The pandemic may have doubled the workload of Hawaii’s community health clinics and nonprofits, but new funding and more relaxed rules have provided unexpected opportunities and collaborations, local health leaders say.

As a result, many have actually expanded their services and forged new outreach programs — meeting patients where they are to care for them on the spot.

Maui’s Mālama I Ke Ola Health Center has worked with rural and low-income patients for decades, but it wasn’t until a few months ago it could afford to launch a brand new program to bring medical services and prescriptions to homeless people where they live.

“I had wanted to do something like this since 2013,” said Cassie Savell, the chief operating officer. “There are a lot of barriers to make things happen and COVID-19 kind of opened doors for us.”

Jonathan “Matt” Kanae, a community health worker, assists a patient with paperwork at a pop-up outreach clinic. Courtesy: Malama I Ke Ola

The leaders of community health centers, many of which care for patients regardless of their ability to pay, say the key to sustaining their programs throughout the COVID-19 pandemic has been to stay nimble and ready to pivot to address needs as they evolve.

They’ve hired more staff. They’ve teamed up with would-be competitors. And they’ve provided services beyond their traditional scope, such as COVID-19 testing and vaccine administration.

Project Vision, a nonprofit that traditionally focused on vision screenings, doubled its staff and upgraded its fleet of vans to provide meals, showers and health screenings to people on Oahu, Maui, Kauai and the Big Island. Now it’s among the organizations working with the Department of Health to conduct community COVID-19 testing and organize vaccine clinics.

“The opportunity to grow during this time has been incredible,” said Darrah Kauhane, Project Vision’s executive director. “It’s helped us expand our services but also helped us get the infrastructure together that we needed in order to bill, for example. We never would have had the time to establish that system before.”

Growth In Need And Response

More patients than ever are relying on community health centers and the affordable or free care they provide.

Hawaii’s unemployment rate remains the highest in the nation, said Judy Mohr Peterson, the administrator of the Med-QUEST Division, which provides Medicaid health insurance and other support services to low-income people and the economically disadvantaged. The economic crisis led to massive job loss and a record number of people who need help getting health care coverage, she said.

Since last March, the Med-QUEST division recorded a 25% increase in enrollment — equating to approximately 82,500 newly approved applicants. Statewide, 409,000 people have enrolled in the insurance program — a record for the state, Mohr Peterson said.

The need is most pressing in Maui and Kauai counties, where enrollment in the insurance plan is up by about 30% compared to last year.

It became clear very quickly that Maui’s homeless population was growing, said Savell. To respond, Mālama I Ke Ola Health Center partnered with Maui Rescue Mission to hold pop-up clinic sites, offering on-site wound care and same-day prescription refills, and helping people with Medicaid applications.

On Hawaii island, the Bay Clinic’s mobile clinic staff shifted its attention to shelters when schools closed.

Kimo Alameda, the clinic’s CEO, estimates its Medicaid patient population grew by at least 5%. Three-quarters of the clinic’s patients were already Medicaid-eligible, meaning they live at or near federal poverty levels.

Bringing Health To The People

To Alameda, the pandemic has “enlightened our creative powers,” he said. “It got us to really figure out how to serve the areas that will be hit hardest by the pandemic due to vulnerabilities that already existed prior to the pandemic, like lack of transportation, lack of affordable housing, food security and an unsafe environment.”

New avenues for telehealth have been a big part of that.

When federal and state rules eased to allow clinics to offer virtual doctor’s appointments using video and audio calls during the emergency, things shifted. The federal government also ensured liability protection to medical providers who give care outside of their clinics, which had been a major obstacle, Alameda said.

Dodie Rivera from the Waianae Coast Comprehensive Health Center assists with some outreach in Keeau, Waianae with left, Shaina McEntroe checking a homeless client camped on the beach. Both were checking on swelling from a centipede bite on the head during COVID-19 pandemic.
Waianae Coast Comprehensive Health Center nurse and case management supervisor Dodie Rivera, right, and Shaina McEnroe, community health nurse, check a patient who lives in Keeau Beach Park, after she reported swelling from a centipede bite. Cory Lum/Civil Beat/2020

Now, telehealth is a staple component of many clinics’ outreach, especially since they can get paid with ease. Before the pandemic, Medicaid patients could not meet with doctors by phone.

Being able to schedule virtual appointments has been invaluable to the patients Dodie Rivera sees. The registered nurse and case management supervisor at the Waianae Coast Comprehensive Health Center has worked with her team for years to build trust in homeless communities along the West Oahu coastline.

Video conferences with doctors were a welcome addition to the on-site care she and her team of nurses and community health workers were already providing.

Audio health appointments were particularly helpful for people who lack stable Wi-Fi or access to video conference technology or people who live in areas with no public transportation.

An estimated 18% of households on Hawaii island and 12% in Maui county do not have internet access.

“This opened an opportunity for increased access, not only to our unsheltered patients, but to other patients as well,” Savell said.

Maui, home to 120,000 people, lacks public transportation between its many rural communities.

In tandem with telehealth, many organizations are investing in new vehicles to stretch their reach.

Healthy Mothers Healthy Babies, which secured grant funding to retrofit a solar-powered van into a mobile clinic for expectant and new mothers, added new offerings to its mobile clinic repertoire: food and diaper deliveries and help with accessing rental assistance. Many of its new clients are people who had “never navigated through social services before,” said Sunny Chen, executive director.

The new van helps them address a rising number of patient referrals from health clinics, whose doctors say they haven’t seen them in a while. It also provides a private clinical space that can help them speak to patients one-on-one. Visiting a patient’s house where others are present could prevent a full assessment for things like domestic violence, she said.

“We’ll go in for a social services visit but also making sure they’re OK physically and mentally,” Chen said.

New wheels also come in handy for the vaccine rollout, said Alameda. When making plans for a vaccine event in Milolii on Hawaii island — one of the most rural areas in the islands and one of the last Hawaiian fishing villages — Bay Clinic staff realized they could likely distribute more doses if they went there. They were able to purchase a new shuttle.

“Many of the homes do not have access to power lines or water, with each house providing its own electricity and water with solar panels and tanks that collect rain water,” he said. “The idea is to go to the isolated community rather than the community and kupuna coming all the way to Kona or Hilo for the vaccine.”

It’s a major logistical challenge they may not have been able to pull off in the past.

Will It Last?

In a way, the so-called new normal is working even better for some clinics.

But funding for the long haul is not guaranteed, especially as federal funding dries up and the state’s budget tightens.

The Residential Youth Services and Empowerment Hawaii, or RYSE, was able to expand its housing stock last year and team up with several nonprofits to put together a mobile crisis outreach program for young adults without shelter. But its emergency shelter on Windward Oahu is due to lose funding from a three-year state initiative that ends this year.

The shelter is typically full and dozens of homeless youth are on its waitlist.

“As we know the pandemic has affected us across the board, so that money is not rolling in,” said Carla Houser, executive director. “We see young people who, despite eviction moratoriums, are getting kicked out and living in cars. We anticipate that this pandemic of youth homelessness will continue to grow.”

The strides in telehealth could last. Several measures under consideration at the Legislature could make some emergency telehealth provisions permanent, such as House Bill 473 which allows doctors to establish patient relationships virtually.

Another bill, HB 472, would codify advanced practice registered nurses’ ability to use telehealth to assist patients as well as telehealth-related exemptions that were created by emergency proclamation.

Insurance plan AlohaCare’s CEO Francoise Culley-Trotman said of a survey of 37 providers in 2020, half reported that “patient access to devices” and “patient access to broadband service” are a barrier to telehealth.

HB 1191 could pave the way to increase broadband services in unserved areas, she told Civil Beat by email.

“We hope that if passed, the proposed grants will help improve the quality of life, including remote access to care, for residents in these communities,” she said.

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