the ʻāina and spaces in which we live are honored and respected. A Hawaiʻi that is healthy.

“If we believe that community is the solution to these issues, then we need to invest in ameaningful way that shows that we mean that. A priority is equality and justice - but people
are so disconnected from believing that we can achieve equality and justice.
We forgot that we are the solution to the problems that we face.”
Social Work Educator71

B. Developing Strategies to Address Priorities
One of the requests from the Steering Committee was to include potential strategies that would
allow hospitals to engage with and make an impact on relatively high-level priorities. The
assessment process raised many recommendations and best practice examples, many of which are
discussed throughout this report in their respective sections. This section includes two elements:
1. Recommendations that HAH members might consider approaching collectively, in orderto make a noticeable and meaningful impact with communities while also leveraging
resources, lessons learned, and symbiotic energy.
2. A table of the compiled strategies shared throughout the report.
Collective Strategies
These strategies might be considered collectively as an industry, where the sum is greater than its
parts, and the ability to leverage synergies can improve the opportunity for impact.
Community Health Workers
As was explored in Section II. C., CHWs have had successes in helping many underserved
communities to achieve healthy outcomes, and hospitals choosing to embrace these roles within
the system could be an opportunity to address a number of the 2021 Priorities. Minimally, working
together across the system and where CHWs currently operate to provide a shared definition andgoals would be helpful in identifying where support can be most meaningful.
One of the challenges identified by some of the hospitals is the lack of reimbursement for CHW
services. Hospitals may consider how to integrate housing services into these roles as they are
eligible for Medicaid reimbursement. For residents over 60, hospitals might seek out the Area
Agency on Aging for their respective County to determine how Older Americans Act funding
might be available to support patient care coordination needs.
Workforce Development
HAH has led a workforce development initiative since 2018, identifying workforce needs acrossthe healthcare continuum. One key element identified is the need for growth and careeradvancement while continuing to work, which HAH calls the “glidepath.” Community members
working in and around financial insecurity for communities suggested that hospitals might
consider introducing a living wage for their entry-level professionals and support “earn and learn”
opportunities to advance to family-sustaining wages. This could help to address financial security
for an important sector of the larger workforce and help with recruitment.
Workforce shortages were highlighted in other parts of the healthcare continuum as well, including
social workers, homeless service providers, and in-home care providers. Elderly affairs agencies
expressed that even when there is funding available to support in-home care workers and positions,providers have challenges finding people to fill positions.

72

While many hospitals reported working with local high schools and community colleges to provide
education on healthcare careers, partnership potential may exist to expand programs and an evenbroader spectrum of career pathways with these providers through the UH System, local
businesses, Department of Education schools, and in partnership with the State Workforce
Development Council and Workforce Development Boards in each County, supported throughfunding by the U.S. Department of Labor.
Below is an example of a Nurse Assistant to Nurse glidepath from HAH, where some of the greatest
needs lie.

73

Healthcare Facilities
The lack of critical facilities creates major fracture points that impact people throughout thehealthcare system, a number of them identified both by hospitals and community leaders, who are
engaging with the system on a daily basis and dealing with the repercussions of those limitations.
Hospitals may consider how to partner within the industry and with external public, private, andnon-profit partners to address some of these facility needs. A long-term residential (non-forensic)
mental health facility has the potential to provide care to severely mentally ill persons there (rather
than in hospital beds) and decrease homelessness. Short-term stabilization facilities withincommunities could assist with an alternate location for MH1s and provide for more comprehensive
care. Treatment beds in residential facilities would allow for discharge from hospitals toappropriate care settings. Residential recovery programs can support behavioral health needs.
Continuing Education
Trauma-informed care and cultural competencies are important to be understood by all frontline
workers. Even if CHWs are fully integrated into all hospitals, they are not going to, nor are they
intended to, provide the full panoply of care to an individual and rather assist them in navigating
it. Thus it is important that all frontline workers are regularly trained in care principles and they
do not only live on planning documents. HAH members could consider a blue ribbon standard ofrequirements for all facilities to implement ongoing training that could be centrally coordinatedand provided.

“It's really important for individuals to remember traumatic history when dealing withpatients and be sure not to re-traumatize these individuals.
I've heard many examples of Native Hawaiians who come in to their doctors and talk about
their traditional medicines that they've been using to try to heal themselves, and reallyreceived very dismissive treatment from medical professionals. That registry traumatizes
individuals and communities.
It's really important that we create safe spaces for individuals, and also connect back to the‘āina as much as possible.”
Social Work Educator

Post-Federal Funding Planning
Well over $4 billion has entered the State of Hawaiʻi and its Counties by way of federal funds
throughout the COVID-19 pandemic. These resources have come directly through state and local
governments, as plus-ups to existing entitlement programs, relief aid to address emergencies, andfunding to support community-level programs. The priorities have included both short term relief
needs to address the impacts the COVID-19 pandemic has had on communities and families, aswell as the long-term opportunities to invest in infrastructure and make structural changes to74strengthen the resiliency of government, systems, and communities to improve overall quality oflife and prevent future events from having such devastating impacts.
As these funds have come in, they are complex, have a wide range of eligibility expenditures andpriorities, vary in their jurisdictional implementation, and have differing expenditure deadlines.
For example, the first significant tranche of funding came in 2020 through the “CARES Act,”with an expenditure deadline of just over six months or funding would be lost. In addition to thecomplexities of the funding opportunities, the systems, and organizations responsible have tolayer these duties on top of existing responsibilities, which in many cases were alreadyover-taxed and under-resourced before the pandemic.
While having significant resources may sound like a great opportunity and, in many cases, hasbeen lifesaving, it has been challenging to strategically coordinate and make planful long-term
decisions around those resources. There is growing concern regarding what happens when thoseresources hit a cliff. For example, there are significant concerns about what happens to thosetrained staff and community resources, who were desperately needed and supported by federal
funds through the pandemic, when the funding comes to a close. In other cases, redundant systems
have been set up to address the volume of needs during the pandemic, which can negatively impact
existing systems in the long-term. A number of agencies and community organizations have turned
down funds fearing that capacity was lacking to responsibly implement new programs without
detriment to existing programs and those that rely upon them.
While strategic planning is happening in pockets, several key stakeholders throughout theassessment process identified the great opportunity that the healthcare industry may have toparticipate in and support coordinated discussions among the healthcare continuum regarding
those long-term planning needs, including making strategic decisions based upon the funding thatis available now and how it can help to develop critical infrastructure that outlasts the current
funding opportunities.

“Light was shone brightly on community health workers because of the pandemic.
Their ability to connect to the community and translate what was happening, especially when
you’re dealing with communities that are so distrusting of government, was critical.
That is why the federal government is investing in building up this workforce.”
Healthy Policy Leader

75Summary of Suggested Strategies by 2021 Priority
Below is a table list of suggested strategies made throughout the assessment process forconsideration by hospitals wishing to identify actionable steps in addressing the 2021 Priorities.
The research team recognizes that many hospitals are already individually deploying some of thesestrategies, advocating for these policy changes, and/or participating in community initiatives forcollective action. Indeed, all are integral parts of the communities in which they operate; and, by
virtue of this involvement, work for the betterment of their communities. These are offered simply
as a list of suggestions, requiring their own due diligence by respective and interested hospitals.
PRIORITY
Financial
Security

SUGGESTED STRATEGIES
●
●

●
●

●
●

●

●

Food
Security

●
●
●
●
●
●

Explore funding opportunities for care coordinators to assist householdswith accessing relief funding opportunities
Develop relationships with non-profit service providers addressing
financial security within respective communities and establish systems forwarm handoff of patients
Assist with accessing tax credits e.g. food tax credit
Implement high school and community training programs for entry-level
healthcare jobs that are targeted to low-socioeconomic statuscommunities and under-represented populations with a commitment tohire and provide support for career development
Evaluate a living wage minimum for all healthcare workers
Consider low-cost on-site child care for employees and/or other
employer-funded child care options. Consider collaborating with other
employers for joint employee child care initiatives
Utilize the hospital’s purchasing power to build local wealth in thecommunities you serve by locally sourcing goods, services, and food,supporting diverse and locally owned vendors, and helping to incubate
new community enterprises to fill supply chain gaps
Designate a percentage of the hospital facility’s investment portfolio toprovide affordable capital for projects in the hospital’s service area that
address the upstream drivers of health in collaboration with community
partners, such as affordable housing, healthy food access,environmental disparities, and economic empowerment for underserved
communities
Participate in communications around food as medicine
Greater collaboration between groups/coalitions being built
Purchasing food for hospital facilities from local farmers to support
production and be resilient to external interruptions
Partner with healthy food providers to identify households in need coming
in for care and providing meals upon discharge
Pursue collaborative funding to support meals at Title I schools
Support community farmers’ markets and local grocery stores

76

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Housing

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Screen patients for food insecurity and implement “food as medicine”
initiatives including: physician referrals to on-site food pantries,
partnerships with healthy food providers to provide meals upon discharge,
vouchers for local produce purchases at farmers markets
Partner with schools to develop healthy eating curricula, school gardens,
Farm to School networks, and healthy local meals
Support Farmers Markets and development of healthy food options
located at hospital facilities and in communities with low access to healthy
food options
Assist eligible patients to enroll in SNAP and contribute funding to
SNAP “double bucks” voucher programs
Utilize hospital cafeterias as sites for summer meal programs forschool-age children, and kupuna meals/gathering places
Provide space on hospital grounds for community garden; Utilize ahospital garden for culturally-based foods and medicinal plants
Benchmark and leverage hospital purchasing power to buy local andsupport development of local healthy food systems
Expand use of upstream determinants of health in screening questions;
Note food or housing insecurity in patient history
Explore the potential for developing workforce housing where facilities
may have appropriate land available
Partner to support workforce housing for healthcare workers
Integrate housing services into hospital programs now that they are an
eligible Medicaid reimbursable expense
Partner with housing organizations for billing support
Develop care coordinator relationships that create a “hand-off” fromthe hospital to the social service providers
Engage in advocacy efforts to support affordable housing initiatives

77Mental &Behavioral
Health

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Support de-stigmatization and training for proper care and customer
service, including considering mandatory training
Message publicly the cost of treating negative outcomes being higher thanre-investing in preventative treatment
Encourage and further develop delivery of service to meet people where
they are, via non-traditional channels, such as telehealth, street medicine,grocery kiosks, etc.
Build or enhance psychiatric capacity in Emergency Rooms
Address mental health needs of healthcare workers
Training on trauma-informed care, seeing the person beyond the crisis
Raise public awareness to help destigmatize mental and behavioral healthas well as access to resources
Engage in “normalizing strategies” such as supporting mental healthprofessionals in school, screening for teens, coping skills training
Partner with mental health service providers to address mental healthneeds while hospitalized, including discharge support and residential
treatment, when needed

Engage in efforts to support development of mental and behavioral
health workforce within our state
Support up-stream investment in existing community-based programs
Increase QUEST Field Service Coordination and allow for in-home
visits to identify and address needs before they become a crisis
Increase and develop mobile mental health resources and providers(Case Managers, LCSWs, Psychiatric APRNs, Psychiatrists,
Pharmacists) to frequently go into the community to clients
Seek partnerships to develop additional 24/7 mental health Crisis Sheltersin the community, where individuals could go if experiencing a mental
health crisis or high risk of substance abuse relapse and reduce
Emergency Department visits

78

Trust &Equitable
Access

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Greater collaboration with FQHCs and nonprofit organizations working
within marginalized communities
Invest in community health workers and medical social workers asimportant connectors to community
Build cultural competencies through training and hiring more bilingual
staff and those with deep community relationships
Build competencies through training on trauma-informed care,
understanding how to meet people where they are
Conduct consistent outreach in underserved populations in collaboration
with community partners
Increase signage in all areas around safety and violence
Support the cost of attendant travel for insurance purposes
Expand mobile and pop-up clinics
Expand and continue to promote telehealth initiatives
Support the expansion of broadband and programs that provide service
and equipment support to patients needing it
Invest in built environments that seek to break down shame and bias
Support healthcare in the schools such as the return of school healthnurses and health screenings
Partner to help address barriers to access such as transportation, childcare, language, digital literacy, etc.
Raise public awareness of need to destigmatize key populations or accessto resources
Increase digital access to patients, including technical assistance tosupport, such as through providing computers or kiosks on property
Work with established kiosks such as AlohaQ to add healthcare
and beyond services access and information
Promote and implement programs to support diversity, equity,and inclusion internally within hospitals to guide internal hiring
Support the development of culture that creates roles for non-clinicalstaff within emergency departments

79

“COVID laid it bare and showed us how weak our safety net is.
Some of these messes, we didn’t get into overnight.”
Youth Policy Advocate

C. Policy Opportunities
Many community organizations working in upstream social determinants are involved in policymaking and advocacy around those issues. One of the critical ways that the CAC had identified
that HAH and Hawaiʻi’s hospitals could be involved in supporting those upstream determinants is
by lending their voice to those policy discussions, whether at the executive branch, administrative,
or legislative level. Hawaiʻi’s hospitals are well respected and have an impactful voice in thesespaces and could help to establish and reinforce these social determinants as intrinsically related
to health. Supporting select advocacy efforts could also help to develop stronger working
relationships with community-based organizations and broaden the coalition of those advocating
for a better quality of life for Hawaiʻi residents.
Potential example policy initiatives are included below. A number of hospitals already support
various important social determinants. This report encourages hospitals to further connect with thecommunity and policy organizations working within the upstream social determinants to discuss
where there is alignment and greatest opportunity for healthcare voices to be effective.
● Advocating for a healthy Hawaiʻi through policy change, such as increased regulation of
tobacco products, sugary beverage fees, bringing more local produce into schools, andother initiatives● Raising Hawaiʻi’s minimum wage, currently $10.10/hr ($21,008/year full time)● Prohibiting housing discrimination against renters based upon source of income, so thosewith vouchers cannot be excluded so long as they can pay the rent
● Supporting Operating and Capital budget allocations to support any of the priorities● Allowing homeless youth in shelters without parental consent● Strengthening protections for domestic violence survivors● Support language access compliance in all state agencies and funding for in-state medical
interpreter training initiatives● Support taxing items to disincentivize such as sugar-sweetened beverages, tobacco, etc.
● Supporting progressive tax structure efforts that provide for sustained investment in thesecommunity-based health programs versus one-off grants80

D. Pali Momi Medical Center’s Selected Priority Health Needs
In 2016, the Hawai‘i Pacific Health system undertook an internal planning process to provide
focus for HPH’s community health initiatives and develop a strategy to more meaningfully
address the social (non-clinical) determinants of health. A work group made up of leadershipfrom across the HPH system conducted “listening sessions” with a wide range of community
organizations to learn about critical social issues impacting the health of our community, withspecial attention to vulnerable populations.
As a result of this process, HPH adopted the following priority areas of focus for its community
health partnerships: Strengthening families and developing resilient children by promoting 1)
Economic Empowerment through food security, housing stability, and self-sufficiency; and 2)
Education through holistic child development and family educational attainment.
This CHNA has identified five priority health needs: Financial Security, Food Security, Mental
Health, and Housing. To arrive at these priorities, the Ward Team synthesized input from all
sources and proposed prioritization options for feedback to the Steering Committee and CAC.
The Ward Team guided this process by presenting progressive prioritizations for feedback,integrated input, refined the prioritization, and presented again for feedback until agreed upon.
A committee of community benefits professionals from across HPH, including Pali Momi, thenevaluated the priority health needs identified in this CHNA using the following criteria:
 Alignment with the above HPH community health focus areas, Opportunity to leverage planned and existing HPH community partnerships andinitiatives,
 Alignment with HPH’s resources and expertise, and Potential to make a measurable impact in collaboration with partners.
Based on these criteria, Pali Momi Medical Center selected the following community healthpriorities to address in its 2023-2025 Implementation Strategy: Food Security
 Financial Security
 Trust & Equitable Access
E. Evaluation of Prior 2020-2022 Implementation Strategy Activities
Over the past three years, Pali Momi Medical Center conducted the following community benefit
activities to address the four priority community health needs identified in Pali Momi’s 2019
Community Health Needs Assessment: Strengthen Families, Build Good Food Systems, Invest in
Teenagers and Healthy Starts, and Provide Accessible Proactive Support for Those with High
Needs. Due to COVID-related restrictions on in-person gatherings and other precautions, certain
programs outlined in Pali Momi’s 2020-2022 Implementation Strategy were revised orsuspended. Pali Momi also stepped up to address pressing community health issues and social
needs triggered by the pandemic.

81Community Support to Address the COVID Pandemic
Pali Momi provided extensive community support to address the COVID public healthemergency, including standing up community COVID testing sites and vaccination clinics as wellas collaborating extensively with state agencies and other health care systems to provide expertise,assistance and public health education. From December 2020 through March 2022, Pali Momi
partnered with the other hospitals of HPH to administer 231,827 COVID vaccinations on Oahu,
at Pali Momi’s campus, community vaccination sites, and through a mobile clinic in a converted
bus that traveled to locations across the islands.
Priority 1: Strengthen Families by Addressing Financial Stress
Strategy 1.1: Increase affordable financial services and other economic empowerment
programs for low-income working families
Hawai‘i Community Lending: Pali Momi partnered with Hawai‘i Community Lending,a community development financial institution, to provide emergency micro-loans, alongwith financial counseling, to aid low-income families experiencing hardship due to theeconomic impacts of the COVID-19 pandemic. Collectively, funding from the hospitals of
Hawai‘i Pacific Health, Hawai‘i Community Foundation, the Chan Zuckerberg Foundation,
the County of Kaua‘i and the City & County of Honolulu provided 890 at-risk residents ofKaua‘i and O‘ahu with emergency loans that helped them to sustain their housing andprevent homelessness. All borrowers received financial counseling and establishedemergency household budgets to help them meet financial goals.



Health Careers Job Training: Pali Momi and the other HPH hospitals partnered with the
Hawai‘i Department of Education, Kamehameha Schools, Lili`uoukalani Trust, andResidential Youth Services and Empowerment to provide training in entry level allied healthoccupations such as medical assistant, nurse aide and patient services representative. These
highly-in-demand health care positions pay starting salaries above Hawai‘i’s minimum
wage and offer living wage career pathways. More than 250 students have successfullycompleted an HPH training program and more than 50 of them were hired by HPH.

Priority 2: Build Good Food Systems
Strategy 2.1: Increase access to healthy foods for food insecure families


SNAP Double-Up Food Bucks Incentives: In Hawai‘i, food insecurity increased
significantly due to economic fall-out from the pandemic, with nearly half of all children
identified as “food insecure.” Pali Momi partnered with a multisector coalition to support
a fund that offers double the value for all purchases of fresh, local produce made with
SNAP-EBT. Programs such as this have been demonstrated to increase consumption offruits and vegetables among SNAP-eligible households, as well as increase householdincome. The program also strengthens Hawai‘i’s food system by supporting local small
farmers. From 2018 to 2020 SNAP-participating households with access to a Double-Up
Food Bucks retailer near them increased by 272%, resulting in 77% of all SNAPparticipating households having access to a Double-Up Food Bucks retailer within shopping
distance of their homes. In 2020 and 2021, the program supported $2,641,387 in incentives,82

doubling the purchaser’s value on 373,375 local fruit and vegetable purchases. An estimated7,500 individuals benefited from the program each year.
Farm to Preschool: In 2021, Pali Momi, together with the other hospitals of Hawai‘i
Pacific Health and partner Kamehameha Schools, initiated a jointly-funded project to pilot
a Farm to Preschool program at two KS preschools on Kaua‘i. The intent of the pilot is todevelop a model that can be implemented in preschools across Hawai‘i. In the first six
months of the pilot, school gardens have been planted at both preschools, 18 teachers haveparticipated in 6 hours of professional development, serving 120 children and their families.
Locally grown fruit was purchased from local farmers and served to all 120 children withaccompanying curricula.

Grab and Go Preschool Meal Service: Pali Momi provided financial support for Parents
and Children Together’s 2020 meal program for preschool children. For many children,
school meals are a primary source of nutrition, and the grab and go meal program provided
access to healthy meals while schools were closed due to pandemic restrictions. In 2020,
PACT provided 15,191 meals to 502 preschool age children and 276 pregnant mothers andtoddlers living in socio-economically disadvantaged communities.



Aloha Harvest rescues excess commercially-prepared foods from markets and institutions
that would otherwise be thrown away and delivers it to social service organizations feedingvulnerable members of the community. Pali Momi’s food service participates in thisprogram, donating a total of 7,289 pounds of leftover meal items from its cafeteria over the
past three years.

Priority 3: Invest in Teenagers and Healthy Starts
Strategy 3.1: Address obesity among vulnerable children and youthHealthy Weight and Your Child is an intensive, family-based adolescent weight
management program to combat childhood obesity. Pali Momi and the other hospitals of
Hawai‘i Pacific Health, partnered with the YMCA of Honolulu and the Kidney Foundationof Hawai‘i to make the program accessible to families across O‘ahu right in theircommunities. In 2019 and early 2020, 4 cohorts were conducted reaching 32 participants
and their families. More than 60% of participants were in populations with healthdisparities, including Native Hawaiian, Pacific Islander, and Filipino. Due to pandemic
restrictions on in person gathering, the program was suspended during the early part of thepandemic and then re-designed so it could be delivered in an entirely virtual format toparticipants in their homes. In 2021 and 2022, 3 cohorts were conducted in this new format,
with 13 participants and their families successfully completing the program.

Strategy 3.2: Increase age-appropriate services that support healthy development andresilience among vulnerable children and youth

Residential Youth Services & Empowerment (RYSE): Pali Momi provided financial
support to this youth-specific shelter providing temporary overnight lodging and support
services to help homeless youth achieve housing, employment and self-sufficiency. From2020 to 2022, RYSE served over 300 youth and added three additional shelter locations.
83Priority 4: Provide accessible, proactive support for those with high needs
Strategy 4.1: Increase access to clinical services and improve health literacy for under-servedfamilies and individuals


Kahauiki Village is an affordable rental community for families who previously
experienced homelessness. Pali Momi has been providing on-site health education,screenings and check-ups for residents at periodic community Wellness Day events.
However, these activities were suspended from April 2020 to April 2022, due to pandemic
restrictions. At events in July 2019 and January 2020, attended by more than 200 Kahauiki
Village tenants, Pali Momi and the other hospitals of Hawai‘i Pacific Health provided backto school children’s health screenings, biometric screenings for adults, oral healthscreenings, and health literacy and nutrition education. HPH worked with Kahauiki Villagesocial services staff to refer those screened to the appropriate health care providers.



HOME (Homeless Outreach & Medical Education) Project: Pali Momi financially
supported the University of Hawai‘i John A. Burns School of Medicine’s HOME Project
which provides free medical services in community for homeless individuals by deployinga mobile clinic and utilizing volunteer medical students and physicians.

84

IV.

Conclusion
A. Mahalo from the Research TeamThe past nine months of this assessment has provided such an incredible experience. The researchteam has had the opportunity to engage with over 200 people across our island home, who care so
deeply about our Hawaiʻi. Social workers, teachers, farmers, doctors, policy advocates, mothers,
daughters, survivors, students, policy makers, nurses . . . all asking the question, “What makes
Ours a Healthy Community?” For the communities in which they live, the clients they serve,
the people they love.
With a charge of updating the 2018 Community Health Needs Assessment (CHNA) and withconsiderable recognition of the pandemic effects on the social determinants of health, the 2021
CHNA research team sought out a wide range of voices, perspectives, and communities tounderstand the unique and Significant Health Needs facing Hawaiʻi’s communities. The
foundations laid in 2018 focusing on upstream social determinants provided a critical backdrop
for building upon and delving into the barriers to healthy communities and people today.
While there initially were concerns about possible survey and interview fatigue and the thoughtthat these might dampen participation, it was clear that the pandemic experience had sharpened
community focus on the social determinants of health and, indeed, had resulted in a generous
willingness to participate. There was tremendous recognition of the sacrifices and contributionsof hospitals and the entire continuum of healthcare throughout the last two years, and what could
even be described as excitement for an opportunity to identify ways to strengthen healthcare
systems and build trust with communities.
Recommendations and best practices were bountiful. This report seeks to lift those up and provide
specific pathways for hospitals to consider being part of addressing Significant Health Needs.
Trauma experienced throughout the community is profound, both individually and collectively.
This report seeks to honor and learn from those experiences.
We were inspired by community members that shared stories of the strength of honoring place
and acknowledge the healing that Hawaiʻi’s ‘āina can provide. We were influenced by the ʻōlelo
noʻeau: “Mōhala i ka wai ka maka o ka pua,” - people, like flowers, thrive where there iswater and resources for a good quality of life. We are honored to have been a small part of theimportant work of keeping our communities alive and thriving, and we believe the hospitals o
Hawaiʻi have the power and passion to be life bringing wai to Hawaiʻi’s communities.
Me ka mahalo a me ke aloha pumehana. E mālama. E ola.
Becki & Becky

85

B. Acknowledgments
Many people throughout the healthcare community, healthcare continuum, and our community
broadly helped input into this 2021 update of the Community Health Needs Assessment. The
research team saw its role primarily as a conduit for a deep well of knowledge to provide aframework for understanding the complex and interconnected needs facing our communities
today and a pathway with actionable and achievable next steps.
Our client and partner in this process was HAH. Mahalo to the executive leadership and theSteering Committee, who entrusted us with this critical responsibility. We also want to offer
special thanks to Jodi Hashimoto, who served as our project manager, and Lori Henning, without
whom this CHNA would not have come together as it did. The critical project management,
expertise, and leadership they provided were invaluable and helped keep every stakeholder
engaged and every critical deliverable on track. We highly recommend that future CHNA’s
include strong project management support.
We also want to extend gratitude to the 2018 research team, who moved mountains in shifting
the lens of this vital work from clinically focused to more broadly understanding and embracing
the social determinants of health as the framework for this work moving forward. Building uponthat foundation was an honor, and we sincerely appreciate the 2018 team and those involved inthat report.
In addition to the formal partners, stakeholders, key informants, community connectors, andstakeholders identified throughout this report and its appendices, many individuals served as kumu
- sources of knowledge and mentorship - to our team. Out of respect for the preferred anonymityof many, we simply say, our most sincere mahalo.

“In public health, we often think about our objectivity and being actually removed from
communities, when in fact we should be embedded, immersed, and part of.
How do we make communities more resilient?
What we know is that trauma isolates, and we know that that isolation keeps people
separate from others who could be resources, both formal and informal. And we knowthat the healing process for trauma means bringing people together.”Social Work Educator

86

V.

AppendicesA. Appendix A - Shared Kuleana Strategies

The resources below are a sample of projects and special programs currently operating withincommunity around the 2021 Priorities. It is not an exhaustive list of all programs and is notintended as a list of providers, although they are referenced and mentioned where appropriate orwhere a specific program wasn’t named but housed within an organization.
1. Coalitions
There are a number of coalitions working in and around the various 2021 Priorities andother Significant Health Needs. Some hospitals already participate. These could be good
opportunities to join existing work and support the collective work being done with
communities around social determinants of health. Suggested examples include:● Affordable Housing Coalition: https://www.ahafellows.com/home● Hawaiʻi Coalition for Immigrant Rights: https://www.hicir.org/● Hawai‘i Oral Health Coalition:
https://www.hiphi.org/hawaii-oral-healthcoalition/● Kūpuna Food Security Coalition:
https://www.hiphi.org/kupuna-food-securitycoalition/● Obesity Prevention Task Force (OPTF) - originally convened through statuteby the Department of Health, the OPTF continues to meet and is convened by
HIPHI: https://www.hiphi.org/heal/healthy-eating-active-living-coalitions/● Partners in Care (PIC): https://www.partnersincareoahu.org/● Working Families Coalition: https://www.workingfamilieshawaii.org/
2. Financial Security
ALICE. Aloha United Way recently released a report, ALICE: A STUDY OF
FINANCIAL HARDSHIP IN HAWAI‘I. ALICE (Asset Limited, Income Constrained,
Employed) individuals and families are those who have at least one job yet cannot
afford housing, child care, food, transportation and health care. Nearly one in twohouseholds in Hawaiʻi are ALICE and below. Since releasing its report, AUW has
focused on supporting the ALICE community on strengthening their financial health.
AUW embraces the reality that sustainable social change must involve cross-sector
coordination, long-term commitment, and investment in deeper relationships withstrategic partners. Additionally AUW hotline at 211 provides referrals to relevant
programs. (https://www.auw.org/alice)87

Hawaiʻi Budget & Policy Center (HBPC). A program of Hawaiʻi Appleseed,
HBPC works on state and local economic policies to increase opportunity for all
residents by analyzing and understanding the implications of tax and budget
decisions and educating public and policy-makers. The HBPC’s advisory board
includes representatives from Kaiser Hospital, Federally Qualified Health Centers,
the University of Hawaiʻi System, and community-based organizations.
(https://hibudget.org and https://hiappleseed.org)
Maui Economic Opportunity (MEO). A nonprofit Community Action Agency
committed to helping low-income individuals and families become stable and achieve
economic security, MEO provides many important programs. This report focuses on
itstransportation services. On Maui and Molokaʻi, van drivers transport their participants todoctor’s offices. The services, funded largely via County of Maui grant appropriation,
include transport for services such as Ala Hou, Easter Seals & Adult Day Care,
Employment for the Disabled, Dialysis, Low-income and Economically Challenged,
Kaunoa Leisure Program, Ka Lima O Maui Program, Rural Shuttle, Senior Nutrition
Program, Youth and Community, HeadStart Program, Hospice of Maui, Independent
charter, Maui Memorial Medical Center, and Medicaid. (http://www.meoinc.org)
Working Families Coalition: Organized by Hawai‘i Children’s Action Network,
this coalition of advocacy and service-providing organizations advocates for proworking family policies including raising the minimum wage, Earned Income Tax
Credit and affordable child/elder care.
(https://www.workingfamilieshawaii.org)
3. Food Security‘Āina Pono: Farm to School Program , Hawaiʻi State Department of Education(HIDOE). This program is increasing local food in student meals as well as
connecting keiki with the ‘āina through their food, using produce from local farms.
HIDOE hasestablished partnerships that include the Office of the Lieutenant Governor, theHawaiʻi Department of Agriculture (HDOA), the Hawaiʻi State Department of Health(DOH),The Kohala Center, Kōkua Hawaiʻi Foundation, Ulupono Initiative, the Hawai‘i
Farm to School Hui, Dorrance Family Foundation, Hawaiʻi Appleseed, Johnson
ʻOhana Charitable Foundation, Kaiser Permanente, the Hawaiʻi Farm Bureau
Federation(HFBF) and HMSA.
Blue Zones Project. Dan Buettner’s book, The Blue Zones: Lessons for Living Longer
from the People Who’ve Lived the Longest , evolved into a worldwide network of“community-wide well-being improvement initiatives” intended to help people live
longer, healthier, and happier lives. The Hawaiʻi Medical Service Association (HMSA)
brought the Blue Zones Project to Hawaiʻi, with program staff implementing various
activities in communities throughout the state. For example, in September 2018, Blue
Zones held a Big Island Food Policy Summit in Hilo that convened close to 100

88stakeholders from agriculture, the food industry, health, education, local government,
and various parts of the community to build a common agenda for Hawaiʻi Island’s
food self-reliance and work toward creating a healthy food system for Hawaiʻi Island.
(https://hawaii.bluezonesproject.com)
The Bodacious Women of Pāhoa, Nānāwale, Hawaiʻi. What began as a small groupof friends getting together to socialize grew to volunteers helping with a monthly foodpantry. In the summer of 2014, when Hurricane Iselle hit Hawaiʻi Island, isolating
many communities from assistance, the group began to aggregate and distribute
hundreds of bags of groceries to households that needed food. Following thatexperience, Bodacious stationed shipping containers stocked with food in several Puna
communities to prepare for future disasters.
(https://www.punalavaflow2018.com/bodacious)
Community Meal, St. James’ Church, Waimea, Hawaiʻi Island . The Community
Meal is a weekly Thursday evening dinner hosted by St. James’ Church in Kamuela,
which began as a meal for the “homeless, working poor, lonely and downright hungry in
our community.” It has grown into a popular and diverse community event for everyone.
Local farmers and ranchers contribute food to the meal; volunteers cook, bake and serve;
and leftovers are delivered to senior homes, houseless shelters, and to the homes offamilies who need food. Many cite the weekly event as a source of community pride,
bringing people together to build relationships and help each other.
(http://stjameshawaii.org/community-meal)
Community “Poi Day,” Waipā Foundation. This community gathering happens
every Thursday at 5 am when community volunteers gather to process cooked kalo intopoi
and lunch is served when the job is done. Poi Day was started about 30 years ago by the
Hawaiian families along Kauaʻi’s north shore to keep poi available and affordable.
Today, Waipā distributes poi to kūpuna and ʻohana throughout theisland. (http://waipafoundation.org/community_poi)
Double Up Food Bucks. This program helps low-income people who are on SNAP orfood stamp benefits buy more healthy fruits and vegetables at participating markets andgrocery stores. As its name suggests, the program doubles the value of benefits thatenables people to eat local produce and support local farmers. Many organizations areoffering this program throughout Hawaiʻi, including The Food Basket (HawaiʻiIsland’s Food Bank), Sust‘āinable Molokaʻi, Mālama Kauaʻi, Mālama Learning
Center’s Mākeke Kapolei market, Waiʻanae Coast Comprehensive Health Center’s
MākekeWaiʻanae, Kōkua Kalihi Valley, and others. (http://www.doubleupfoodbucks.org)
Farm to School Hui Under the Hawaiʻi Public Health Institute, this hui aims tostrengthen the farm-to-school movement in Hawaiʻi. It does this by supporting networks
on five islands by sharing resources, capacity building, professional development, andadvocacy. It works with community organizations, and representatives of the
Hawai‘i departments of agriculture, education, health, and the University of Hawai‘i.
(https://www.hiphi.org/farmtoschool)89

Hawai‘i Good Food Alliance. The Hawai‘i Good Food Alliance is a diverse hui ofcommunity leaders who share in the production, aggregation and distribution of food to
re-build thriving community food systems in Hawai‘i. Partners work in and with thecommunity for community-led economic and social development.
hawaiigoodfoodalliance.org
Keiki Produce Prescription . The Mākeke Waiʻanae Farmacy Keiki Produce
Prescription Pilot Project provides children and their families with produce prescriptions,redeemable for locally grown produce at Mākeke Waiʻanae (farmers market). Each“prescription” is good for three $24 refills to be distributed to patients monthly when
they visit the Waiʻanae Farmers Market. The objective of the project is to increase
access to healthy, locally grown food, improve diet quality and reduce the burden ofchildhood obesity and risk for future chronic disease.
KEY Project Kūpuna Program . The Kūpuna Program promotes socialization,
culture, exercise, and access to healthy foods. On Wednesdays and Fridays, up to
100 senior citizens fill into the KEY Project campus to have fellowship and a freshly
prepared meal. The program involves many other activities, like ukulele and art
classes, field trips, and guest speakers.
(https://keyproject.org/index.php/senior-citizenskupuna)
Kūpuna Food Security Coalition: Recently organized to meet the immediate nutritional
needs of elders during 2020 and the start of the COVID-19 pandemic, the coalition brings
together nonprofits, community leaders, and government entities to ensure that kūpuna
have access to food. (https://www.hiphi.org/kupuna-food-security-coalition/)
Roots Mobile Market, Kōkua Kalihi Valley . The Mobile Market is a mobile
produce service, bringing local farmers’ products right to local businesses, agencies, orcommunity sites. The Mobile Market began as a way to distribute produce to KKV
employees who couldn’t make it to the market during their work day.
(https://www.rootskalihi.com)
Transforming Hawai‘i Food Systems. An newly formed initiative that seeks to build
statewide capacity and pave the way for a robust, sustainable and resilient food system.
The initiative harnesses innovation and momentum developed in response to the
COVID-19 pandemic, documents lessons learned, articulates policy and planningrecommendations, and sets up the State to expand large-scale institutional purchasingof local foods. (https://transforminghawaiifoodsystem.org/)

4. Mental & Behavioral Health
Hawai‘i Health and Harm Reduction Center (H3RC). The Hawai'i Health and Harm
Reduction Center serves Hawai’i communities by reducing the harm and fighting the90stigma of HIV, hepatitis, homelessness, substance use, mental illness, and poverty in ourcommunity. They focus efforts on those disproportionately affected by social
determinants of health, including but not limited to: people living with and/or affectedby HIV, hepatitis, substance use, and the transgender, LGBQ and the Native Hawaiian
communities. They seek to foster health, wellness, and systemic change in Hawai’i and
the Pacific through care services, advocacy, training, prevention, education, andcapacity building. (https://www.hhhrc.org/)Ho‘omau Ke Ola. A residential treatment and recovery program, they base theirapproach on a philosophy of creating a learning environment that is based on cultural andspiritual values from Hawaiʻi’s rich past. Moʻolelo, or storytelling of some Hawaiʻi’slegends and history, can engage those who have been reluctant to share their own history
and pain. They are working to create an ʻāīna-based program that will pair traditionalfarming and learning to help restore severed connections to land, families, and culture.
(http://www.hoomaukeola.org/)
Kōkua Kalihi Valley (KKV) Elder Services. KKV’s Elder Care Programs provide
Kalihi seniors from all cultural backgrounds with holistic care. At KKV’s ElderCenter and at the nearby public housing community of Kūhiō Park, elderly clientsgain daily opportunities for social engagement, physical activity health education, andprimary health care. (http://kkv.net/index.php/elder-care)
Kōkua Life, Suicide Prevention App for Hawai‘i . Kōkua Life is a suicide prevention
app that provides users with Hawaiʻi resources and tools related to suicide prevention. It
is designed for use by both healthcare or other professionals and the general public tofind help for oneself or others. It includes a resource directory for mental health andsocial service providers on each island. Kōkua Life was created by Mental Health
America of Hawaiʻi with funding from the State of Hawaiʻi Department of Health.
(https://kokualife.org)
Mental Health Kōkua. Mental Health Kokua assists people with mental health andrelated challenges, to achieve optimum recovery and functioning in the community.
MHK has grown to an organization serving a broad range of behavioral healthneeds, with 40 locations throughout Oahu, Maui, Kauai, and on the Island of Hawaii.
(https://mhkhawaii.weebly.com/)School-Based Health Centers . Waiʻanae Coast Comprehensive Health Center
manages three School-Based Health Centers located at Waiʻanae High,Waiʻanae
Intermediate, and Nānākuli High & Intermediate Schools so that students are able toreceive primary care and behavioral
health services at school. The Health Centers offer a full range of health services,from sick visits to sports physicals, keeping students healthy and focused on theirstudies. (http://www.wcchc.com/SBHC)91

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). This treatment
for children and adolescents impacted by trauma and their parents or caregivers
successfully removes a broad array of emotional and behavioral difficulties associatedwith trauma. There are 30 providers being trained in TF-CBT on Kaua‘i, includingorganizations such as the YWCA of Kaua‘i. ( https://tfcbt.org)

5. Housing
ALEA Bridge. Based in Wahiawā, ALEA Bridge works with at-risk individuals,
families, youths, and veterans including people who are houseless through a personal,
respectful, collaborative and grassroots approach. They help with finding
employment and housing; managing finances; and placing people into substanceabuse and behavioral health program. They often partner with Wahiawā General
Hospital. (http://www.aleabridge.org)
Hawaiʻi Housing Coalition. The Federal Reserve Bank of San Francisco has been
convening a group of Hawaiʻi stakeholders to develop a vision and strategy forestablishing a multi-sector, community-driven coalition that promotes
affordable housing for low-income residents of Hawaiʻi. (https://www.frbsf.org)
Hawaiian Community Assets. HCA helps low- and moderate-income communities,
particularly Native Hawaiians, become more self-sufficient in their housing andfinances. They provide workshops in housing and financial education, counseling forindividuals, and access to asset building services—all of which are grounded in Native
Hawaiian culture. HCA has been playing a critical role in assisting with relief andrecovery efforts in the aftermath of the 2018 natural disasters on Hawaiʻi Island
and Kaua‘i—providing housing counseling, financial coaching, emergency
financial planning, and access to grants and loans for assistance.
(http://www.hawaiiancommunity.net)
Kahauiki Village. This housing community will provide long-term, permanent,
affordable housing for approximately 153 currently houseless families with children on
Oʻahu. Kahauiki Village is a community of approximately 144 one- and two-bedroom
homes being built on 11.3 acres of land located between Nimitz Highway, Keehi
Lagoon Park, and Sand Island. When completed, Kahauiki Village is expected to houseover 600 adults and children. This project, led by the State of Hawaiʻi, City and Countyof
Honolulu, and aio Foundation, has another goal to provide employment opportunities
within walking distance for houseless parents. (http://www.kahauiki.org)
Housing Now! A coalition project by Faith Action, a grassroots interfaith non-profit
organization seeking to collectively address the root causes of social justice challenges
facing our community. Housing advocacy has been a critical element of building
healthy and just communities. (https://www.faithactionhawaii.org/)
92

Pūnāwai Housing by Pacific Housing Alliance Corporation (PHAC). A project of
the City & County of Honolulu, Pūnāwai is a comprehensive project seeking to address
the wide range of needs of those experiencing homelessness. The project is located in
Iwilei and includes a hygiene center, clinic, respite housing, and permanent supportive
housing for those transitioning out of homelessness.

6. Trust and Equitable Access
The Baldrige Award. This program, established by Congress in 1987 andadministered by the National Institute of Standards and Technology within the
U.S. Department of Commerce, recognizes U.S. organizations and businesses that
demonstrate “an unceasing drive for radical innovation, thoughtful leadership, andadministrative improvement.” Adventist Health Castle won the Malcolm Baldrige
National Quality Award in 2017, becoming the first recipient of the Baldrige Awardin Hawaiʻi. Castle was recognized for its “demonstrated continuous improvement
practices for delivering health care services, exhibited efficient and effective
operations, and revealed systematic methods for engaging and responding to patientsand other stakeholders.” (https://www.nist.gov/baldrige)
Basic Adult Dental Care for Medicaid Members in Hawaiʻi. AlohaCare and ‘Ohana
Health Plan will offer basic adult dental care coverage beginning January 1, 2019.
Since 2009, dental care coverage for adults enrolled in the state’s Medicaid program
has been limited to emergency care. (https://www.wellcare.com/Hawaiʻi andhttps://www.alohacare.org)
Cardiac Rehab Lab. At the Cardiac Rehab Lab at Wilcox Medical Center, patients
receive customized treatment plans that focus on their own conditions and limitations.
The Cardiac Rehab Lab utilizes exercise treadmills, bikes, cross-trainers, and freeweights. The program was launched in 2012 in response to a lack of rehab options
for residents of Kaua‘i following cardiac interventions.
(https://www.hawaiipacifichealth.org/wilcox/services/heart-health)Care for houseless discharged from hospital facilities. OHANA (Oʻahu HealthAccess and Network Association) project provides case management and short-term
residential care that allows houseless individuals discharged from Queen’s Medical
Center and Adventist Health Castle the opportunity to rest in a safe environment
while accessing medical care. Tūtū Bert's Homes, an 8-bed private medical respite,
offer medically frail houseless individuals who are no longer in need of in-patient
hospitalization but still too frail to recuperate on the streets. The house facilitates
short-term stabilization and supportive case management that accelerates their transitionout of houselessness, and into available housing options.
(http://www.kphc.org/patient/healthcare-homeless)93

Chief Community Health Officer. At a systemwide level, Kaiser Permanenteestablished a position of Chief Community Health Officer, reporting directly to theChief Executive Officer, reflecting an effort to move beyond the minimum
compliance of “community benefit” and elevating the centrality of place in building
health andwell-being.
(https://share.kaiserpermanente.org/article/kaiser-permanente-names-becharachoucair- md-m s-as-first-chief-community-health-officer)
Community Health Workers Association. A Community Health Worker (CHW) is atrusted member of the community and a valuable member of a healthcare or social
services team. Maui College and Kapiolani Community College offer Certificate
programs for CHWs, and Hawaiʻi Public Health Institute is helping to develop andfacilitate a statewide network of CHWs. The Hawai’i CHW Association seeks to bring
together their voices to further expand the role and presence of Community HealthWorkers in the state. (Hichw.org http://maui.hawaii.edu/communityhealth ;https://www.kapiolani.hawaii.edu/academics/programs-of-study/community-healthwo rker)
Hāna Ola Project . Hāna Ola aims to reduce the burden of obesity and othercardiovascular disease risk factors among Native Hawaiians. The project utilizes
community practices of lo‘i restoration, organic agriculture, kūpuna assisted living,
and ku‘i (the cultural practice of pounding kalo or taro into pa‘i ‘ai and poi). It is apartnership between Ma Ka Hana Ka ‘Ike and Queen’s Medical Center.
(https://hanabuild.org)
Hawai‘i Oral Health Coalition. Working to expand access and restore access todental services for adults from all income backgrounds. Subcommittees on advocacy,
access, education, workforce development and oral health surveillance.
(https://www.hiphi.org/hawaii-oral-health-coalition/)
Healthy Mothers Healthy Babies Coalition of Hawai‘i. This local nonprofit, with
offices in Chinatown, Honolulu, is part of a national network of organizations andindividuals committed to improving Hawai‘i’s maternal, child and family health.
Their program includes creating support groups and community spaces for mothers
andchildren to connect. Their mobile clinic has offered on-site vaccination andpostpartum care. (https://www.hmhb-hawaii.org)
Hawaiʻi County Fire Department Paramedicine Program. The Hawaiʻi Fire
Department has been focusing on advocating for vulnerable populations that havebecome disconnected from health care for any of a variety of reasons. These groups
could include the elderly, the medically fragile, the houseless, high utilizers of the EMS
system, and those at high risk of falling. This program tries to identify these individuals,
assess their situation and work as their advocates to find solutions that will improve theiroverall health and wellness. (http://www.hawaiicounty.gov/fire)94

Kailua Homeless Aid . On the fourth Tuesday of each month, the Windward branchof the YMCA of Honolulu and neighboring Daybreak Church provide support forhouseless people in Kailua. Supported by Alexander & Baldwin and the Harold K.L.
Castle Foundation, partner agencies include AlohaCare, Waimānalo Health Center,
Veteran Services, Residential Youth Services Empowerment, Catholic Charities, Legal
Aid, Institute for Human Services, Child and Family Services, Hiehie Mobile Hygiene,
and Community Outreach Court. (https://www.daybreakhawaii.church andhttps://www.ymcahonolulu.org/locations/windward)
Kukui Ahi Patient Navigation Program. Molokaʻi General Hospital’s Patient
Navigation Program, Kukui Ahi, helps patients, families and their caregivers navigate
the healthcare system. They assist with coordination of air and ground transportationand lodging for patients requiring services and treatment on the neighbor islands. Patientnavigation services are tailored to the individual patient’s needs and provide culturally
sensitive care. They work closely with community organizations such as MolokaʻiCancer Fund, Cancer Care, Pacific Cancer Foundation, Senior Aging Services, andAmerican Cancer Society.
(https://www.queens.org/molokai/patients-and-visitors/patient-tools-resources/patient-na
viga tion-mgh)
Medical-Legal Partnership for Children in Hawai‘i . MPLC provides legal services
to low-income clients in a community health setting. These populations may not know
they have a legal issue or know how to get help, and health centers are spaces morefamiliar than legal service offices. MPLC is a partnership between the William S.
Richardson School of Law (University of Hawaiʻi at Mānoa), Kōkua Kalihi
Valley Comprehensive Family Services, and Waikīkī Health Center.
(http://www.mlpchawaii.org)
The Native Hawaiian Traditional Healing Center, Waiʻanae Coast
Comprehensive Health Center. The center promotes traditional Native Hawaiian
healing and cultural education, practices, and traditions. The primary practices
include lomilomi, lāʻau lapaʻau, lāʻau kāhea (spiritual healing), and hoʻoponopono(conflict resolution). (http://www.wcchc.com/Healing)
PILI ‘Ohana Partnership (POP). POP addresses obesity in Hawaiʻi and the larger
Pacific. It integrates community wisdom with scientific methods to conduct research in
Native Hawaiian and Pacific Peoples (including Filipinos, Chuukese, and other PacificIslanders). The partnership includes Hawai‘i Maoli of the Association of Hawaiian Civic
Clubs; Kula no nā Po‘e Hawai‘i of the Papakōlea, Kewalo, and Kalāwahine Hawaiian
Homestead communities; Ke Ola Mamo; Kōkua Kalihi Valley; the Pacific
Chronic Disease Coalition; the Department of Native Hawaiian Health at the
University of Hawai‘i at Mānoa; and the Office of Hawaiian Affairs.
(http://www2.jabsom.hawaii.edu/pili/about.html)

95PRAPARE . The Protocol for Responding to and Assessing Patients’ Assets, Risks, andExperiences (PRAPARE) is a national effort to help health centers and other providers
collect the data needed to better understand and act on their patients’ social
determinants of health. Health centers and other providers can define and document theincreasedcomplexity of their patients, transform care with integrated services and community
partnerships, advocate for change in their communities, and demonstrate the value theybring to patients, communities, and payers. PRAPARE is being used by facilities in
Hawaiʻi, including West Hawaiʻi Community Health Center and Waiʻanae
Coast Comprehensive Health Center.
(http://www.nachc.org/research-and-data/prapare)
Project Hiehie Mobile Hygiene Services . This mobile unit, named after “theHawaiian way to express an inalienable sense of dignity,” provides access to bathing
and hygiene services to houseless individuals—to reduce infections and disease,improve feeling of self-worth, and allow houseless individuals to connect with socialand community services without having to “walk through an office door.”(http://hiehie.org)
Waipahū Safe Haven Immigrant Resource Center. In 2015, Safe Haven began as
a computer access center for youth and adults in Waipahu, and a site to help train anddevelop women’s sewing skills so that they would be able to use their skills for theirfamilies and as a source of income. The center’s mission expanded to include a focus
on improving the success of the community and helping individuals and families out ofpoverty. Currently, the center provides services to a variety of migrant and immigrant
populations, including Samoan and Filipino, and the majority are Marshallese andChuukese families. (https://www.waipahusafehaven.com)
Other Health Resources
Community First, Hilo, Hawaiʻi. Community First is a non-profit organization
established in 2014 in East Hawaiʻi to change the definition of healthcare to caring for
health and not just treating disease. Community First formed a Regional Health
Improvement Collaborative (RHIC), which aims to fundamentally reform healthcare
payment. (https://www.communityfirsthawaii.org)
Epigenetics Study in Wai‘anae. The University of Hawai‘i at Mānoa andMA‘O Organic Farms is researching community health impact of ‘āina or landbased
programs in Waiʻanae. The study hopes to identify how a community program suchas MAʻO’s community-based program focused on restoring our connection to ‘āinacan actually impact the health of individuals, especially in the reduction of obesityand other cardio-metabolic disorders. The study is sponsored by the HMSA
Foundation
and Kamehameha Schools. (http://mauliolanetwork.com)
96

Hui Pono, the Ornish Lifestyle Medicine at Hilo Medical Center. The Intensive
Cardiac Rehabilitation program helps participants adopt and sustain lifestyle changes inwhat they eat; how active they are; how they respond to stress; and how much love andsupport they have in their lives. The result is a decrease in their reliance on medication,
avoidance of future surgeries, and most importantly, control of their health.
(https://www.hilomedicalcenter.org/the-ornish-lifestyle-medicine.html)
Keiki to Career Kaua‘i . Launched in 2012, Keiki to Career Kaua‘i is a network ofpartners in education, health, human service and youth programs, families, andbusinesses working together to ensure Kaua‘i’s young people are “ready to learn andready for life.” The goal of Keiki to Career is for every young person to be ready foreach key transition point in their life—entry to kindergarten, middle school, highschool, and college or work. (http://keikitocareer.org)
Lānaʻi mural project. A partnership between Lāna‘i Culture & Heritage Center,
Lāna‘i High & Elementary School, and local artist collective 808 Urban created alarge-scale mural at Lāna‘i High & Elementary School depicting scenes from
Lāna‘i's history—creation, settlement, native lore, historic era, plantation, andongoing practices. The creation of the mural included artists and students visitingsome of
Lāna‘i’s storied places and conducting interviews with elder residents to develop
the themes for the mural. The mural has become a source of community pride.
(https://www.lanaichc.org/mural-project.html)
Milestones Hawaiʻi. Milestones was founded in 2018 by a team of physicians andtherapists who saw an opportunity and unmet need for a unified effort to improve
care for children with neurodevelopmental and behavioral conditions in Hawaiʻi.
They
provide medical assessments and treatments for children with disabilities; interisland andrural care; child-centered therapy for children on the autism spectrum; and care forchildren ages 0-5 with behavioral conditions. (https://www.milestoneshawaii.org)
Molokaʻi Child Abuse Prevention Pathways (MCAPP). Launched in 2013 by theConsuelo Foundation as an exploratory pilot program, MCAPP addresses
childhood sexual violence on Molokaʻi through primary prevention education. The
program partners with schools to educate children in a culturally responsive way on
how toaddress and prevent this devastating problem. (https://www.molokaicapp.org)
NHPI 3R. The Native Hawaiian & Pacific Islander Hawaiʻi COVID-19 Response,
Recovery & Resilience Team (NHPI 3R) was established in May 2020, in alignment
with the national NHPI Response Team, to improve the collection and reporting of
accurate data, identify and lend support to initiatives across the Hawaiian Islands
working toaddress COVID-19 among Native Hawaiians and Pacific Islanders, and unify to establish
a presence in the decision-making processes and policies that impact our communities.
More than 40 agencies, organizations, and departments comprise the NHPI 3R
Team. (https://www.nhpicovidhawaii.net/)

97

PATH (Peoples Advocacy for Trails Hawaiʻi). This advocacy organization
aims to safely connect people and places on Hawaiʻi Island with pathways andbikeways. (https://pathhawaii.org/about-path)
The Sundays Project of the Parents and Children Together Family Center atKūhiō Park Terrace. This program aims to reduce the high rates of absenteeism inpublic schools among children from The Federated States of Micronesia, theMarshall Island, Palau, and others who are new to Hawaiʻi. It provides learning
opportunities grounded in culture for families. (https://pacthawaii.org)
Sustainable Transportation Coalition of Hawaiʻi. This network of organizations andindividuals aims to reduce the use of cars. The work of the coalition has direct health
implications, whether related to active modes of transportation such as bicycling andwalking, or reducing the stress and time of commutes with car sharing, carpooling, andpublic transportation. (http://www.stchawaii.org)
Transition to Success (TTS). Transition to Success, which began in Detroit in2006, coordinates care across healthcare, human services, government, faith-basedorganizations and education to work on social determinants affecting low-income
families. This includes racism, low-paying jobs, and lack of food, healthcare,transportation, affordable housing, reliable, stable child care and education. TTS isbeing piloted in Hawaiʻi by Child & Family Service through its Family Centers on
Maui, Molokaʻi, and Kauaʻi, with hopes to expand statewide.
(http://transitiontosuccess.org) (https://www.childandfamilyservice.org)
Walking School Bus. The Walking School Bus is a program in which children walk toschool as a group, led by parents or another adult. Students are picked up in front of
their home or at a designated stop. Children and their parents can choose when they
participate. The goal of the “walking school bus” is to increase childrenʻs rates of active
commuting to school and physical activity. Communities throughout Hawaiʻi, including
Kaua‘i and Hawaiʻi Island, have experimented with the Walking School Bus program.
(http://www.walkingschoolbus.org)
Walk with a Doc. Started in 2005 by a cardiologist in Columbus, Ohio who began
inviting his patients to go for a walk with him in a local park, Walk with a Doc hasgrown as a grassroots effort. In association with North Hawaiʻi Community Hospital, it
is a simple model that involves a doctor giving a brief presentation on a health topic andthen leading participants on a walk at their own pace. (https://walkwithadoc.org)

98

B. Existing Healthcare Facilities
This CHNA calls for a healthcare ecosystem approach to community health that includes all
community entities, too numerous to list in this document. Among those are healthcare
facilities that serve the public, updated from the 2018 list. HAH member hospitals are
specifically required by the IRS to describe “existing health care facilities and resources
within the community that are available to respond to the health needs in the community.”
Health care facilities in Hawaiʻi registered with the federal Health Resources and Services
Administration (https://findahealthcenter.hrsa.gov), U.S. Department of Veterans Affairs(https://www.va.gov/find-locations), and Hawaiʻi State Office of Health Care Assurance(http://health.hawaii.gov/ohca) are listed, by island, below.
HAWAIʻI ISLAND
Health Centers
Bay Clinic, Inc.

https://www.bayclinic.org/

Hāmākua Health Center

http://www.hamakua-health.org/

Hui Mālama Ola Nā ‘Ōiwihttps://hmono.org/

West Hawai‘i Community Health Center

https://www.westhawaiichc.org/

Rural Health Clinics
Kīpuka o ke Ola

https://www.kipukaokeola.com/

Kaʻū Hospital Rural Health Clinic

https://www.kauhospital.org/rural-health-clinic.html

Medical/Surgical/Critical Care/Obstetric
Hilo Medical Center

https://www.hilomedicalcenter.org/

Kona Community Hospital

https://kch.hhsc.org/

North Hawaiʻi Community Hospital

https://www.queens.org/north-hawaii/north-hawaiicommuni ty-hospital

Acute Care, Skilled Nursing Facility (SNF), and Intermediate Care Facilities for
Individuals with Intellectual Disabilities (ICF)99

Hale Ho‘ola Hāmākua

https://www.halehoolahamakua.org/

Ka‘ū Hospital

https://www.kauhospital.org/

Kohala Hospital

https://kohala.hhsc.org/

Skilled Nursing Facility (SNF) and Intermediate Care Facilities for Individuals with Intellectual
Disabilities (ICF)
Hale ʻĀnuenue Restorative Care Center

http://haleanuenuecarecenter.com/

Hilo Medical Center

https://www.hilomedicalcenter.org/

Legacy Hilo Rehab & Nursing

https://ohanapacific.com/legacy-hilo-rehab-nursing

Life Care Center of Hilo

http://lifecarecenterofhilo.com/

Life Care Center of Kona

http://lifecarecenterofkona.com/

VA Facilities
VA Hilo Community
Based Outpatient Clinic

https://www.hawaii.va.gov/locations/Hilo_Hawaii.asp

VA Kona Community
Based Outpatient Clinic

https://www.hawaii.va.gov/locations/Kailua_Kona_Hawaii.
a sp

Yukio Okutsu State
Veterans Home

https://www.yukiookutsustateveteranshome.org

Psychiatric
Hilo Medical Center

https://www.hilomedicalcenter.org/

Kona Community Hospital

https://kch.hhsc.org/

Ambulatory Surgery Centers

100

Big Island Endoscopy Center,
LLC

http://www.bigislandgastro.com/

Hilo Community Surgery Center

http://www.hiloeye.com/hilo-community-surgery-center.html

Kona Ambulatory Surgery Center,
LLC.

http://www.konasurgerycenter.com/

The Endoscopy Center

http://www.hawaiigastro.com/treatment/endoscopy-center

End Stage Renal Disease Programs
Liberty Dialysis – Hawaii LLC – Hilo
Dialysis Facility

https://www.freseniuskidneycare.com/dialysis-centers/hawaii/hilo/

Liberty Dialysis – Hawaii LLC– Kona Dialysis Facility

https://www.freseniuskidneycare.com/dialysis-centers/hawaii/kailua-kona/

Liberty Dialysis – North Hawaiʻi
LLC

https://www.freseniuskidneycare.com/dialysis-centers/hawaii/kamuela/

Home Health Care
Bayada Home Health Care — Hilo

https://www.bayada.com/offices/hi/hilo/68-kekuanaoast/ho me-health

Hilo Medical Center Home Care

https://www.hilomedicalcenter.org/long-term-care.html

Kohala Home Health Care

https://www.queens.org/north-hawaii/services/kohala-home-health-care/k ohala-home-health-care-nhch

Kokua Nurses, Inc. Home HealthServices, Inc.

http://kokuanurses.com/

Mastercare, Homecare, andHealthcare

https://www.gomastercare.com/homecare/

Hospice101

Hawaiʻi Care Choices formerly
Hospice of Hilo

https://www.hawaiicarechoices.org/

Hospice of Kona

https://hospiceofkona.org/

North Hawaiʻi Hospice, Inc.

https://northhawaiihospice.org/

Special Treatment Facility
C.A.R.E. Cottage - Hilo
Care Hawaiʻi Licensed Crisis
Residential Services

https://www.carehawaii.info/programs/crisis-services/

Hawaiʻi Island Recovery

https://hawaiianrecovery.com/

Ku Hoʻomana Family Intervention
Services - Hilo
The Exclusive
Addiction Treatment
Center

https://theexclusivehawaii.com/

MAUI
Health Centers
Hāna Health

http://hanahealth.org/

Hui No Ke Ola Pono

http://hnkop.org/

Mālama I Ke Ola Health Center

http://ccmaui.org/

Rural Health Clinics
Kīhei Clinic

https://healthy.kaiserpermanente.org/hawaii/facilities/kaiser-permanente kihei-clinic-100440

Lahaina Clinic

https://healthy.kaiserpermanente.org/hawaii/facilities/Kaiser-Permanente Lahaina-Clinic-100437

102Medical/Surgical/Critical Care/Obstetric
Maui Memorial Medical Center

https://www.mauihealthsystem.org/

Acute Care, Skilled Nursing Facility (SNF), and Intermediate Care Facilities for
Individuals with Intellectual Disabilities (ICF)
Kula Hospital

https://www.mauihealthsystem.org/kula-hospital/

Skilled Nursing Facility (SNF) and Intermediate Care Facilities for Individuals withIntellectual Disabilities (ICF)
Hale Makua -- Kahului

https://www.halemakua.org/

Hale Makua -- Wailuku

https://www.halemakua.org/

Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF)
The Arc Of Maui (Hale Kanaloa)

http://www.arcofmaui.org/

The Arc Of Maui (Hale Kīhei)http://www.arcofmaui.org/

The Arc Of Maui (Mana Ola
Na Keanuenue)

http://www.arcofmaui.org/

VA Facilities
VA Maui Community
Based Outpatient Clinic

https://www.hawaii.va.gov/locations/Maui.asp

Psychiatric
Maui Memorial Medical Center

https://www.mauihealthsystem.org/

103

Ambulatory Surgery Centers
Aloha Eye Clinic Surgical Center,
LLC

https://alohaeyeclinic.com/

Aloha Surgery Center

https://alohasurgicalcenter.com/

Kaiser Wailuku Clinic Asc

https://healthy.kaiserpermanente.org/hawaii/facilities/Kaiser-Permanente Wailuku-Medical-Office-100431

End Stage Renal Disease Programs
Liberty Dialysis – Hawaiʻi LLC –Kahana Dialysis Facility

https://www.freseniuskidneycare.com/dialysis-centers/hawai
i/lahaina/4405 -honoapiilani-hwy-96761/7385

Liberty Dialysis – Maui Dialysis
Facility

https://www.freseniuskidneycare.com/dialysiscenters/hawai i/wailuku/105- mauilani-pkwy-96793/7375

Rainbow Dialysis Lahaina

https://www.mauihealthsystem.org/

Rainbow Dialysis Wailuku

https://www.mauihealthsystem.org/

Home Health Care
Bayada Home Health Care —Wailukuhttps://www.bayada.com/offices/hi/wailuku/2200-mainstre et--suite-660/home-health

Cradles n Crayons - Kahului

https://cradlesncrayons.com/

Hale Makua Home Health Care
Agency — Wailuku

https://www.halemakua.org/home-health

HiHomeCare - Kahului

https://hihealthcarehawaii.com/

Home Health by Hale Makua

https://www.halemakua.org/home-health

Kaiser Permanente Home HealthAgency—Maui

https://kpinhawaii.org/

104

Mastercare Homecare &Healthcare - Wailuku

https://www.gomasatercare.com/

Hospice
Hospice Maui, Inc.

https://www.hospicemaui.org/

Special Treatment Facility

Ai Pono Mauihttps://www.aipono.com/

Aloha House, Inc

http://www.aloha-house.org/

Nova Luna, Inc.

https://www.novalunacenter.com/

MOLOKAʻI
Health Centers
Moloka‘i Community HealthCenterhttp://molokaichc.org/

Na Pu‘uwai

https://www.napuuwai.org/

Rural Health Clinics
Molokai General Hospital Rural
Health Clinic

https://www.queens.org/molokai/molokai-general-hospital

Obstetric, Acute Care, Skilled Nursing Facility (SNF)
Molokai General Hospital

https://www.queens.org/molokai/molokai-general-hospital

VA Facilities
105

VA Molokai Outreach Clinic

https://www.hawaii.va.gov/locations/molokai.asp

Hansen’s Disease
Kalaupapa Care Home

https://www.nps.gov/kala/index.htm

End Stage Renal Disease Programs
Liberty Dialysis – Hawaiʻi LLC –https://www.freseniuskidneycare.com/dialysis-centers/hawa

Molokai Dialysis Facility

ii/kaunakakai/ 28-kamoi-street-96748/7382

Home Health Care
Careresource Hawaiʻi — Molokai

http://www.careresourcehawaii.org/

Hospice
Hospice Hawaiʻi -- Molokai

https://www.hospicehawaii.org/

LĀNAʻI
Health Centers
Lāna‘i Community Health Center

https://lanaihealth.org/

Ke Ola Hou o Lānaʻi Na Pu‘uwai

https://www.napuuwai.org/

Home Health Care
Lānaʻi Kinaʻole, Inc.

https://www.lanai9673.com/businessprofile/lanai-kinaole-inc/

106Medical/Surgical, Skilled Nursing Facility (SNF) and Intermediate Care Facilities for
Individuals with Intellectual Disabilities (ICF)
Lānaʻi Community Hospital

https://www.mauihealthsystem.org/lanai-hospital/

VA Facilities
VA Lānaʻi Outreach Clinic

https://www.hawaii.va.gov/locations/lanai.asp

End Stage Renal Disease Programs
Fresenius Medical Care – Lānaʻihttps://www.freseniuskidneycare.com/dialysiscenters/hawa ii/lanai-city/62 8-7th-st-96763/2809

Hospice
Hospice Hawaiʻi — Lānaʻihttps://www.hospicehawaii.org/our-services/caresettings/la nai-hope-hous e/OʻAHU
Health Centers
Kalihi-Pālama Health Center

http://www.kphc.org/

Ke Ola Mamo

http://www.keolamamo.org/

Ko‘olauloa Health Center

https://koolauloachc.org/

Kōkua Kalihi Valley

http://kkv.net/

Wahiawā Center for Community
Health

https://www.wahiawahealth.org/

Wai‘anae Coast Comprehensive
Health Center

http://www.wcchc.com/

Waikīkī Health

http://waikikihc.org/

Waimānalo Health Center

https://waimanalohealth.org/

107

Rural Health Clinics
Castle Health Clinic of Lāʻie

https://www.adventisthealth.org/locations/health-clinic-oflai e/

Kahuku Clinic

http://www.kmc-hi.org/

Medical/Surgical/Critical Care/Obstetric

Adventist Health Castle

https://www.adventisthealth.org/castle/

The Queen’s Medical Center

https://www.queens.org/the-queens-medicalcenter/queens- medical-cente r

Kaiser Permanente – Moanalua
Medical Center

https://healthy.kaiserpermanente.org/hawaii/facilities/kaiser-permanente moanalua-medical-center-100434

Kapʻiolani Medical Center for
Women & Children

https://www.hawaiipacifichealth.org/kapiolani/

Medical/Surgical/Critical Care
Kuakini Medical Center

https://www.kuakini.org/

Pali Momi Medical Center

https://www.hawaiipacifichealth.org/pali-momi/

Straub Medical Center

https://www.hawaiipacifichealth.org/straub/

Wahiawā General Hospital

https://wahiawageneral.org/

Pediatric, Neonatal ICU
Kaiser Permanente – Moanalua
Medical Center

https://healthy.kaiserpermanente.org/hawaii/facilities/kaiser-permanente moanalua-medical-center-100434

Kapʻiolani Medical Center for
Women & Children

https://www.hawaiipacifichealth.org/kapiolani/108

Child Ortho
Shriners Hospital for Children -Honolulu

https://www.shrinershospitalsforchildren.org/honolulu

Acute Care, Skilled Nursing Facility (SNF), and Long Term Care (LTC)
Wahiawā General Hospital

https://wahiawageneral.org/

Skilled Nursing Facility (SNF) and Intermediate Care Facilities for Individuals withIntellectual Disabilities (ICF)
15 Craigside

https://arcadia.org/companies/15-craigside/

Aloha Nursing & Rehab Centre

http://www.alohanursing.com/

Ann Pearl Nursing Facility

http://www.ohanapacific.com/locations/oahu/kaneohe/ann-pearl/Arcadia Retirement Residence

https://arcadia.org/companies/arcadia/

Avalon Care Center -- Honolulu

https://www.avalonhealthcare.com/honolulu/

Care Center of Honolulu

https://www.ccoh.us/

Clarence T.C. Ching Villas at St.
Francishttps://www.ohanapacific.com/the-villas-post-acute-care-rehabHale Ho Aloha

http://halehoaloha.com/

Hale Malamalama

http://www.halemalamalamanursing.com/

Hale Nani Rehabilitation &Nursing Center

https://www.avalonhealthcare.com/halenani/

Hale Ola Kino

https://www.haleolakino.com/

Harry & Jeannette Weinberg Care
Center at Pohai Nani

https://www.good-sam.com/locations/pohai-nani109

Hi‘olani Care Center at Kahala
Nui

http://www.kahalanui.com/

Liliha Healthcare Center

https://www.newfamilyhealthhi.com/liliha-healthcare-center

Ka Punawai Ola

http://kapunawaiola.com/

Kalākaua Gardens

http://kalakauagardens.com/

Kuakini Geriatric Care, Inc

https://www.kuakini.org/wps/portal/public/ProgramsServic es/Geriatric-Ca re-Services

Kūlana Mālama

http://kulanamalama.com/

Leahi Hospital

https://leahi.hhsc.org/

Maluhia Hospital

https://maluhia.hhsc.org/

Mānoa Cottage Kaimukī

https://manoacottage.com/

Maunalani Nursing andRehabilitation Center

https://maunalaninursing.org/

Nuʻuanu Halehttps://www.newfamilyhealthhi.com/nuuanu-haleOʻahu Care Facility

http://oahucarefacility.com/

Palolo Chinese Home

https://palolohome.org/

Pearl City Nursing Home

http://pearlcitynursinghome.com/

Pu‘uwai ‘O Mākaha

http://www.ohanapacific.com/locations/oahu/waianae/puuw
a i-o-makaha/Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF)
Opportunities And Resources, Inc.

http://www.ori-hawaii.com/

The Arc In Hawaiʻi (6a)http://www.thearcinhawaii.org/

The Arc In Hawaiʻi (6b)http://www.thearcinhawaii.org/

The Arc In Hawaiʻi (ʻEwa B)

http://www.thearcinhawaii.org/

110

The Arc In Hawaiʻi (ʻEwa C)

http://www.thearcinhawaii.org/

The Arc In Hawaiʻi (Kaimukī A)

http://www.thearcinhawaii.org/

The Arc In Hawaiʻi (Kaimukī B)

http://www.thearcinhawaii.org/

The Arc In Hawaiʻi (Wahiawā A)

http://www.thearcinhawaii.org/

VA Facilities
Spark M. Matsunaga VA
Medical Center

https://www.hawaii.va.gov/locations/directions.asp

Tripler Army Medical Center

https://www.tamc.amedd.army.mil/

VA Leeward Community
Based Outpatient Clinic

https://www.hawaii.va.gov/locations/Leeward.asp

National Center for PTSD

https://www.ptsd.va.gov/

Rehabilitation Facility
Rehabilitation Hospital of the
Pacific

https://www.rehabhospital.org/

PsychiatricAdventist Health Castle

https://www.adventisthealth.org/castle/

The Queen’s Medical Center

https://www.queens.org

The Queen’s Medical Center –West Oʻahu

https://www.queens.org/west-oahu/queens-medical-centerw est-oahu

Hawaiʻi State Hospital

http://health.hawaii.gov/amhd/hawaii-state-hospital-about-us/

Kāhi Mōhala Behavioral Healthhttps://www.sutterhealth.org/kahi

111

Ambulatory Surgery Centers
Asia Pacific Surgery, LLC

https://www.drshimching.com/

Cataract And Vision Center
Of Hawaiʻi

https://www.cataractandvisioncenter.com/

Endoscopy Institute Of Hawaiʻi

https://endoscopyhawaii.com/

Eye Surgery Center Of Hawaiʻi

http://www.eyesurgeryhi.com/

Hawaiʻi Endoscopy Centers,
L.L.C.

http://www.hawaiiec.com/

Hawaiian Eye Surgicenter

http://www.hawaiianeye.com/

Honolulu Spine Center

https://www.honoluluspine.com/

Kaiser Permanente Mapunapuna
Clinic – Asc

https://healthy.kaiserpermanente.org/hawaii/facilities/Kaiser-Permanente Mapunapuna-Medical-Office-100428

Minimally Invasive Surgery Of
Hawaiʻi

http://www.mishawaii.com/

Pacific Endoscopy Center, LLC

http://pacificendoscopy.com/

Surgicare Of Hawaiʻi

https://surgicareofhawaii.com/

The Surgical Suites, LLC

http://www.thesurgicalsuites.org/

Windward Surgery Center

http://windwardsurgerycenter.com/

Hansen’s Disease
Hale Mohalu Hospital

https://leahi.hhsc.org/

End Stage Renal Disease Programs
DSI – Aloha Dialysis

http://www.usrenalcare.com/locations/aloha

DSI – Honolulu Dialysis

http://www.usrenalcare.com/locations/honolulu

DSI – Kapahulu Dialysis

http://www.usrenalcare.com/locations/kapahulu

112

DSI – Kapolei Dialysis

http://www.usrenalcare.com/locations/kapolei

DSI – Koʻolau Dialysis

http://www.usrenalcare.com/locations/ko%20olau

DSI – Pearlridge Dialysis

http://www.usrenalcare.com/locations/pearlridge

DSI – Wahiawā Dialysis

http://www.usrenalcare.com/locations/wahiawa

DSI – Windward Dialysis

http://www.usrenalcare.com/locations/windward

Liberty Dialysis – Hawaiʻi – Kaimuki
Dialysis Facility

https://www.freseniuskidneycare.com/dialysis-centers/hawa
ii/honolulu/36 25-harding-ave-96816/7381

Liberty Dialysis – Hawaiʻi LLC –Ala Moana Dialysis Facility

https://www.freseniuskidneycare.com/dialysis-centers/hawa
ii/honolulu/50 0-ala-moana-blvd-96813/100115

Liberty Dialysis – Hawaiʻi LLC –Hawaiʻi Kai Dialysis

https://www.freseniuskidneycare.com/dialysis-centers/haw
aii/honolulu/71 92-kalanianaole-hwy-96825/7384

Liberty Dialysis – Hawaiʻi LLC –https://www.freseniuskidneycare.com/dialysis-centers/hawa

Kailua Dialysis Facility

ii/kailua/25-ka neohe-bay-dr-96734/7372

Liberty Dialysis – Hawaiʻi LLC –Leeward Dialysis Facility

https://www.freseniuskidneycare.com/dialysis-centers/hawa
ii/honolulu/22 30-liliha-st-96817/7379

Liberty Dialysis – Hawaiʻi LLC –Mililani Dialysis Facility

https://www.freseniuskidneycare.com/dialysiscenters/hawa ii/mililani/95-1 105-ainamakua-drive96789/9226

Liberty Dialysis – Hawaiʻi LLC –Salt Lake Dialysis Facility

https://www.freseniuskidneycare.com/dialysis-centers/hawa
ii/honolulu/43 80-lawehana-st-96818/9227

Liberty Dialysis – Hawaiʻi LLC –Siemsen Dialysis Facility

https://www.freseniuskidneycare.com/dialysis-centers/hawa
ii/honolulu/22 26-liliha-st-96817/7380

Liberty Dialysis – Hawaiʻi LLC –Waiʻanae Dialysis Facility

https://www.freseniuskidneycare.com/dialysiscenters/hawa ii/waianae/86- 080-farrington-hwy96792/7389

Liberty Dialysis – Hawaiʻi LLC –Waipahu Dialysis Facility

https://www.freseniuskidneycare.com/dialysiscenters/hawa ii/waipahu/94- 450-mokuola-st-96797/7388

U.S. Renal Care Beretania Dialysis

http://www.usrenalcare.com/locations/beretania-2

U.S. Renal Care Waipahu Dialysis

http://www.usrenalcare.com/locations/waipahu%20home

113

U.S. Renal Care West Oʻahu Dialysis

http://www.usrenalcare.com/locations/west-oahu

Home Health Care
Adventist Health Castle Home Care

https://www.adventisthealth.org/home-care-services/locatio
ns/castle/

Arcadia Home Health And
Home Care Services

http://www.arcadiahomecare.com/

Attention Plus Care

https://www.attentionplus.com/

Bayada Home Health Care —Honolulu

https://www.bayada.com/offices/hi/honolulu

Careresource Hawaiʻi — Honolulu

http://www.careresourcehawaii.org/

Cradles n Crayons

https://cradlesncrayons.com/

HiHomeCare

https://hihealthcarehawaii.com/

Hoʻokele Health Navigators, LLC

https://www.hookelehealth.com/

Kaiser Home Health Agency--Oʻahu

https://kpinhawaii.org/

Lou’s Quality Home Health Care
Services, LLC

http://louscare.com/

Mastercare Homecare & Healthcare

https://www.gomastercare.com/

Oʻahu Home Healthcare

http://www.oahuhomehealthcare.com/

Prime Care Services Hawaiʻi, Inc.

http://primecarehawaii.com/

Wilson Homecare

https://www.wilsoncare.com/

Hospice
Bristol Hospice, Hawaiʻi LLC

https://bristolhospice-hawaii.com/

Islands Hospicehttps://www.islandshospice.com/

114

Mālama Ola Health Services, LLC

https://malamaolacares.com

Navian Hawaiʻi

https://www.navianhawaii.org/

St. Francis Hospice

http://www.stfrancishawaii.org/services/hospiceSpecial Treatment Facility
Benchmark Behavioral Health System

https://www.bbhsnet.com/

Bobby Benson Center

http://bobbybenson.org/dev/

Habilitat, Inc

https://www.habilitat.com/

Hina Mauka

http://www.hinamauka.org/

Hoʻomau Ke Ola

http://www.hoomaukeola.org/

Hope Inc

http://www.hopehi.com/

Ka Pa Ola

https://www.childandfamilyservice.org/programs/kapaola/

Pearl City Specialized Residential
Services Population

https://www.carehawaii.info/Po‘ailani, Inc -- Kailua

https://poailani.org/

Po‘ailani, Inc -- Kāneʻohe

https://poailani.org/

The Salvation Army
Addiction Treatment Services

https://hawaii.salvationarmy.org/hawaii/ats

The Salvation Army
Family Treatment Services

https://hawaii.salvationarmy.org/hawaii/fts

KAUAʻI
Health Centers
Ho‘ōla Lāhui Hawai‘i

http://www.hoolalahui.org/

115

Medical/Surgical/Critical Care/Obstetric
Wilcox Memorial Hospital

https://www.hawaiipacifichealth.org/wilcox/

Medical/Surgical/Acute Care/Skilled Nursing Facility (SNF)
Samuel Mahelona Memorial Hospital

http://smmh.hhsc.org/

Medical/Surgical/Critical Care/Skilled Nursing Facility (SNF), and Intermediate Care Facilities
for Individuals with Intellectual Disabilities (ICF)
Kauaʻi Veterans Memorial Hospital(KVMH)

http://kvmh.hhsc.org/

Skilled Nursing Facility (SNF) and Intermediate Care Facilities for Individuals with Intellectual
Disabilities (ICF)
Garden Isle Rehabilitation &Healthcare Center

http://www.ohanapacific.com/locations/kauai/lihue/gardeni sle-rehabilitati on-healthcare-center/

Hale Kūpuna Heritage Home

http://www.ohanapacific.com/locations/kauai/koloa/haleku puna-heritage home/

Kauaʻi Care Center

http://www.regency-pacific.com/seniorliving/hi/waimea/ka uai-care-center/

VA Facilities
VA Kauaʻi Community
Based Outpatient Clinic

https://www.hawaii.va.gov/locations/

PsychiatricSamuel Mahelona Memorial Hospital

http://smmh.hhsc.org/

West Kauaʻi Medical Center (KVMH)

http://kvmh.hhsc.org/

116

End Stage Renal Disease Programs
Liberty Dialysis – Hawaii LLC –Kauaʻi Dialysis Facility

https://www.freseniuskidneycare.com/dialysiscenters/hawa ii/lihue/3224-e lua-st-96766/7386

Liberty Dialysis – Hawaii LLC – West
Kauaʻi Dialysis Facility

https://www.freseniuskidneycare.com/dialysis-centersHome Health Care
Haumea Home Health Agency, LLC
Mastercare Homecare & Healthcare

https://gomastercare.com‘Ohana Home Health, LLC

http://ohanahomehealthllc.com/

Stay At Home Healthcare Services

http://www.ohanapacific.com/locations/kauai/lihue/stayat- home-healthca re-services/

HospiceKauaʻi Hospice

http://kauaihospice.org/

117

C. Appendix C - Steering Committee

COMMITTEE MEMBER

ORGANIZATION

Tracie Ann Tjapkes(Director, Wellness,
Lifestyle
Medicine, Community Outreach)

Adventist Health Castle

Alan MacPhee(Chief Executive Officer)

David Tumilowicz(Vice President, Public Relations,
Communications, and Brand
Management

Kahuku Medical Center
Nina Miyata (Manager,
Community Benefit &Community Relations),
Mehrnaz Davoudi (Senior
Manager, LEAP &Community Health),
Suzanne Rauzon (Directorof Community Health,
University of California)

Kaiser Permanente – Moanalua
Medical Center

Gregg Oishi(Senior Vice President & Chief
Administrative Officer)

Kuakini Medical Center

Mike Robinson(Vice President, Government
Relations/ Community Affairs)

Hawaiʻi Pacific Health● Kapiʻolani Center for
Women and Children● Pali Momi Medical Center● Straub Medical Center● Wilcox Memorial Medical
CenterLorraine Lunow Luke
(Manager, Community
Benefits)

Jim Diegel(Chief Strategy Officer)

Maui Health System● Maui Memorial Medical Center● Kula Hospital● Lānaʻi Community Hospital

Punahele Alcon(Director of Outpatient andBusiness Services)

Moloka‘i General Hospital (TheQueen’s Health Systems)

Cindy Kamikawa(President)

North Hawaiʻi Community Hospital(The Queen’s Health Systems)

Rowena Buffett Timms(Executive Vice President andChief Administrative Officer)

Sonya Greck(Consultant)

The Queen’s Health Systems● The Queen’s Medical Center– Punchbowl● The Queen’s Medical Center West Oʻahu
118

Kyle Maschhoff(Community Engagement
Liaison)Makana McClellan(Director of Business
Development and Community
Relations)

Rehabilitation Hospital of the Pacific
Anita Becker(Interim Administrator,
Nurse Executive, Director ofPatient Care Services)

Shriners Children’s Hawaiʻi

Quin Ogawa(Chief Financial Officer)

Sutter Health Kāhi Mōhala

Brian Cunningham(Chief Executive
Officer)

Wahiawā General Hospital119

D. Appendix D - Community Advisory Council

COMMITTEE MEMBER

ORGANIZATION

Bob Agres

Department of Research & Development, County of Hawaiʻi

Carla Houser

Residential Youth Services & Empowerment (RYSE) Hawaiʻi

Connie Mitchell

The Institute for Human Services, Inc.

Darrah Kauhane

Project Vision Hawaiʻi

Deborah Zysman

Hawaiʻi Children’s Action Network (HCAN)

Derrick Ariyoshi

Elderly Affairs Division, City and County of Honolulu

Heather Lusk

Hawaiʻi Health and Harm Reduction Center

Janet Berreman, M.D.

Kauaʻi District Health Office, Hawaiʻi Department of Health

Jessica Yamauchi

Hawaiʻi Public Health Institute

Josie Howard

We Are Oceania (WAO)

Lisa Kimura

Aloha United Way

Lola Irvin

State Department of Health, Chronic Disease Prevention

Michelle Kauhane

Hawaiʻi Community Foundation

Nanci Kreidman

Domestic Violence Action Center (DVAC)

Randy Kurohara

Community First Hawaiʻi

Sheri-Ann Daniels

Papa Ola Lōkahi

Wilfred Alik, M.D.

Big Island Marshallese Community Association120

E. Appendix E - Community Meetings
Meeting
Location

Connectors

Communities of Need2018
Location

Mokupuni

In-person
Confidential

Domestic Violence
Action Center

DV Survivors

No

Oʻahu

Kunia Farm
Lots

Pacific Gateway Center

Refugees, asylees, victims of
trafficking

No

Oʻahu

Virtual

FilCom and FilAm-Maui

Filipinos, ALICENo

Oʻahu ; Maui

VirtualParents and Children
Together Hawaiʻi

DV Survivors

No

Maui

VirtualFamily Hui

Families of young keiki

No

Maui

In-Person

Residential Youth
Services & Empowerment

Youthexperiencing
homelessness

No

Oʻahu

VirtualNā Hoaloha

KūpunaYes

Maui

KalihiKōkua Kalihi Valley

Micronesians, ALICE

No

Oʻahu

Molokaʻi

Mini Clinic

Native Hawaiian, Rural

Yes

Molokaʻi

Hilo Town

Vibrant Hawaiʻi

Native Hawaiian, RuralNo

Hawaiʻi
IslandWaimeaHōʻola Lāhui

Native Hawaiian, Niihauans

Yes

KauaʻiLīhuʻeMarshallese
Association of KauaʻiMarshalleseNo

KauaʻiLīhuʻeKauaʻi Planning andAction Alliance

Service providers: ALICE,
Native Hawaiian, youth

No

Kauaʻi

VirtualComunidad Latina and
Hawai’i County
Immigration Info. Office

Spanish-speaking
immigrants and
COFA migrants

No

Hawai’iIsland ; Maui

Kāne’ohe

KEY Project

Native Hawaiian Kūpuna,
Rural

No

O’ahu

VirtualLāna’i Community
Leaders

KūpunaRural

No

Lāna’i

VirtualHawai’i Health and Harm
Reduction Center (H3RC)

LGBTQIA+

No

O’ahu

VirtualHawaiian Homestead
Associations

Native Hawaiian
homesteaders

No

Hawaiʻi
Island ; Maui

121

122

F. Key Informant Interviews

KEY INFORMANTORGANIZATION

Alexandra Wroe

The Queen’s Medical Center

Alissa James

Adventist Health Castle

Amy Lasher

Adventist Health Castle

Anita Becker

Shriners Hospitals for Children

B. Puni Kekauoha

Papakōlea Community Development Corporation

Barb Craft

Pali Momi Medical Center

Bob AgresCounty of Hawaiʻi

Brandee Menino

Hope Services Hawaiʻi, Inc. (HOPE)

Brian Cunningham

Wahiawā General Hospital

Carla Houser

Residential Youth Services andEmpowerment (RYSE)

Chris Van Bergeijk

Hawaiʻi Community Foundation

Cindy Kamikawa

Queen's North Hawaiʻi Community Hospital

Claudia Crist

Sutter Health Kāhi Mōhala

Connie Mitchell

The Institute for Human Services

Coty “Buffy” Trujillo

Kamehameha Schools
Kauaʻi Community Investing

Danette Wong Tomiyasu

State Department of Health, Health Resources
Division

Daniela Spoto

Hawaiʻi Appleseed Center for Law and Economic
Justice

Darrah Kauhane

Project Vision HawaiʻiDavid Chow

Straub Medical CenterDavid Derauf, M.D.

Kōkua Kalihi Valley

David R. Tumilowicz

Kaiser Permanente - Moanalua Medical Center

123

Deborah Mattheus

Hawaiʻi Keiki Healthy & Ready to Learn, School of
Nursing and Dental Hygiene

Deborah Zysman

Hawaiʻi Children’s Action Network

Derrick Ariyoshi

Honolulu C&C, Elderly Affairs Division

Eddie Mersereau

Department of Health, Adult Mental Health Division

Gary K. Kajiwara

Kuakini Health System

Gavin Thornton

Hawaiʻi Appleseed Center for Law and Economic
Justice

Gidget Ruscetta

Hawaiʻi Pacific Health, Pali Momi Medical Center

Glenn Izawa

Retired from DOH, Mental Health Division

Gloria Brooks

Hawaiʻi Pacific Health, Pali Momi Medical Center

Gregg Oishi

Kuakini Medical Center

Hao Nguyen

Pacific Gateway Center

Heather Lusk

Hawaiʻi Health and Harm Reduction Center

Helen Kekalia Wescoatt

Molokaʻi Community Health CenterʻIolani Kuoha

Molokaʻi Middle/High School

Janet Berreman, M.D.

State Department of Health, Kaua‘i District Health
OfficeJarrett Keohokalole, Sen.

Hawaiʻi State Legislature

Jen Chahanovich

Wilcox Memorial Medical Center

Jessica Yamauchi

Hawaiʻi Public Health Institute

Jim Diegel

Maui Memorial Medical Center

Jim Ireland, M.D.

C&C of Honolulu,
Emergency Services Department

Johanna Nakashima

The Queen’s Medical Center - West Oʻahu

Joey Keahiolalo

Child & Family Service

John Leong

KUPU

Josie Howard

We Are Oceania

124

Joyce O'Brien

Waiʻanae Coast Comprehensive Health Center

Judy Mohr Peterson

State Department of Human Services

Julius Bravo

The Queen’s Medical Center - Punchbowl

June Drumeller

Kuakini Medical Center

Kate Saavedra Garcia

Adventist Health Castle

Kaui Manera

Alu Like, Inc.

Kaui Nishizaki

The Queen's Medical Center - Punchbowl

Keawe Kaholokula, Ph.D.

Native Hawaiian Health, John A. Burns School of
Medicine (JABSOM)

Kūhiō Lewis

Council for Native Hawaiian Advancement

Laura BonillaKapiʻolani Medical Center for Women and Children

Laura E. Thielen

Partners in Care

Lauren Nahme

Kamehameha Schools

Linda Spencer

Catholic Charities

Lisa Kimura

Aloha United Way

LJ Duenas

Alzheimer's Association

Lola Irvin

Chronic Disease Prevention, Department of Health

Makana McClellan

Shriners Hospitals for Children

Mary Brogan

Developmental Disabilities Division, Department of
HealthMary Burgess

Sutter Health Kāhi Mōhala

Mary Komomua

Kaiser Permanente

Maureen Bates

Dept of Vocational Rehab, Department of Health

Melissa Hashimoto-Binkie

Hui No Ke Ola Pono

Michael Fujimoto

Rehabilitation Hospital of the PacificMichelle Kauhane

Hawaiʻi Community Foundation

Monique Ibarra

Ka Hale A Ke Ola Homeless Resource Center

125

Noa Emmett Aluli, M.D.

Molokaʻi Family Health Center

Nanci Kreidman

Domestic Violence Action Center

Noelle Lau

Wilcox Memorial Medical Center

Paula Arcena

Aloha Care

Punahele Alcon

Molokaʻi General HospitalRich Bettini

Waiʻanae Coast Comprehensive Health Center

Robin Matsukawa, M.D.

Adventist Health Castle

Rona Fukumoto

Lanakila Pacific

Ryan Tenn

Adventist Health Castle

Ryan Yamane, Sen.

Hawaiʻi State Legislature

Sally Ancheta

Hawaiʻi Public Health Institute Hawaiʻi Island

Sean Chun

Native Hawaiian healer

Shanty Asher

City & County of Honolulu

Sheri-Ann Daniels

Papa Ola Lōkahi

Sunny Chen

Healthy Mothers Healthy Babies

Susan Murray

The Queen's Medical Center - West Oʻahu

Susan Passalacqua

Adventist Health Castle

Tanya Suapaia

The Queen's Medical Center - Punchbowl

Terrina Wong

Pacific Gateway Center

Toby Taniguchi

KTA, Community First Hawaiʻi

Tom Matsuda

Hawaiʻi Community Foundation

Tracie Ann Tjapkes

Adventist Health Castle

Travis Clegg

Straub Medical Center

Valerie Janikowski

Lāna'i Kina'ole

Valerie Saiki

Hawaiʻi Public Health Institute Kauaʻi

Whitney Lim, M.D.

The Queen's Medical Center - Punchbowl

126

Wilfred Alik, M.D.

Kaiser - Marshallese, RMI Task Force

William Thomas

Molokaʻi General Hospital

William Trujillo

Kauaʻi County, Department of Parks
and Recreation

127

G. UH Partnership

128