Episode 4 – Health & Wellness, Part 2, CHANGE Event Series

(00:01:21) Steve Petranik

You know, I have a side gig. I teach at UH Mānoa. And what’s different from my generation is kids are talking a lot more about mental health and mental illness and suicide. And it’s much more in the open now. But they’re very concerned about it. And many of them talk or write their papers about it. What can we do? And we have some young people here in the audience who probably know people who are in that situation. What are some of the ways that we can deal with that and help our young people with their mental health issues?

(00:01:59) Connie Mitchell

I was really impressed when I was sitting with the group that was talking about mental illness in the session prior to this one. And I think that one thing that is so important is connectedness to people. I think when people are isolated and they feel like they’re experiencing something that no one else understands, it makes it very difficult. For young people to even understand that someone is going through something that they may have never experienced is really important.

(00:02:26) Connie Mitchell

Community connectedness is really important. They asked about why people don’t want treatment. When you have a brain disorder and it is not giving you the judgment that you should have to make good decisions, you don’t make that decision to go seek treatment. It’s part of the disease. And so what they need is someone that they can trust. If you have a friend and you can be a good friend to someone and just really tell them what you see and tell them that there’s treatment, there’s really hope for them, they might more likely go seek treatment.

(00:02:59) Mark Mugiishi

Steve, just say I just want to tag on to my answer about what can the families do to protect themselves — just tie on to those comments because it’s so important. We’re going to get into more periods probably of social isolation and you can’t go out, everyone’s afraid and stay away from crowds. Pay attention to the mental well-being of your families, too, because this is going to be stressful times.

(00:03:28) Mark Mugiishi

People are gonna be isolated. They’re going to be afraid. And if you don’t pay attention to that component — the physical will pass, I guarantee you, but the mental scars could last forever. If you don’t pay attention.

(00:03:42) Bob Harrison

To add onto that there’s going to be financial stress. You know, the economy is having an impact right now, lack of people coming to Hawaii and tourism. So this is going to exacerbate a lot of what’s happening in the next few months.

(00:03:56) Steve Petranik

Bob, hang on to the mic. You, in addition to running First Hawaiian Bank, you are also leading the Health and Wellness Committee for the Hawaii Executive Collaborative. Can you tell us about some one of the initiatives that you’re working on?

(00:04:10) Bob Harrison

Sure. First, let me explain why. The only non health care professional and I acknowledge all my fellow panelists that actually do things to help people versus the guy that just goes to meetings. But a very persuasive friend of mine said, “hey, you’d be great for this job.” Duane Kurisu, thank you very much. You know, but I really have a passion for health care, been on the HMSA board for quite some time. My wife is a nurse practitioner in women’s health and it’s just always been important to me. It’s so much a part of Hawaii and we need to take care of each other. And so when we started down this path, what are we trying to accomplish? Health care is one of the most regulated industries you’re going to find at the national level and also at the state level.

(00:04:54) Bob Harrison

But what we’re trying to do is find a way for all of these people that know each other, know each other pretty well, somewhat competitors, somewhat not — how can we take the pieces that we can collaborate on and find a way to make a way better out of that?

(00:05:10) Bob Harrison

And so not pick the points of conflict, but pick the points that we can work together on. And what you’re hearing up here is a lot of the things we’re trying to do along those lines. One of the things that we’ve focused on so far has been homelessness and how to help the homeless. And I fear for the virus coming because that’s going to be in that population and it’s going to have a pretty devastating effect or it has potential to be. So we need to do a lot of outreach in that.

(00:05:34) Bob Harrison

I think as time comes up, going forward, that will be an area we continue to focus on. Once we get pass this, one of the things that our group is trying to take a look at is what are the the pukas in health care in Hawaii that really need more focus. And one of them was tying onto something Jill was just talking about, which is rural health and how do we do a better job of taking the level of health care that we’re sitting here, almost ground zero, urban Honolulu that you can get right around to. Literally Queens up the street. Straub over here, Kaiser clinic right over there. How do you take at least some level of that same care to every citizen in the state of Hawaii? And it’s not an easy task. Telehealth is certainly part of that, but I think it’s gonna be a multi-modal solution that tried to get to that. So those are some of the things we’re trying to work on.

(00:06:22) Richard Bettini

Bob. I’d like to thank you for the line of credit. We may need it.

(00:06:28) Bob Harrison

Big supporters of Waianae Coast Comprehensive for a long time. Great work they do.

(00:06:34) Steve Petranik

We’ve got some great questions. And please use the app to put your questions along and to start with some questions from those students who are sitting up front here on my left. And here’s a question about diabetes. And we’ve talked about the underlying factors. How about when people get it? What are the what are some of the issues to deal with people who already have it? And we need to help them still have a fruitful, productive, happy life. Who wants to start with one?

(00:07:05) Jill Hoggard Green

I’ll go ahead and start. Jump in if you’d like. I’m going to speak both as a nurse of 40 years and having a spouse who’s had diabetes since he was 25.

(00:07:17) Jill Hoggard Green

So it’s a chronic condition. And a lot of people usually develop diabetes in their 50s and 60s. Some actually have it earlier. And you can also have it as a child in juvenile onset. It’s an it really is a disease that you are managing it. You have great physicians and nurses that help you. But your daily decisions about how you eat, how you exercise, how you take your medications makes such a difference. I love telling you stories about my husband, who was a flight nurse and was a nurse for 30 years, should know had to do all of the care related to diabetes, wasn’t taking my advice even though I was helpful. Very helpful. But what really helped him be able to have the best life possible is he had a nurse and and pharmacist coach that was part of our health plan. And what he was what they were able to do is they met with him instead of giving him long goals about what you need to eat and how you exercise. He started to set very small goals that he could accomplish each week. And then they would text him and say, “Did you, in fact, walk five minutes a day? Did you, in fact, do X or Y?”

(00:08:37) Jill Hoggard Green

It’s behavior change, which is really hard for all of us. It’s how we eat, how we exercise, how we take our medications. Over a year, his hemoglobin A1C level, which is how we know how well you’re managing your diabetes, initially was 11, which is very bad. And it went to seven, which is very good. So it does take your family, it takes your workplace and takes everyone working together with you, and it takes being able to live a healthier life. And he lives a healthier life with his chronic condition than he did before.

(00:09:15) Dr. Joseph Keawe‘aimoku Kaholokula

And I just want to jump on to that because watching what you eat, taking your medication, watching it , reducing your stress, getting more physical activity, certainly is the optimal way to deal with and manage diabetes. But for most people, that’s the challenge when they’re working two jobs. You’ve got go from job A to job B in traffic in Hawaii, and you have one hour to get there. The natural tendency would be to stop off at a fast food place. So the challenge we face in getting people to be able to manage their health better goes back to those social determinants of health. We really need to address these, because the reality is when someone’s in their 30s, 35, diagnosed with diabetes, they don’t feel it at that moment in time. It’s not till years later the complications come in.

(00:10:01) Dr. Joseph Keawe‘aimoku Kaholokula

But they’ve got to feed their children at that moment in time. So I want to just want to add that and we have developed community based diabetes programs that really work well, helps for the physicians, the clinics to make sure what’s happening, what they’re recommending happens in the community. We have programs that community folks, health workers, community health workers can actually deliver effectively. And we found that a three-month program addressing, eating and other things in a culturally respectful manner, but also in a realistic manner, given their economic situation, can significantly reduce their A1C or their blood sugar levels, their average levels to reduce it to under the 7 percent that you would want to get to.

(00:10:41) Richard Bettini

I’d like to add an addendum to that. There’s considerable disparities in the Hawaiian community on the onset of diabetes. I think there’s an eight year differential in years of life lost to chronic disease. And a lot of that is socioeconomic, a lot of that is poverty. Part of it is whether people have hope and whether they’re vested in being healthy. We’ve been involved with two studies looking at perceived social needs of our patients.

(00:11:12) Richard Bettini

One of those with the HMSA the other called The Prepare Project and also the Accountable Community Project Project with UnitedHealth. So if you survey people, we looked at the results and what are their biggest concerns? You would think it would be housing. But housing comes in second to food, food insecurity. And we gave away 200,000 pounds of food last year. And I visited one of the sites where we did it — at one of the schools. The kids actually come to school on a school bus and it gets there right about the time the cafeteria closes. The kids run to get to the cafeteria to get breakfast or they’re not going to have a meal that morning. That was so below the radar of me. It was an eye opener. So as we move forward with addressing the social determinants, food is going to be way up there in terms of what we intervene in.

(00:12:03) Dr. Joseph Keawe‘aimoku Kaholokula

And Mark, I know you want to jump, but just because he touched on the Hawaiian issue. I wouldn’t be doing my duty as a native Hawaiian if I don’t mention it. He’s totally correct. The added burden to native Hawaiians, the stressors really has to do a lot, in addition to racism and the other things like economic deprivation and other challenges, really has to do with the historical and cultural disrespect that has not been adequately addressed. And that comes up often for us in insensitive political decisions and business decisions around development or other things that don’t respect. And it’s just this continuous reliving the trauma. So I want to put that out there, because you mentioned that Hawaiians are three times more likely to develop diabetes compared to whites. There are also three times more like to develop stroke and heart disease.

(00:12:50) Mark Mugiishi

I’m actually going to jump in with a very non-clinical answer. The students may not know because they all look too young to remember when I used to be a coach, but I actually was a coach before. So this is a shot out for teams, right? The treatment of diabetes is a team sport. So it’s not a patient and a doctor. It’s a person and a community that has to support them. So whether it’s upstream, the the community providing them food and the right resources and and the help with the social determinants, or whether it’s a clinical team of nurses, pharmacists, coaches, health coaches, behavioral health people, because if you’re depressed and anxious, you’re not going to take care of yourself. That is like fundamental. So it’s a team sport. That’s how you manage diabetes.

(00:13:35) Connie Mitchell

And similarly, I just want to say that when I’m listening to you talk about diabetes, mental illness is the same way. You know, we need people to come around, people to support them. It’s also something that can be shaped. You know, when we talk about behavioral health, especially with substance abuse. People have to have motivation, they need to have hope.

(00:13:55) Connie Mitchell

Like Rich was talking about. Otherwise, there’s no reason to change the behaviors that they have. If any of us try to make any kind of behavioral change, it’s usually with someone at our side. It’s really hard to do by yourself. If you’ve ever tried to lose weight or, you know, something simple like that is not that simple sometimes. But when you do it with other people, sometimes it’s a lot easier to do.

(00:14:19) Bob Harrison

And being there in the community makes a huge difference. When I visited for outreach in Chinatown on Hotel Street, they develop relationships with so many of their patients, many of which are homeless. And just when they know there’s somebody that cares about them, it makes a huge difference. Then they start to interact with them. You don’t know if it’s gonna be a path to full recovery, but it’s a path very different than the one they had been on. And that’s progress.

(00:14:45) Connie Mitchell

And we always see, you know, when we’re trying to entice someone to take medications, you know, for their mental illness or to begin drug treatment, it begins with that relationship. If you don’t have a relationship, it’s usually not going to happen.

(00:14:59) Richard Bettini

Somebody asked me the other day, what is the best thing the Health Center does to address social conditions and wellness? And I said we employ 800 people, many of which have never worked anywhere else. And we have training programs to promote people. And, you know, in a community of 40,000 people, that’s an incredible economic force. And you look at Medicaid and where it’s going. This is an opportunity to take it to the next level for community economic development and to move away from “entitlement” and towards real development.

(00:16:31) Steve Petranik

You know, so many of the things you’ve just said, all of you said tie into the next couple of questions from the students so I’m going to take them one at a time. And the first is communication. You talk so much about communication. The the methods that it’s a community effort. What are some ways that we can improve our communication to help break down those barriers so people are listening to the message?

(00:17:03) Richard Bettini

The closer the person is in values and culture (the person giving the message), the closer they are to the person receiving. There’s actually a term called homophile, which means that relationship in which the person training and the person listening is very they’re like neighbors. So I think that’s really important. The concept of a community health center is is really something in its purest form we need to look at because we’re owned by the patients.

(00:17:33) Richard Bettini

But the board of directors is made up with from business leaders. We’ve had an incredible history with First Hawaiian Bank. And, you know, other business professionals sitting with community people, looking at assets, paying particular attention to what the patients want and what the local community wants. And in the high poverty community, that is essential to change. So, again, it’s that homophile.

(00:18:00) Mark Mugiishi

Yeah, I agree with that. I think if you’re going to communicate to anybody, you have to speak their language, number one. And second, something that took me a while to learn, because as a physician before my first question to everybody is what’s the matter with you? And really, the right question in any in any communication is, “What matters to you?” Right. And if you understand what matters to the person, the ability to communicate and deliver a message becomes so much easier.

(00:18:31) Steve Petranik

So maybe doctors nowadays are listening more than they were in the past

(00:18:36) Mark Mugiishi

And health plans, too.

(00:18:39) Steve Petranik

So the second question was related to what we said is racism in the health care system. And I think the most obvious example is the Micronesian community, but I’m sure there’s other examples we can talk about. What do you do to create change that combats the racism that’s in the system?

(00:19:05) Dr. Joseph Keawe‘aimoku Kaholokula

Well, that’s my area of research — racism and health risk. Yeah, it’s a tough one. Racism is just across society, right. So ultimately, you want to eliminate racism. I don’t have a good answer for that one. But in the health care system, certainly there’s a thing called implicit bias. It’s not so much racism, it’s unconscious biases that we all have. As people, we grow up hearing certain messages on television, seeing certain things, people that we associate with certain conditions or skills or intelligence and others, maybe because of things that we’re presented over time with.

(00:19:43) Dr. Joseph Keawe‘aimoku Kaholokula

And it gets into our psyche, it becomes unconscious and it seeps in through the decisions we make. It’s it’s a well-studied issue. Implicit bias in health care becomes problematic when health care providers do hold certain belief systems that seep into their medical recommendations or lack thereof, or how they may interact with a patient to develop the communication and trust that’s very important to get people to where they need to be. So racism or implicit biases work that way. But racism itself is just as interpersonal systemic racism — It really does affect people’s health. There’s so much scientific studies on this among African-Americans, Hispanics and now native Hawaiians and soon Micronesians that shows that racism does puts you at risk for hypertension, heart disease, adverse birth outcomes, especially for African-American women. These are real issues. Racism. It does affect people we need to address. That’s a good question.

(00:20:43) Connie Mitchell

I think it also speaks to the need for a more diverse workforce in the health system. And that’s why we really need to recruit a lot of people who can represent more of Hawaii’s diversity and to really encourage them to stay here in Hawaii as well.

(00:20:59) Jill Hoggard Green

Building on both comments is very, very important. We can actually learn about our own implicit biases and we can actually change. So one of the things that we do as a health system is we actually do assessments of our own implicit biases, we do education about that. We think about and learn how to better understand. And your comment about diversity is critical. The more we have a lot of individuals from our community actively engaged. And this is one of the things I think is most important. For me, listening starts with deep love and respect for the individual that you are trying to understand and a search for understanding before we search for telling what is going to happen. So for me, we can teach a lot of this if we really have a love and compassion for each other, if we truly desire to improve. If we really want to improve health, we have to start with love, compassion, understanding and listening and then being open that we don’t know and we don’t understand and being humble about learning. And I believe if you look at our community and I’m coming from a different community, I’m coming from Asheville, North Carolina, for the last 10 years, I’ve said to several people I’ve only been here five months.

(00:22:29) Jill Hoggard Green

And the aloha spirit, the love and kindness, the connection that we have as family and the the the definition of family being so large, I believe that we actually have the chance to have a deeper understanding and move faster than almost any other place in the United States. And I say that coming from Utah, Oregon, North Carolina, because there is this deep connection. So I believe we actually have a chance to do things better, address those social determinants of health.

(00:23:05) Jill Hoggard Green

I watch the we talk about insurance companies across the country as not being caring. We have a benevolent insurer in HMSA. From my perspective, they’re investing in the social determinants of health. We have a board committee on Native Hawaiian Health so that we keep remembering what Queen Emma started, which is seeing the needs of the people she was serving and ensuring that we always embrace them. I think we have real possibilities here to do it better than almost anywhere else.

(00:23:44) Jill Hoggard Green

But we have to be humble and know that we don’t know and listen as much as we can.

(00:23:50) Steve Petranik

And we’re now going into overtime. But I’m going to be the editor of the magazine and say we can do that. I love this discussion. We have lots of good questions. And one of them from the audience now is about building the workforce of tomorrow. I know Connie mentioned, Rich may have. We’ve heard it over and over again. So maybe, Jill, go back to you because you have a huge workforce, you’re hiring all the time?

(00:24:16) Jill Hoggard Green

There’s no question we have a deep dedication to building the next generation. In health care, we have to. There are many of us that are a little bit older and wise. We’ll say we’re just wise. When we look at our health care, let’s look at the nurses average age of nurses is 45. If you think about the rising needs, we will far outstrip the resources that we have unless we invest in our next generation.

(00:24:45) Jill Hoggard Green

And for me, that starts in elementary. What are we doing to support every child, to have a healthy start in their education and have the potential to be able to do whatever they chose? I use the word caregiver in health care and caregiver includes everyone from our environmental service technicians to our facility developers to our individuals that keep our facilities working effectively to our technicians, to nurses, to physicians, to business folks. We have a huge, diverse workforce.

(00:25:20) Jill Hoggard Green

So we’re focusing right now on how do we start partnering in the elementary schools, middle schools, high schools. You have such great potential and we have got to figure out ways to help amplify our educational systems. And then, of course, we need to honor our universities and our community colleges. I’m a little taken back when I watch our conversations about our universities because our universities are so critical to our future. So I believe in partnering with not only our medical schools and our nursing schools, our pharmacy schools, but our technical schools as well.

(00:26:01) Jill Hoggard Green

We have some great programs going on now at University of Hawaii about helping to develop clinicians that need an extra bit of support to make sure they get into medical school and then support through medical school. And if you look at the outstanding clinicians we have on this island, physicians and nurses, the majority are coming through University of Hawaii and our community colleges. So, I fully believe that we must invest, we must partner. And we have incredibly talented people that if we invest in them, they will do it.

(00:26:40) Richard Bettini

This is a topic that I feel passionately about. I think we’ve got a crisis coming when it comes to primary care providers willing to work in poor communities. We’ve got an amazing medical profession and a group of professionals in this state. I’m so happy we have some of the best specialists. They put different parts of me back together. But beyond that, when it comes to primary care and people willing to work with a complex patient population where if we work with folks that are complex, we can actually produce some really good outcomes.

(00:27:17) Richard Bettini

But it’s there’s a lot of pressure on our docs. A lot of them are retiring that were in family practice and we need to look at new models. I don’t think most people know that we operate our own medical school in partnership with 10 low income communities. We’ve graduated 63 medical students. One has come back to work in Hawaii and there’s a reason for that. We also have a nurse practitioner residency, post-doctorate psychology training and a dental residency program at Waianae that builds community capacity.

(00:27:49) Richard Bettini

It’s attractive for our young people to go into the fields. It’s part of economic development for our community. So why are we losing these 63 (medical students)? There’s a lack of residency programs in primary care in this state. We now have some hope. I think so. Thank you. What happens? Those 63 medical graduates have to leave the state in order to get a residency slot. Hilo’s program is locked in at six, no more than six. And if you look at JABSOM, they’ve recently accepted some of our students. I think we’ve had a couple and there’s one that may come back, but it’s not enough. So we need to pool our resources. And the advantage of doing a residency in a community health center is you get trained with those psychology residents, the nurse practitioners dealing with a medically complex patient with a little bit of culture thrown in. And I think we need to really look at that.

(00:28:48) Richard Bettini

We need to look at Queens to help us with that. We need more partnerships with JABSOM, because if we don’t, we’re going to find ourselves very short.

(00:28:56) Dr. Joseph Keawe‘aimoku Kaholokula

Can I jump in as JABSOM, really quickly? Because I feel obligated because I’m from the medical school. So totally spot on with Jill and as Rich has mentioned, we have a physician workforce shortage, especially on a neighbor islands here in Hawaii. It lacks the diversity that really represents our communities.

(00:29:12) Dr. Joseph Keawe‘aimoku Kaholokula

So we need, again, more Native Hawaiian, Pacific Islanders, Filipinos that represent the people that will actually serve going back to the reasons we mentioned, the message, the deliverer of the message and all that. And I agree with Rich. We need to rethink how we train the next generation of physicians. It’s an old model, the infectious disease model. It’s a whole new environment with chronic disease. They have to be behavioral experts, social experts.

(00:29:34) Dr. Joseph Keawe‘aimoku Kaholokula

Now they have to be experts in health care delivery and payment transformation. This is a whole new generation for our providers and we develop the resources and the other wraparound services and other things to really make that work. Want to throw that out there, because I really hope that our universities and our high schools really think about health academies to strengthen their interest in health sciences early on. So we get more students wanting to come to medical school. Whether it’s us, whether it’s you, just to get more of them out in the community.

(00:30:02) Mark Mugiishi

I agree with every comment that’s been made. I’m just going to add an “and” and we’ve talked a little bit about telehealth being part of the future of rural health. We didn’t talk about, but it’s just as real, artificial intelligence, big data, all kinds of other things, technology that’s going to change the way health care is delivered in 10 years. So what the workforce will look like then, we don’t know. So I’m just saying, make sure that the curriculum that we’re using for all of this features adaptability, curiosity, you know, an ability to adapt, to change the environment.

(00:30:41) Mark Mugiishi

And most importantly, that we forget about, is empathy, because when no matter what else comes, the healthcare workforce has to care about the population that they’re serving.

(00:30:52) Bob Harrison

As a businessperson, I have to jump in for a second here, too, my dad was a physician. So one of the reasons we’ve seen health care evolve into more of a specialist model than a general practitioner or family practitioner, internal med model is the money.

(00:31:07) Bob Harrison

And we have to acknowledge that. And one of the things I give credit to Mark and his predecessors at HMSA is they’re trying to change the money discussion from how many times I do a certain procedure is how much I get paid to I want to take care of you, Steve, as an individual. And if I keep you healthy, you’ll get paid, you know, and it just changes so much of the discussion. Hopefully we can kind of push that through so people don’t feel that they have to make a career decision within medicine, within the different specialties of medicine based on financials, and they can do it on what their hopes and desires are in the communities they want to serve.

(00:31:46) Steve Petranik

I’m gonna do one last question and there’s lots of other questions. I apologize that I didn’t get all the questions, but they’re so good and gotten such great responses.

(00:31:53) Steve Petranik

The other looming crisis, of course, we’re getting old and there’s going to be a bulge of older people. And these young folks have that crisis. We have to deal with it. A few words on it? I know that could be a whole discussion of two hours itself.

(00:32:14) Steve Petranik

But a few quick thoughts on how we can cope with that best in Hawaii.

(00:32:20) Jill Hoggard Green

Absolutely. And we want you to be really talented to stay here and take care of us. Most of us can live actually very healthily till we die. If we manage our chronic conditions and we are not socially isolated and we have the kind of support and love and kindness that we’ve been talking about. So the more we think about how do we support older adults, how do we embrace them?And particularly, I think the young and the old working together is one of the things we’ve seen clearly makes a difference in terms of reducing social isolation. But we really can, if we focus on chronic disease support, preventing social isolation, see healthy living. But I think you have a tremendous opportunity to both develop your skills and be a part of hopefully choosing health care. You can choose Queens or the Community Health Center and you can choose geriatrics…

(00:33:26) Jill Hoggard Green

You’re focused on how do we help our old our older adults live healthily? And how did they help our children live healthily actually makes a big difference in communities where you see that happening.

(00:33:39) Connie Mitchell

And keeping people who are aging in the community is really important. And I was just in a conversation recently about how nurses in acute care get paid a lot more in the hospitals. And I think that the care is moving out into the community and my hope is that payers will understand that it’s really important to reimburse, you know, for community nursing as well so that we can really keep people out there healthy.

(00:34:06) Steve Petranik

Well, we’ve run out of time. Thank you. I want to thank our panelists, thank our high school students. Thank you for coming out today. Thank you so much.

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