Caring for the Community

A Safe Landing Place

Medical respite provides a supportive and stable place for unhoused people as they recover from medical issues or injuries.

Think back to small-kid time. When you got sick, maybe Mom and Dad, or Grandma, or a beloved neighbor, took loving care of you. They touched your forehead with a cool hand when you were feverish, brought you soup and noodles, fluffed up an extra pillow for you, and made sure you had some good TV shows to watch. You knew you were supported, and you could feel that care, literally speeding you on the road to recovery.

That combination of safety, support, and healing – it’s the bedrock of the concept of medical respite.

“We want people to not just get the medical care they need, but also the feeling that somebody cares about them,” says Connie Mitchell, the executive director of the Institute for Human Services a Honolulu-based nonprofit dedicated to homeless people and the issues they face. Among its services, the organization has medical respite homes for medically frail homeless people.

An Emerging Trend

Hawai‘i has been an early adopter of the medical respite model, an emerging health care strategy that seeks to support homeless people after hospital stays. And it is leading to positive outcomes, especially in the fight against chronic health issues common among the homeless population, including COPD, heart disease, and kidney failure.

Kaiser Permanente has supported medical respite efforts with grants, and contract beds with local medical respite homes.

IHS’ Tutu Bert Medical Respite Homes offer a cozy atmosphere, with meals, medical monitoring, and other support. Tutu Bert’s comprises three medical respite homes, in Makiki, Kalihi, and Pearl City. With a total of 36 beds, they offer stability and access to health care, both of which can drastically improve outcomes for participants.

The Institute for Human Services has three Tutu Bert Medical Respite Homes, offering stability and access to health care, improving outcomes for participants. | Photo: The Institute for Human Services

The facilities are the namesake of Roberta “Tutu” DuTeil, the widow of IHS founder Claude DuTeil. “She was very involved in helping homeless individuals go to and from the hospital when her husband was running IHS,” explains Mitchell.

Medical respite, Mitchell explains, is an approach that has evolved out of need. Before, unhoused people were hospitalized and then released back onto the streets. With no support, they’d often be unwell again and headed back into the hospital. It was like a revolving door.

“They’re living on the street where there’s no refrigeration for medications like insulin,” Mitchell says of the challenges facing unhoused persons. “No hygiene, you’re bound to get infections, and then you’re subject to a lack of sleep and physical or even sexual assault.”

Medical respite helps stop the cycle. Clients at Tutu Bert’s usually recuperate for six to eight weeks, says Mitchell. Professionals such as nurses or physical therapists provide the needed health care, and nurses are available after hours, too, in case a client needs help with things like pain management. Meanwhile, the IHS staff works to find transitional or permanent housing for the clients.

Mitchell can think of plenty of success stories. For example, one of Tutu Bert’s first guests, five or six years ago, had been injured in an auto accident. He couldn’t go back to work, and eventually he became not only homeless, but displaced from his home island as well, says Mitchell. Via the supportive setting at Tutu Bert’s, the man was able to recover fully and return to his home island.

Medical respite helps people get back on track in numerous ways, such as reconnecting with family, coordinated mental health care services, and access to permanent housing.

In addition to funding medical beds that serve homeless individuals in need of home care when they are discharged from the hospital, Mitchell says, “Kaiser Permanente is enabling us to share our learnings from five years of experience with other organizations beginning medical respite services to broaden the state’s capacity to serve medically vulnerable homeless individuals.”

New Projects on the Big Island

Hope Services Hawai‘i is a nonprofit homeless services provider on Hawai‘i Island. A participant in the National Institute for Medical Respite Care cohort, it has been implementing new respite beds on Hawai‘i Island, including at the medical respite home Wilder House, which opened in July 2024.

In its spare but tranquil homelike setting, eight residents will have constant nursing assistance, while also enjoying common areas like a kitchen, living room, and backyard space.

Clients typically stay with Hope Services medical respite for about 60 days, says Brandee Menino, chief executive officer of Hope Services Hawai‘i. “It really is just a transition. We get people connected and get them into housing, and that’s when they can get better, when they have their own space, when they have their own dignity, when it’s private.”

The home-like atmosphere at Hope Services medical respite helps residents feel comfortable. | Photo: Courtesy Hope Services Hawai’i

According to Hope Services, medical respite is more cost-effective for insurers than frequent emergency room visits or hospital stays for people experiencing homelessness. By addressing health issues in a more holistic and preventive manner, insurers can save the costs associated with avoidable medical interventions, Menino notes.

“By piloting and developing partnerships with Kaiser Permanente, with the hospital, it’s a community, it’s a team,” says Menino. “We’re excited about that, because we see that this helps get people to stay indoors, to move toward their pathway to housing, and not wanting to go back to the street. They’re getting care in the medical respite and they want to continue that care in housing.”

Menino also notes that the medical respite homes can even help unhoused individuals mend relationships with their ‘ohana. “We’re helping them rebuild community,” she says. “It’s exciting, helping them reconnect, and we do see better outcomes. We know that housing improves health. All of this is connected.”

A Clearer Picture

A new study homes in on the health care needs of Lāhainā’s Filipino wildfire survivors.  

Graphic: Courtesy Meldrick Ravida

For Lāhainā’s Filipino community, which made up 40% of the town’s pre-disaster population, the 2023 Maui wildfires hit especially hard.

A new study by Meldrick Ravida, MPH for Kaiser Permanente Hawai‘i, sought to assess the unique health needs and challenges within this community, as well as ways to improve outcomes and well-being. Ravida is a public health practitioner who did an American Public Health Association fellowship at Kaiser Permanente.

Ravida’s study examined the socioeconomic, cultural, and health factors affecting the recovery of Filipino wildfire survivors in his report, “Lāhainā is in the Heart: A Landscape Analysis of Health Needs and Recovery Strategies for Lāhainā’s Filipino Community.” Research included “talking story” with community members, leaders, and advocates, as well as data analysis and a literature review.

The study found several key areas of health challenges including a cultural stigma regarding mental health care; a limited number of health care professionals fluent in Ilocano, Tagalog, and other Filipino languages; higher rates of diabetes and cardiovascular disease; and economic instability, with job losses especially extreme among those working in tourism and food service.

Next, Ravida’s report suggested tailored health interventions, as well as potential programs and partnerships that could support the long-term recovery of Filipino wildfire survivors. For example, culturally sensitive mental health programs could be developed to address the stigma associated with that type of care. Another example: Expanding language support to include Ilocano, Tagalog, and other Filipino languages. Another potential initiative would create pathways for Filipinos to enter health care careers, the study suggests, which could both reduce unemployment rates and boost health care service within the local community. By focusing on the specific needs of the Filipino community in Lāhainā, this new study contributes not only to a more equitable and effective recovery process, but ultimately can help support the broader goal of improving health outcomes for all residents of Hawai‘i.

Growing the Pipeline

Meet some of the people devoted to improving the Native Hawaiian community’s health and mentoring the next generation of Native Hawaiian medical experts. 

KULA trains community health workers, Photo: Courtesy Kula no Nā po’e (left) | Dr. Marcus Iwane, alongside Maile Tauali‘i, PhD, MPH, the assistant clinical investigator for Hawaii Permanente Medical Group, speaks at their Kaiser Permanente School of Medicine presentation in May 2024, Photo: Courtesy Kaiser Permanente (right)

Growing up, Marcus Iwane spent a lot of time with his grandfather in his garden in Nānākuli. “I remember him speaking to his plants in the Hawaiian language,” recalls Iwane. “It wasn’t until long after he passed that I started to connect to my roots, to being a Native Hawaiian, and what that means to look toward cultural health as a whole.”

Today, he is Marcus Iwane, M.D., an internist with Kaiser Permanente Hawai‘i. With Kaiser Permanente, he works out of the West O‘ahu Medical Office at Kapolei and he’s also an assistant clinical professor in medicine at his alma mater, the John A. Burns School of Medicine.

“I chose to become an internist and primary care physician because I enjoy getting to know my patients and seeing them across a continuum of time,” Iwane says. Combining Western knowledge with the fundamental teachings and wisdom of the Hawaiian culture and its kūpuna is, he says, “an art form, and something that helps me make better connections to my patients.”

Iwane notes that social and environmental determinants play a large role in Native Hawaiian health. “Native Hawaiians have a high prevalence of chronic health diseases, such as diabetes, heart disease and hypertension, and cancer. We now have the highest infant and maternal mortality in the nation across all ethnicities. What can we do to shift this? Because when Captain Cook first arrived on our shores in 1778, he described in his journals a thriving, healthy, robust community, Hawaiians who were strong and nimble.”

As a professor of medicine at John A. Burns School of Medicine, he now shares his experiences, culture, and insights with a new generation of doctors. “I also help to teach some of our students at the Kaiser Permanente School of Medicine in Pasadena, where they also have a focus on social and cultural determinants and on health equity. “It’s important to educate people, not just within Hawai‘i, but also across states that have a large and growing population of Native Hawaiians, because these future doctors are going to care for them and see them in their clinics.”

Iwane is president of the board of ‘Ahahui o nā Kauka, the Association of Native Hawaiian Physicians. The nonprofit organization champions better health care for Native Hawaiians overall and seeks ways to increase the number of indigenous doctors in Hawai‘i – and beyond. “Approximately 20% of Hawai‘i’s population is Native Hawaiian, but less than 5% of the state’s practicing physicians are Native Hawaiian, so we have a far way to go to parity,” he notes.

To meet that goal, he says mentoring young people is a priority, as is tailoring health care approaches to the unique needs of a community. “We are building the pipeline of not just Native Hawaiians, but any folks who are vested in improving the health of our communities.”

Coming Full Circle

“I have known Dr. Iwane since he was a medical resident. Residents from JABSOM have supported our lomilomi group taking vitals for residents, such as blood pressure checks for over a decade,” says Adrienne Dillard, PhD.

Dillard, who has a master’s in social work and is a licensed clinical social worker, is the CEO of Kula No Nā Po‘e Hawai‘i. Known as KULA, it’s a nonprofit that promotes cultural, educational, environmental, and health equities for the residents of the Papakōlea, Kewalo, and Kalāwahine Hawaiian Homesteads, which together make up the Papakōlea region on O‘ahu.

One of Kula No Nā Po‘e’s main missions is to help keep kūpuna healthy and engaged | Photo: Courtesy Kula no Nā po’e

“KULA has been training community health workers in certificate and apprenticeship programs and bringing in nursing, social work, public health students, and medical residents for service learning opportunities from the University of Hawai‘i at Mānoa, Hawai‘i Pacific University, and Chaminade University to work within the community,” says Dillard. Students, working with a multidisciplinary team, might do home visits with a kupuna, for example.

KULA and the student medical professionals also play a role in research, working with the Dept. of Native Hawaiian Health at JABSOM for studies on chronic diseases that disproportionately affect Native Hawaiians.

“We are training community health workers,” says Dillard. “Kaiser Permanente has been instrumental in supporting that. At KULA we have on staff Native Hawaiians who were born and raised in the community and now work with us, and we have other members who are not Native Hawaiian but are passionate about serving in the community health arena. Community health is vast. It’s education, it’s clinical, but it’s also all the aspects of supporting your community.”

Kaiser Permanente Hawai‘i has supported these health initiatives, she says. “Most of our grants have been around Kaiser Permanente saying, ‘What do you need?’ We partnered with them for Covid vaccination clinics; we partner with them for the annual health fair. We train, mentor, and support this generation that is coming up.”

Now, KULA is looking for ways to develop its own health-training curriculum that is appropriate for Native Hawaiians in Hawai‘i. And it’s sharing insights on community health that the organization has gleaned over the years.

“I have been working in Papakōlea for 30 years,” says Dillard. “A lot of the staff that I am helping to train, they were born and raised in Papakōlea. We are raising them up to take it over and to do the work. It’s how we raise that next generation of Native Hawaiian health leaders.”

Charitable Health Care Program Expands

Photo: Courtesy Kaiser Permanente

Launched in 2023 to support Maui residents affected by the wildfires, the Hawai‘i Health Access Program (HHAP) has now been expanded to O‘ahu residents. HHAP provides a subsidy that eliminates monthly premiums, copays, and out-of-pocket costs for most services at Kaiser Permanente facilities. It includes preventive care, prescription drugs, and pediatric vision services. The program is funded by Kaiser Permanente and operates without any public or private contributions. Eligible residents without access to Medicaid or other health coverage can apply during open enrollment (through Jan. 15, 2025). U.S. citizenship is not required to qualify. For details, visit kp.org/hhap