Abstract
Health and social service organizations across Hawai‘i were surveyed between April 29 and May 11, 2020 by the Community Care Outreach Unit of the Hawai‘i Emergency Management Agency. This article contextualizes and describes some of the major findings of that survey that reveal the impact of coronavirus disease 2019 (COVID-19) on Hawai‘i community agencies, service organizations, and the individuals they serve. Major issues for individuals served by the responding organizations included securing basic needs such as food and housing as well as access to health services, mental health needs, and COVID-19 concerns (such as inadequate personal protective equipment, cleaning supplies, quarantine, and testing issues). Respondents reported that job loss and the resulting financial problems were a root cause of personal strain among clients served. Community-level stress was related to the distressed economy and store closures. Fulfilling immediate and future needs of health and social service agencies and the individuals they serve, as articulated in this report, could dampen the effect of COVID-19, promote population wellbeing, and support community resilience.
Introduction
The coronavirus disease 2019 (COVID-19) pandemic has resulted in deep health and social needs across communities in Hawai‘i. As of July 2, 2021, there were 36 120 cases, 518 deaths, and 2484 hospitalizations in the state of Hawai‘i.1 The US National Response Framework (NRF) established Emergency Support Functions (ESF) to provide organization and support needed in response to emergencies. ESF #8, Public Health and Medical Services, is the mechanism to provide support for states in the case of public health and medical care needs.2 Under ESF #8, the Hawai‘i Emergency Management Agency (HI-EMA) established a medical/public health branch, and within this branch a Community Care Outreach Unit (CCO Unit) was established.
The CCO Unit was tasked with identifying capacity, needs, and threats to members of the community during this time, and making recommendations to mitigate the situation. The CCO Unit team decided that the first step in this endeavor was to assess the current capacity, needs, and threats to agencies that provide health and social services support to the population. This project was an evaluation of urgent needs. From this work, we produced a preliminary report3 and then a full report,4 which can be found at https://dod.hawaii.gov/hiema/files/2020/06/ESF-8-CCO-Unit-Survey.pdf.
This article contextualizes and describes major findings from that report especially around the impact of COVID-19 on Hawai‘i community agencies, service organizations, and the individuals they serve from the perspective of health and social service organization leadership. More details, including community perspectives on solutions from the agency survey and more details about agency capacity, can be found in the full report.4
Methods
The survey of community based health and social service entities was conducted across the state between April 29 and May 11, 2020. The survey was sent to a list of relevant contacts at agencies that provide health and social services. These agencies were also encouraged to share the survey with other organizations in their communities. The survey instrument included 26 questions that addressed agency/organization demographic information in terms of location, services provided, and populations served; the impact of COVID-19 on the population served; and current and projected agency/organization capacity and needs as a consequence of COVID-19. In open-ended questions, survey respondents were asked to identify both immediate and long term community needs related to COVID-19. Data were analyzed descriptively. Quantitative data were analyzed with R: A Language and Environment for Statistical Computing (R version 3.6.3. 2020. Vienna, Austria: R Foundation for Statistical Computing), and qualitative data were analyzed using Dedoose (Version 8.0. 2018. Los Angeles, CA: SocioCultural Research Consultants, LLC).
Results
A total of 121 organizations responded, representing a wide range of volume and type of services provided. Seventy-nine (65%) respondents were from health care service organizations and 42 (35%) were from social services organizations. Health care service entities included community health centers, behavioral health providers, health insurers, substance abuse support organizations, primary care providers, maternal and child health services, including Women, Infants, and Children (WIC) program and child care services, and many others. Social services/education entities included, for example, food focused services, social services, youth services, culturally based organizations, HIV/AIDS supportive organizations, and legal services. Forty-seven percent routinely offered home based visits, and 33% provided primary care services.
Organizations from all counties were represented proportionally to the state population in that county. Across all responding organizations, the median number of clients or patients served was 1200 (range 4–155 000), and the median number of encounters was 5200 (range: 12–251 958). Nearly one-third of responding entities (n=39, 32%) provide services across the state of Hawai‘i. While all populations across the state were served, nearly two-thirds (63%) of the organizations listed older adults, homeless, low income migrants/immigrants, and persons with diverse sensory abilities (hearing, vision) as specific groups served. Respondents reported that both home care and primary care services were severely curtailed due to COVID-19. Sixty-three percent (63%) provided services via telehealth.
Community Needs from the Organizational Perspective
Immediate Needs
In Spring 2020, from the organizational perspective, immediate needs were largely related to the economic and social consequences of COVID-19 (Figure 1). Basic needs were mentioned 91 times: housing (mentioned 36 times), including housing instability and families being unable to pay rent as a result of job loss; food insecurity (mentioned 34 times); and meeting other basic needs (mentioned 21 times), such as transportation and utilities. Economic consequences were mentioned 48 times, including individual economic consequences, such as job loss, reduction of income, and financial strain, and community economic consequences (mentioned 15 times) such as business closures. These immediate needs were linked to other outcomes and challenges. As a respondent described: “Many people are having economic issues as their income sources have dried up, which results in other issues with housing, interpersonal conflict (including within a family).”
Figure 1.
Word Cloud for Survey Question, “What do you see as the top IMMEDIATE issues or problems for the community that you serve resulting from the coronavirus pandemic?”
An increase in mental health challenges was another common concern (mentioned 39 times). Concerns included access to behavioral health services; stress, fear, and anxiety; and concerns of substance use. The increase in mental health issues was believed to be due to social distancing/isolation and drastic and rapid changes in lifestyle. This was acute in the elderly as described: “The mental health challenges have been obvious with most all of our patients. However, it's more significant with the Kupuna we serve that are accustomed to going to church, having regular outings, seeing friends and family regularly.”
Other common concerns included those surrounding medical care (mentioned 32 times). This included lack of access to care, either due to fear of exposure to COVID-19, reduction in services, or lack of transportation; and health insurance challenges due to loss of employment. Other concerns centered on COVID19-related needs (mentioned 29 times), including PPE, cleaning supplies, facilities for quarantine, and adequate testing.
Long Term Community Needs
The projected long term needs of the communities served were closely linked to current issues centered on financial strain due to job loss. The majority of the respondents regarded economic consequences (mentioned 60 times) as the major issue that will emerge or be exacerbated in the community within the next 6–12 months. Community economic consequences, such as the economy and business closures (mentioned 29 times), were most common, while individual economic consequences (mentioned 26 times), including financial strain, job losses, and unemployment, were also mentioned. Homelessness, including the inability to pay rent and housing affordability, was the second most commonly mentioned issue expected to emerge or be exacerbated within the next 6–12 months (mentioned 41 times). These financial strain issues fed into additional difficulties, such as those described by a respondent: “job losses from businesses closing or making more permanent layoffs, evictions and homelessness, increased violence and crime at home and in community.”
A special concern for homeless youth was noted. This group is deemed to be extremely vulnerable, and often a hidden population: “Homeless youth/young adults have always been a “slippery” population and good data have always been hard to come by. COVID-19 has, thus far, seemed to reduce the number of youth on the streets (at least in the Waikiki/Downtown areas), but I think that many may be “couch surfing” for the short to medium term and I would not be surprised to see an increase over the next few months as they wear out their welcomes and/or get kicked out again.”
Mental health issues were also commonly mentioned as a long term concern (36 times). Stress, fear, and anxiety were the most commonly mentioned, followed by behavioral health and substance abuse. “Mental health challenges are already surfacing and we see that continuing for our staff and patients. We've also seen an increase in anxiety and stress related medical emergencies.”
Other long-term COVID-19-related concerns included lack of adequate PPE, fear of a second wave, inadequate testing, and isolation/social distancing. Access to healthcare, including primary care and insurance, was also commonly mentioned as another problem that may be exacerbated in the next 6–12 months. Family-related concerns, including domestic violence, child abuse, and child care remained important, as did concerns about telemedicine and the technological divide, and increased isolation.
Organizational Capacity
Respondents were asked if they could increase their organization's capacity to serve additional people today and in 6 months. Ninety-four percent (94%) reported that they could increase their capacity today, and 97% said they could increase it in 6 months. The majority reported that increasing capacity would require more resources, including funding and additional healthcare personnel, personal protective equipment (PPE) for safety, and expanded telehealth equipment and technology upgrades. The desire to grow to meet new needs was competing with other issues, including uncertainty around future budgets and decisions being made to prepare for those contingencies. As one respondent noted: “Our program is currently in a hiring freeze. Though we at our local center would like to increase our capacity, the workload could increase, but the staff would not.”
Organizational Needs
Organizational Needs
Key issues that negatively affected organizations’ abilities to provide services centered on organization strain, inadequate supplies of PPE, client isolation and social distancing, gaps in technology for telehealth, and the declining quality of medical care (Figure 2).
Figure 2.
Word Cloud for Survey Question, “Please describe any IMMEDIATE needs or issues that your organization is encountering that negatively affects your ability to provide services as a result of the coronavirus pandemic.”
Organization strain was the most frequently reported issue that hindered agencies’ abilities to provide services. This strain was evidenced by issues related to specific COVID-19 challenges (mentioned 19 times), including the reduction in patient visits due to perceived fears and closure of businesses; funding (mentioned 18 times), such as the lack of financial assistance to provide resources, support, and staffing; and the impaired quality of services (mentioned 7 times) due to social distancing regulations and the inability to have face-to-face or home assessments.
The second most frequently reported issue at the organizational level was the need for PPE. This included inadequate amounts of quality PPE supplies such as masks, hand sanitizers, cleaning supplies, gowns, and face shields that are needed to disseminate supplies to vulnerable populations, employees, patients, and especially for healthcare providers.
Isolation and distancing (16 mentions) was another reported organizational issue that negatively affected the ability to provide services. This included social problems, such as loneliness among members who seek social services and accelerated dementia symptoms of patients. It also included concerns about home visits, such as challenges in providing in person support groups or home assessments for patients, especially those in long term-care. Many respondents noted that, while important for infection control, social isolation and lack of human contact was interfering with generating the trust needed to form effective partnerships between providers and patients/clients.
Organizations also identified other technological issues (mentioned 11 times) as a barrier to providing services. This included technology gaps: technology training, including educating people on how to access services with technological devices or how to participate in telehealth; and technology needs such as a lack of bilingual interpreters, internet services, and equipment.
Lastly, organizations identified lack of access to medical care as another issue that has affected their ability to provide services. This included lack of medications, childcare services, and healthcare access, especially for timely management of chronic diseases; and problems regarding the lack of health insurance.
Risk of Closure
Twenty-four (19.8%) organizations responded to the question about concerns with risk of closure. These centered on concerns about complete closure, loss of certain program areas, and feeling that although they were fine in the short-term, much uncertainty remained in the long-term. Concerns due to COVID-19 included lack of funding or loss of patient/client revenue, reduction in staff and provided services, lack of PPE, and telehealth challenges.
Additional Services
The majority of the respondents said they would like to provide additional services that meet the basic needs of the communities they serve. Respondents also mentioned that they would like to expand their services to include more public information sharing and awareness. Many mentioned a desire to communicate effectively with their community, including reaching clients across health literacy levels.
Respondents would also like to provide affordable housing services to help community members meet housing needs. As one noted: “This could include funding to purchase housing that could be rented at an affordable rate. Funding to build affordable housing. Or even funding to provide rent subsidies.”
Additional services mentioned by respondents included provision of robust telehealth services, as well as the need for funding to hire more human resources to support telehealth; enhanced linkages with social services and new capacities to address social and behavioral health needs; and COVID-related support (PPE, testing, client education). There was also hope for greater accessibility to service, especially to alleviate stressors related to basic needs, and for more flexibility, including relaxation of telehealth rules.
Services for Individuals with Disabilities
Sixty-four percent (77/121) of organizations serve individuals with disabilities. Diminished or reduced hours of many organizations have contributed to a marked barrier to access to care and services, as well as increased social isolation among people with disabilities. Closure of day programs has resulted in families being required to provide 24/7 care for children and older adults, and home care attendant services have been curtailed. The need for telecommunication has been more difficult for people with disabilities. Some individuals with disabilities may not understand the meaning of stay-at-home orders, leaving them bewildered or stressed about the circumstances.
One of the most common challenges faced by individuals with disabilities is the issue of self-isolation and social distancing. Numerous facilities that were deemed “non-essential” closed their doors, which dramatically hindered the ability of those with disabilities to have social interaction with family and friends, as well as access to supportive services that may assist individuals with activities of daily living. Mental health was identified as another challenge faced by persons with disabilities due to the social isolation.
Many individuals with disabilities rely on the support of family members and friends for access to medical care/supplies such as medication and transportation for various health care visits. The inability to conduct face-to-face interactions with people with disabilities has created significant challenges in terms of conveying health information, assuring adequate medical supplies, and providing access to other support services such as interpreters. The ability of persons with disabilities and those who care for them to access mental and social welfare support and provide for basic needs was also mentioned as a common challenge. This includes access to personal care attendants who frequently assist clients with activities of daily living. Numerous care centers have been required to close their doors, which has increased caregiver stress. Challenges due to inadequate transportation during this time has resulted in increased difficulty for providing basic needs as no in-person services were being offered.
Another common concern included challenges with utilizing technology to maintain communication for individuals with disabilities with health care providers and other forms of support.
Respondents mentioned that the need for telecommunication (such as video conferences and phone calls) may be particularly inaccessible to individuals with disabilities. As one respondent noted: “We have some who are hard of hearing at the moment. They need someone else with them if we need to communicate by phone, so that person can relay information to them – the phone itself isn't loud enough, and it's often not easy to show them writing or a screen like we can do if they're at our office in person.” It was also noted that there may also be a degree of distrust that prevents this group from utilizing telehealth technology.
Solutions
Organizations
Various potential solutions to address these needs were provided by responding agencies. Collaboration was a common suggestion, including the need for “Continued collaboration between national, state and city & counties to disperse accurate data and information to community.” Other insightful ideas included providing a one-stop resource library, allowing flexibility in how federal funds can be used, avoiding duplication, addressing the need for affordable housing, and expanding Hawai‘i's food/plant distribution program to help families to grow their own food at home. Respondents would also like to see a more open and transparent process for assuring that funding to nonprofits and community groups is more widely dispersed; it was noted that “A lot seems to be happening behind closed doors without public info or opportunity”.
Numerous organizations mentioned the increased use of telehealth technology to maintain relationships with their clients, while also reporting challenges. Responding agencies clearly noted a digital divide in terms of access and ability to use telehealth. Those with the most need seem to have a lower degree of access to telehealth services. Due to fears of exposure to COVID-19, there was concern that patients may not seek primary health care and follow up for management of their chronic conditions. This may exacerbate their chronic diseases, especially for those who do not have access to medications/refills as a result of expired prescriptions due to lack of follow-up visits or loss of health insurance.
Increasing funding and positions for community health workers was noted as something that would be beneficial for addressing many of the problems our communities are facing. “Public health and social navigation should be one of the top drivers of solutions. Start there and we can really ensure our most vulnerable are supported through this.” While there were deep concerns about increased demand with limited resources, many organizations noted that they are ready to expand to meet needs and praised their volunteers and staff who deserve recognition for their dedication and hard work. Table 1 presents some challenges and solutions from the organizational perspective, and Table 2 presents these from the community perspective.
Table 1.
Strategies for Responding to Needs/Issues Identified by Agencies that Provide Health and Social Services
| Issues/challenges | Strategies to address |
|---|---|
| Organization strain related to severe decline in revenue | Address funding and reimbursement issues that are driven by patient volume |
| Challenges with meeting basic needs of individuals | Monitor and augment services to assure access to food, housing, mental health, transportation and social services |
| Lack of resources required to expand telehealth services | Provide support for telehealth (financial and technical support) |
| Inadequate supplies of PPE and assurance of employee safety | Assure availability and access to appropriate quantities and types of PPE |
| Lack of resources to support client isolation and social distancing | Provide funding to support expansion of social services |
| Lack of means to address declining quality of medical care related to missed care for chronic disease management and decline in face to face interaction with clients | Provide adequate PPE and transportation to support home care and community based encounters with providers |
| Lack of resources needed to expand services | Increase funding for personnel and increased capacity and expertise for telehealth services to support chronic disease management and expand social services to meet basic needs. |
Table 2.
Strategies for Responding to Key Needs/Issues of Individuals
| Issues/challenges | Strategies to address |
|---|---|
| Economic insecurity related to unemployment | Expand social service support for basic needs |
| Mental health services for exacerbation of existing and emergency of new metal health issues | Expand access to mental health services |
| Housing – risk of eviction or loss of home | Social policy to protect those at risk |
| Food insecurity – lack of funds to pay for food, low knowledge about access to food banks | Assure availability of food via food bank and educate community about how to access |
| Decreased access to health care for chronic disease management (includes access to telehealth as well as access to medications) | Provide financial and technical support as well as PPE and transportation to support access to primary care |
| Access to adequate levels of PPE and household cleaning supplies | Develop a distribution system for PPE and household clearing supplies |
| Mitigate effects of social isolation/social distancing | Increase access to social services |
| Need for adequate childcare | Increase access to childcare services |
Discussion
The findings from this report were considered and discussed among the CCO Unit team and the CCO Unit Community Partners. They noted the urgency of addressing food, housing, and other immediate needs such as assuring telehealth support, including for those who may not have access to the internet, computer equipment, or a safe place to store or charge a phone. Partnerships with entities that already have technology, such as libraries and schools could provide solutions. It was noted that other individuals may have difficulties with accessing telehealth technology due to low technological literacy. For example, Kaiser Permanente and Hawai‘i Medical Service Association, 2 major insurers in Hawai‘i, require that patients use their own apps to access telehealth. Community health workers or other individuals could be available to assist individuals in navigating these apps.
The team recognized the need to support and create policies that establish and sustain health insurance, access to healthcare, and paid sick leave for workers remains urgent. Adapted in-person services that allow for physical distancing are important for high-risk individuals and those with co-occurring needs because these individuals’ services may not be able to be delivered through telehealth platforms. There is a need to increase awareness of mental health resources that include Crisis Text Line, CARES Crisis Line, National Suicide Prevention Lifeline, and free Hawai‘i TelePsych Visits. Opportunities need to be provided for individuals with disabilities to participate in discussions regarding COVID-19. Linguistically and culturally diverse populations should assist in the development and dissemination appropriate health information. A collaboration with faith-based organizations and support groups to reach out to the community to combat isolation and facilitate connectedness was also recommended.
Conclusions
Since this survey was completed, the pandemic has continued and many agencies have pivoted their missions to meet these needs. It remains useful to see this snapshot of needs and concerns at the start of the pandemic as the responding agencies represent a large segment of the health and social service infrastructure of the state of Hawai‘i. Fulfilling the immediate and future needs of health and social service agencies and the individuals they serve, as articulated in this report, can serve to dampen the effect of COVID-19 and promote population wellbeing and support community resilience. Lessons learned from the experience can inform response for future pandemic events.
Acknowledgements
We are deeply grateful to our HI-EMA S ESF-8 COO Unit Community Partner Advisory Group for their insights during this project who represented perspectives from Native Hawaiian, Pacific Island, Filipino, elderly and neighbor island and rural communities. We are also grateful to Christine Chaplin from the ESF-8 GIS team for the maps that were presented in the HI-EMA report. Research in this report was partially supported by the National Center on Minority Health and Health Disparities of the National Institute of Health (NIH) under award number U54MD007601 (Ola HAWAII grant). The content is solely the responsibility of the authors and does not necessarily represent the official views of NIH.
Abbreviations and Acronyms
- CCO Unit
Community Care Outreach Unit
- COVID-19
Coronavirus disease 2019
- ESF
Emergency Support Functions
- HI-EMA
Hawai‘i Emergency Management Agency
- NIH
National Institutes of Health
- NRF
US National Response Framework
- PPE
personal protective equipment
Conflict of Interest
None of the authors identify a conflict of interest.
References
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- 2.Emergency support functions. Public Health Emergency website. Available from: https://www.phe.gov/Preparedness/support/esf8/Pages/default.aspx. Last Reviewed June 11, 2019. Accessed April 3, 2021.
- 3.Honore M. Pandemic survey: Hawaii is already enduring widespread socioeconomic strain. Civil Beat website. Available from: https://www.civilbeat.org/2020/05/pandemic-survey-hawaiiis-already-enduring-widespread-socioeconomic-strain/. Published May 31, 2020. Accessed April 3, 2021.
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