Community-Clinical Linkages Within Health Care in Hawai‘i: History, Innovation, and Future Directions

Today's complex health care environment and new payment structures demand innovative partnerships and collaborations to meet patients' social and behavioral needs to prevent illness, manage conditions, and address the health disparities that fall outside of the traditional purview of clinical medicine.^1–2 Many such collaborations fall into the broad classification of community-clinical linkages, which improve patients' preventative and chronic care by connecting health care providers and systems with supportive community organizations and public health agencies to meet patient needs.³ This is a dynamic topic in both research and practice, and models are actively evolving across the United States and elsewhere.⁴

The articles in this special issue highlight the many innovations in community-clinical linkages in Hawai‘i in recent years and over time, and the extensive expertise in clinical medicine and community care that inspired those innovations. The 14 original, peer-reviewed manuscripts highlight the history and scope of this work, along with successes, challenges, insights, and future directions. These articles present the perspectives of those working in hospitals, clinics, community health centers, and nonprofit organizations. In addition, the 5 accompanying editorial commentaries in this issue provide a broader view of the landscape and offer considerations for future directions across the health care workforce, insurers, and systems in our state. We are especially excited to share the viewpoints of community health workers in a number of the articles.

Community Health Workers

The first articles in this issue provide insights into the endeavors of Hawaii's community health workers (CHWs). These critical frontline workers hold deep cultural and community relevance and play key roles in many efforts around community-clinical linkages. In Community Health Workers in Hawai‘i: A Scoping Review and Framework Analysis of Existing Evidence, Stupplebeen, et al, describe evidence around community health workers efforts in Hawai‘i over time, including workforce programs, intervention roles, barriers, and outcomes considered within national workforce and public health framework roles. In Community Health Workers in Action: Community-Clinical Linkages for Diabetes Prevention and Hypertension Management at 3 CDC 1422-Funded Community Health Centers, Stupplebeen, et al, give further insights into the specifics of CHW roles and linkages for chronic disease management. They provide insights into the need to stabilize funding and reimbursement for the CHW workforce. Similarly, in Legislative Definitions of Community Health Workers: Examples from Other States to Inform Hawai‘i, Cacal, et al, explore the formalization of the CHW role and scope of care in Hawai‘i by providing historical context and recommendations for moving forward gleaned from insights into other states' efforts to formally define CHWs in policy. This can support workforce development that is critical for the establishment of more stable funding streams for, and increased utilization of, CHWs in Hawai‘i.

In related commentaries, Yamauchi, et al, provide insights for Hawai‘i from the perspective of allies supporting the formation of a state-level CHW association in Community Health Worker (CHW) Movement in Hawai‘i: Moving Towards a CHW Association. Spock and Wennerstrom, both founding board members of the National Association of Community Health Workers, provide vivid insights into the value of CHWs in health care and best practices about CHW self-governance from the local and national perspectives in “Nothing About Us Without Us”: Lessons from Community Health Workers in Hawai‘i Nei and Beyond.

Health Systems-Based Programs

Our next section of articles comes from health systems and consider how community resources can be engaged to support critical health issues within hospitals and clinics. In Engaging a Community Chaplaincy Resource for Healthcare Provider Training in Facilitating Family Decision Making for Child at End-of-Life: An Interprofessional Team Approach, Wada, et al, provide insights into training with an interprofessional team, including chaplaincy services, which are a valuable resource that are often underutilized in health care, to provide needed, holistic care for the anguishing decisions for children at the end-of-life. In As a Community, We CAN: How Collaboration in East Hawai‘i Led to Community-Wide Initiatives Focused on Reducing Avoidable Emergency Department Visits and Inpatient Admissions, Walker, et al, provide useful insights into ways in which medical services, social services, and health plans can collaborate towards common goals to support patients with complex needs to improve quality of care, streamline workflow and administrative systems, provide meaningful connections to services, and reduce unnecessary and costly services. In the article Adding Social Determinants in the Electronic Health Record in Clinical Care in Hawai‘i: Supporting Community-Clinical Linkages in Patient Care, Trinacty, et al, provide an overview of the efforts of 3 distinct health systems in Hawai‘i to integrate social needs into clinical care along with the rationales for these undertakings. They consider the challenges of clinical relevance and capacity. In a relevant commentary, Interprofessional Education in Hawai‘i to Support Community-Clinical Linkages, Otsuki, Hedges, and Masaki provide a perspective about changing patterns and new innovations in professional training that will be needed to meet these identified needs from the perspective of the medical school in our state, the John A. Burns School of Medicine at the University of Hawai‘i at Mānoa.

Community Health Center-Based Programs

The issue then turns to Hawaii's community health centers, which have been central to innovative work in addressing social determinants of health in Hawai‘i for many years. This issue highlights some of these programs. In Building a Patient-Centered Medical-Legal Home in Hawaii's Kalihi Valley, Shek and Turlington explain that, because legal care can remedy medical problems rooted in legal problems, a partnership between doctors and lawyers can improve the health and well-being of patients. They describe an innovative medical-legal home and its role in promoting patient power and autonomy. Also from Kokua Kalihi Valley Comprehensive Family Services (KKV), the article Pedals and Pedagogy: Cycles of Hope and Health by Acido, et al, describes the innovative and collaborative approach of a bike exchange program conducted within a clinical setting. The article highlights the healing aspects of culture circles and shows what it means to hold space for the young men and women of Kalihi. The program addresses generational trauma and violence and aims to restore ancestral connections and practices, thereby reconnecting the youth to reclaim the power of their name, remember their homeland, and summon the guidance of their ancestors. In Implementing a Health Coaching Curriculum in Hawaii's Community Health Centers, Domingo, et al, describe supports for health coaches to help patients become informed, active participants in their care.

Provider-Based Programs

In Greater Community-Clinical Linkages and Attention to Patient Life-Stage: Recommendations to Improve Diabetes Self-Management Education in Hawai‘i, Pirkle and colleagues provide empirical evidence along with new insights and recommendations for the adaptation of diabetes self-management programs to meet the needs of diverse populations in the state. In A Culture-Based Family-Centered Health Navigation Intervention for Chronic Disease Management in Native Hawaiians, Miyamoto and colleagues show that navigators who provide culturally-based case management result in high satisfaction for both patients and primary care physicians.

Queens Health Care System

The issue closes by highlighting programs in one health care setting. In the last few years, The Queens Health Care System has developed innovative programs to address the social needs of some of its most vulnerable patients using non-clinical community health workers as patient navigators. Three articles provide insights from different aspects of these efforts. In Community Linkage Through Navigation to Reduce Hospital Utilization Among Super Utilizer Patients: A Case Study, Shearer, et al, describe a navigation program that connects super utilizer patients to existing community supports, thereby increasing access to care and services and reducing unnecessary hospital utilization. They include their guiding model, a patient-centered, harm reduction framework, along with examples of community linkages and reduction in utilization. Kim, et al, provide the history of the Native Hawaiian value-based approach to support psychosocially vulnerable Native Hawaiians after hospitalization in Ke Ku‘una Na‘au: A Native Hawaiian Behavioral Health Initiative at The Queen's Medical Center. The authors describe their process, their goals, and some of their outcomes from the program perspective. In a companion article by Nishizaki, et al, “It Starts with ‘Aloha…’” Stories by the Patient Navigators of Ke Ku‘una Na‘au Program at The Queen's Medical Center, the 5 Native Hawaiian navigators from this program describe their experiences, including their journeys with their patients, the privilege they feel when serving their community and kupuna (elders), their insights into community-clinical linkages that are needed by their patients, and the ways they maintain self-care to sustain their work. Together, these articles provide important models of meaningful programs deeply grounded in community needs and practical guidance for similar programs starting in other settings.

Conclusions and Mahalo!

What emerges from these articles is a clear picture of the need for collaboration across clinical and non-clinical workforces, and the importance of cultural adaptations and relevance. Some of these innovations are in their first few years of practice. Future work will evaluate many of these programs in more depth.

The final commentary Community-Clinical Linkages Supported by the Centers for Disease Control and Prevention: The Hawai‘i Department of Health Perspective by Irvin and Sentell provides insights into the funds supporting key activities in this special issue and show how these funding streams have helped to create links across sectors.

We thank the authors of the articles and editorials for sharing their innovative research, deep insights, and diverse perspectives across various settings and locations. We give a huge mahalo to our wise and generous editorial board (Robert Hirokawa, L. Brooke Keliikoa, Blythe Nett, Catherine Pirkle, Alexis Barnett Sherrill, Napua Spock, Yan Yan Wu, Jessica Yamauchi) and our excellent peer reviewers (Kathryn Braun, Mele Look, Deborah Taira, JoAnn Tsark) for giving so generously of their time and expertise. From the Hawai‘i Journal of Medicine and Public Health, we also thank Dr. Kalani Brady for all the support. We hope this work inspires, supports, and encourages new innovation in this area.