Introduction Increasingly, key United States (US) health care system stakeholders have recognized that innovative models of clinical coordination, team-based care, and engagement of the social needs of patients and communities are necessary to achieve optimal health across diverse populations.1-4 For instance, the patient-centered medical home can only achieve its promise of coordinated, cost-effective care from strong collaboration and effective communication between interprofessional care team members, which may include social workers and/or lay community health workers.2,5 Adding social factors to electronic health records will only be useful if providers understand how this information can improve clinical communication and outcomes, if the collection of these data can fit meaningfully within clinical workflows, and if the identification of social needs at the clinical level is also associated with linkages and relationships established to address these needs.6-7 These new care models place increasing emphasis on health professional training that includes interprofessional education, team-based practice, community-based learning, and a deeper understanding of the role of social factors in health care.1 Such training opportunities also allow students to better understand the needs of vulnerable or underserved populations. This approach has promise to deliver culturally-relevant care, strengthen trust, and ultimately reduce health disparities.8
Chronic diseases impact 60% of Americans, with 42% reporting multiple chronic conditions, and account for $3.3 trillion in annual health care costs. In Hawai'i, about 80% of adults report having at least 1 chronic condition, and more than half of those report having multiple chronic conditions. Health coaching is a technique of engaging patients to help them obtain the knowledge, skills, and confidence to become an active and engaged participant in their health care. Health coaching aims to assist patients with understanding their care plans, exploring their perceptions of their care plans, and working collaboratively with their health care team to implement these plans to improve their overall health. In 2016, the Hawai'i Primary Care Association (HPCA) partnered with the University of California, San Francisco's Center for Excellence in Primary Care to train staff from HPCA and Hawaii's community health centers (CHCs) in health coaching. This 2-day training focused on using principles of adult learning theory to create interactive sessions aimed at building staff capacity to improve communication and empower patients to become active participants in their health care. The curriculum highlights 6 core elements of health coaching: ask-tell-ask, setting the agenda, closing the loop, know your numbers, behavior-change action plans, and medication adherence counseling. The aim of this case study is to present insights gained from the implementation of health coaching at 1 FQHC in Hawai'i. Health coaching is found to be an effective approach to engaging patients and improving communication with patients and across clinic departments. Health coaching is a promising practice to address the growing chronic disease burden in Hawai'i.
The Medical-Legal Partnership for Children in Hawai'i (MLPC) has worked to address the social determinants of health for low-income patient-families since 2009. Focused on identifying health-harming legal needs, doctors and lawyers work together to assist families with family law, housing, public benefits, education, employment, civil rights, and other concerns. Providing free, direct legal service in the medical setting allows the medical-legal partnership (MLP) team to identify community-wide concerns such as language access violations, racial discrimination, and unfair policies. These individual concerns then inform systemic advocacy and community engagement efforts. The MLPC Hawai'i team has grown through its experiences working with public housing residents, Micronesian migrant communities, and low-income families, ultimately evolving the national MLP framework to become a patient-centered "medical-legal home." This evolution is possible through the utilization of "rebellious lawyering" concepts of working with, not just on behalf of, community clients. This article will introduce the concept of a medical-legal partnership, provide examples of lessons learned from working alongside vulnerable and resilient communities, and explore the idea of the patient-centered medical-legal home as an innovative program to improve the social determinants of health and reduce health disparities.
Hawai'i faces a significant healthcare workforce shortage, not only with physicians, but also with health science workers. "Health science" is a hands-on field that combines biomedical and psychosocial aspects of health, disease, and health care. Many of the fastest-growing jobs are in the health sciences, including home health aides, physical therapists, school counselors, and social workers. In Hawai'i, an aging population and the retirement of current health professionals increases the demand for health science workers. Innovative approaches and new care models are essential to meet Hawaii's needs. One promising solution involves creating four-year undergraduate degree concentrations that train students in marketable skills that are projected to be in demand in Hawai'i, such as in long-term care, community health, and health information management. These bachelor-level graduates could serve critical roles in relieving nurses and physicians of administrative, managerial, care coordination, and clinical data analysis duties that hamper their abilities to practice at the top of their licenses and training. The undergraduate health sciences program at the University of Hawai'i West O'ahu supports students who want to enter these career paths. The program's primary goal is to establish multiple pathways that provide opportunities for underserved youth in West O'ahu communities to choose marketable healthcare careers that pay a sustainable and living wage. Support for this innovative initiative will create a stronger, more well-rounded and sustainable health care workforce that meets Hawaii's increasing demand for affordable, accessible and high-quality care. The final measure of success will be the quality and number of our graduates from our communities, serving our communities.
This editorial presents the perspectives of allies - a group of governmental, university and public health organizations that support the creation of a professional association for CHWs in Hawai'i. We support the efforts of CHWs as they organize and move towards establishing a professional association. Hawai'i CHWs have held monthly meetings starting in 2017 to discuss variety of issues around their work and share information and experiences. A group of CHWs and allies developed a strategic plan in 2018 in preparation to establish a professional association. They shared the results with colleagues from across the state. One desirable outcome for many was a professional CHW association. Such an association could be a forum of shared learning, information sharing, networking, and advocating for workforce and professional development issues, such as training, reimbursement for services, credentials, and certifications. Furthermore, allies support CHW-led efforts to develop an association, for instance, by securing diversified funding sources for CHW trainings, networking, and planning activities. Allies also help by informing supervisors, employers, and policymakers about the importance of trainings and other workforce and professional development for CHWs. A professional association for CHWs in Hawai'i could be useful to many. This editorial provides more insights into this topic.
