When COVID hit Honolulu, Hawaii, the team at Kōkua Kalihi Valley Comprehensive Family Services (KKV) knew what they needed to do. “We were already doing it,” noted Megan Kiyomi Inada, DrPH, MPH, BS, Research Coordinator. “We were always addressing food security. We were always looking at building relationships. We’re always looking at providing wrap-around care. But, in a strange way, the pandemic allowed us to do it in a bit more urgent way. All of a sudden, everyone’s focus was on COVID, and making sure our families were safe. It just helped us to really push harder.”
The team called this new urgent acceleration of care Hui Hoaka, with the goal of increasing community resilience both with patients as well as their own health center staff as the pandemic pressurized the workplace.
Now, three years into the pandemic, Dr. Inada believes that Hui Hoaka reflects the changes in their organizational culture, of increased connection with the community, and reaffirmed why KKV exists in the first place: to serve their diverse community.
Increased Outreach Leads to Food Deliveries
The 2020 stay-at-home orders prompted Hui Hoaka to begin with outreach. “If you’re asking people to stay home, then you’ve got to make sure they have a home to stay in and enough food so they don’t have to leave the house,” asserted Dr. Inada. The team began their outreach to the elders, who were at highest risk for mortality from COVID, may suffer from chronic diseases, and also may be precarious in their access to food. “It was a social determinants of health and medical needs assessment. But, really, what it was for elders was, ‘Someone remembered me. I thought I would be forgotten. Thank you.’” These early calls alerted KKV staff to the level of fear in the community, food insecurity, and rising unemployment, particularly among the hospitality industry. Hui Hoaka responded with home deliveries.
Over the course of the next two years, Hui Hoaka provided over 12,000 “prevention deliveries,” boxes of food for elders and other high-risk members of the community to ensure they can meet their food needs while avoiding COVID exposure. When COVID began to hit their community, they augmented those deliveries with deliveries of food to families and individuals in quarantine or isolation, eventually providing about 2,000 additional deliveries to a total of around 6,000 people.
As the world begins to ease away from COVID restrictions, Dr. Inada hopes the relationships formed with local farmers, the stronger connections with the community, and the push for integrated care with clinicians and community health workers will help KKV transition this aspect of the Hui Hoaka program into a standard practice of care. “People are still food insecure, right now,” Dr. Inada emphasized. “Before, doctors were hesitant to open Pandora’s box and talk about food insecurity in the exam room when there was nothing they could do to help the situation,” but once the food delivery program started, providers quickly began making referrals, Dr. Inada said. “All of a sudden, our doctors felt confident to talk about social determinants of health (SDOH) in the exam room because they knew they could do something about it, they knew they weren’t alone. That’s what we want to keep up. We know that social determinants of health aren’t just a check mark that we put on the chart. If we’re going to be asking about it, it means we need to address it… Food security is part of health care.”
Dr. Inada is part of a team who is dedicated to advancing SDOH-integrated care – but the challenges ahead are large. “What does it look like when we’re not in an emergency? What are the things we learned? And what are the costs attached to that, and how can we make it part of our standard of care? We’re still trying to figure that out,” Dr. Inada said.
Culturally Safe Communications
One of the other lessons learned from early outreach was that many community members lacked quality health information from trusted sources. In the gap, rumors and misinformation were spreading. The community that KKV supports is diverse, and their outreach needed to be equally diverse. Early on, KKV found that generalized communication efforts were unsuccessful, so they shifted gears to create culturally safe COVID and community-building communications – including brochures, videos, and posters. "We believe these tailored health education materials, provided in multiple languages, helped to increase community engagement with our services,” said Dr. Inada.
Staff Support
Hui Hoaka was also inward-facing: how could their organization support staff so they could continue to serve the community? Instead of furloughing the entire dental department, for example, the team decided to provide pathways for the dental staff to engage in outreach and other mobilization needs that were growing because of the pandemic, which was a surprising success. “Our dentist department had to shut down… so they were the ones taking the bags of rice to our community,” Dr. Inada said. “During the pandemic, a lot of people’s gifts were highlighted in a different way,” she added. “We learned that our dental assistants are the best at talking about really hard issues,” like eviction and food insecurity. In this way, KKV did not have to lay off or furlough any staff. They also increased their support of staff members in less conventional ways as well; recognizing the increase in stress around possible infection, Hui Hoaka began cooking family meals that staff members could take home to their families after work.
The KKV staff is currently around 250 people spread over seven sites – but the pandemic brought them closer together. “The bigger you get, the more you start to feel siloed in your own department and expertise, and, really, COVID helped remind us that we’re all working together,” Dr. Inada said. “We need to be able to communicate and share data really effectively if we want to provide care – and I think those lines of communication are much more well traveled,” as a result of the pandemic.
Many providers, Dr. Inada said, may feel they are working independently, as the only one who can effectively serve the patient, but KKV wants them to feel supported -- something that was emphasized through Hui Hoaka. “[The clinician] doesn’t have to figure out food security and housing, all the things that affect health. We want to make sure that there are people there to support them, so they can focus on what they went to school for and what they are good at,” Dr. Inada said. The clinician holds a very special relationship with the patient. “Through deep listening and caring, our providers build trust over time. And when this happens, they can hear what is really going on in a patientʻs life. But that can be taxing, because many of our patients have complicated lives, with complicated issues,” she said. When asked what she would want clinicians to know, Dr. Inada concluded, “It’s important to know that you’re not alone.”
Hui Hoaka Wins SDOH Academy’s Innovation Showcase First Prize
In early 2022, the SDOH Academy launched its very first competition for health centers, asking them to highlight their unique projects to tackle COVID in their communities, with a $5000 prize to the best presentation. The SDOH Academy is a training series for clinicians at health centers who serve special and vulnerable populations, with the goal of enhancing population health by addressing social determinants of health (SDOH) like affordable housing, availability of healthy food, and access to health care. The trainings are collaboratively organized and delivered by several national training and technical assistance partners funded by the Health Resources and Services Administration, like Migrant Clinicians Network. But COVID presented new challenges in providing effective technical assistance. “We saw increasing difficulty in getting health center staff to engage in webinars, but especially in learning collaboratives,” noted Bethany Hamilton, JD, the co-Director of the National Center for Medical-Legal Partnership and a primary organizer of the SDOH Academy. “This was a time when all of us were facing challenges because of COVID… so we thought, ‘we have got to create an incentive.’” Hamilton and her team decided to “gamify” the training experience by launching the Innovations Showcase Competition.
The Innovations Showcase was not just a competition, however. In addition to a kickoff webinar that presented core concepts delivered by an inspirational keynote speaker, participants were required to complete three mini-training modules of about 20 minutes each in order to proceed to the next phase of the training experience. The first module covered economic, environmental, and educational SDOH factors. The second helped health centers understand how age, race, nationality, and gender are SDOHs. The last module covered the role of data and technology in SDOHs. Quizzes were built into the learning platform to provide participants with the gratifying experience of seeing the immediate results of their knowledge attainment. Once they completed all three modules, they received a certificate of completion and were eligible to submit an abstract for the competition. Participants were eligible for national recognition through the showcase closing webinar and, to their surprise, the $5,000 grand prize sponsored by UnitedHealthcare.
For the showcase, participants developed a short presentation highlighting their health center’s solution to an unmet need. For most participants, this meant showcasing their programs to address SDOHs during the pandemic. Hamilton says she told participants, “We know you’ve been doing amazing work during the pandemic and before then. Let us provide an opportunity to showcase what you’re doing,” she recalled. Some health centers were hesitant, but Hamilton encouraged them to participate. “Everything was innovative when addressing the novel coronavirus. No one on Earth has lived through this before,” and many health centers were working hard to address the “other needs” beyond COVID-19 infection relating to SDOHs, like housing instability, food insecurity, and the increased risk of domestic violence, Hamilton added.
Eight health centers submitted their work to the Innovations Showcase. Hui Hoaka, Kōkua Kalihi Valley Comprehensive Family Services’ innovative program to serve their diverse community, won first prize. Two runners-up were also recognized. AlohaCare presented on A Promise of Hope, an SDOH intervention to address low educational levels among Native Hawaiians. The Center for Health Equity Transformation, with the Northwestern University Feinberg School of Medicine presented on Reimagining Patient Navigation, where they reviewed their remote coaching navigation model to build a sustainable health system to improve health outcomes for their medically underserved populations.
In recognition of their work, all eight entries are featured on the Innovations Showcase webpage on SDOH Academy’s website. At a closing webinar, KVV presented their programs and was awarded the prize. Among the entries, KVV’s work, says Hamilton, stood out to the reviewers. “Their presentation painted a compelling and inspirational picture of community-based culturally competent services, [and] not just health care but broader services for their community during the pandemic,” Hamilton noted.
Learn more about the Innovations Showcase: https://sdohacademy.com/innovations-showcase-competition
Watch the Innovations Showcase Kick-Off Webinar: https://www.youtube.com/watch?v=61xRWtNAsFY
Take the mini-training modules: https://cme.bu.edu/SDOH#group-tabs-node-course-default2
Watch the Innovations Showcase Closing Webinar, including a presentation on Hui Hoaka: https://www.youtube.com/watch?v=PVCj4xP2s4I
Visit the website of United Healthcare, who sponsored the $5000 prize: https://www.uhccommunityandstate.com/
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