'Tausi Feagaiga: A Project to Train Caregivers and Empower the American Samoan Community.

The 'Tausi Feagaiga (Covenant Keeper) project was a partnership to support the traditional values of tausi matua (caring for one's elders). The partners included a non-governmental organization (Pacific Youth and Community Development), a faith-based organization (Roman Catholic Diocese of Samoa-Pago Pago), and an institute of higher education (University of Hawai'i John A. Burns School of Medicine). The project was created to address the lack of community-based health care such as home health or hospice, and families needing to work outside the home. A culturally based caregiving curriculum was developed to educate caregivers and improve their knowledge and skills. Using a train-the-trainer model, 125 caregivers were trained in family caregiving from 2016-2020. Training was conducted through an intensive workshop followed by practicum at Hope House, the Catholic Diocese home for the aged. Participants who expressed a willingness and competency were mentored to be trainers to continue the 'Tausi Feagaiga project. The mean self-rated confidence in caregiving improved significantly from 3.17 ± 1.02 (mean SD) pre workshop to 3.53 ± 0.71 post workshop (P = .001). Competence in geriatric syndromes was improved from 18.04 ± 4.27 to 21.31 ± 4.30 after attending the workshop (P < .001) and the feedback was extremely positive. Technical assistance was provided to obtain funding through American Samoa Medicaid State Agency to improve the existing infrastructure of Hope House, obtain much needed supplies, and increase ability to hire the participants. 'Tausi Feagaiga positively impacted the lives of the residents of Hope House, the course participants, the elders in the community, and those who care for them.

Increasing Geriatric Care Capability in Hawai'i's Healthcare Systems through the Pacific Islands Geriatrics Workforce Enhancement Program (GWEP) at the University of Hawai'i.

There is an increasing shortage of skilled healthcare workers to provide care to the aging US population. In response, the Geriatrics Workforce Enhancement Program (GWEP) was developed in 2015 by the Health Resources and Services Administration (HRSA). This article describes the objectives, accomplishments, and lessons learned by the Pacific Islands GWEP at the University of Hawai'i (UH) over the past 5 years. The program's multi-pronged approach includes: (1) Developing partnerships between academia, primary care delivery sites/systems, and community-based organizations to educate a geriatrics workforce; (2) Training providers and students in medicine and allied health professions to address the primary care needs of older adults; (3) Transforming clinical training environments to become age-friendly health systems that incorporate the principles of value-based care and alternative-payment models; (4) Delivering community-based programs for patients, families, caregivers, and direct care workers to provide knowledge and skills to improve health outcomes for older adults; and (5) Providing training in Alzheimer's Disease and related dementias (ADRD), including the value of dementia-friendly communities. The GWEP provided education to over 3000 providers, 700 healthcare trainees, and 1000 patients and caregivers each year in a wide variety of care settings (eg, outpatient, home care, nursing facilities, care home, and hospice). Caregivers feel better able to care for themselves and/or others, find resources, and improve their practice of caregiving. The program is also transforming primary care delivery in underserved areas (eg, Community Health Centers, Family Medicine clinic, and the GRACE Team Care™ model). Outreach included rural areas, neighbor islands, and Pacific Islands.

Exploring the Impact of Dementia in Samoan Culture: A Qualitative Study on Community Perspective.

Purpose: Explore if and how American Samoan cultural norms influence caregivers' knowledge, attitudes, and care choices for person's living with Alzheimer's Dementia (AD).Design: This pilot study used mixed methods.Methods: 1) Quantitative survey: measuring knowledge/attitudes towards AD (n = 80); 2) Qualitative techniques: a) Focus groups (n= 54) with caregivers; b) Semi-structured interviews (n=26) with health professionals; and c) In-depth interviews (n=3) with key informants. Emergent themes were created using data from all methods.Findings: Quantitative analyses revealed 50% of participants identified AD as normal aging, 83% as mental illness. The majority of participants believed elders with AD do not experience pain (70%) and should be cared for solely at home (74%). Qualitative evidence showed dissonance between cultural norms of respect for elders, familial caregiving duty, shame in others observing elders' dementia-related behaviours, and the current language used to describe AD.Conclusions: Our findings show a need for developing and disseminating culturally sensitive terminology for AD to destigmatize and transmute attitudes, knowledge and care choices for elders living with AD.Clinical Evidence: American Samoan terminology for dementia is discordant with its cultural norms, thus shaping caregivers' perceptions of AD and influencing care choices for managing AD symptoms.

Building Capacity for Caregiver Education in Yap, Micronesia.

The US Affiliated Pacific Islands have an urgent need for family caregiver education to prevent caregiver burnout and strengthen the existing culture where seniors are cared for at home by their families. The Pacific Islands Geriatric Education Center conducted a 32-hour family caregiver train-thetrainer workshop in partnership with the Yap Department of Health Services and the Yap Area Health Education Center (AHEC) from October 16 - 20, 2017. Twenty-seven participants including community health workers, peer educators, health assistants, nurses, and physicians were trained as instructors. Confidence in caregiving increased following the training and feedback was extremely positive. Competence in geriatric syndromes was improved after attending the workshop (P < .001). Lessons from the field revealed an immense value of adding home visits to the training practicum as well as the need to translate caregiving handouts into the outer island languages. Yap AHEC is committed to offering this course as part of caregiver education at the hospital and in the community.

Supportive Care for Superutilizers of a Managed Care Organization.

Background: Ohana Health Plan, Inc., (OHP) is one of the first managed care organizations offering supportive care services targeted to superutilizers. Bristol Hospice Hawaii, LLC, partnered with OHP to provide interdisciplinary supportive care services to home-bound OHP members. Objectives: The purpose of this study was to measure symptom relief, satisfaction, resource utilization, and cost savings associated with supportive care. Design: Prospective study. Setting: Over 12 months, 27 superutilizer members residing in the community were referred by OHP, 21 members were enrolled into supportive care. Measurements: Data were collected upon admission and repeatedly thereafter using the Edmonton Symptom Assessment Scale (ESAS) and the Missoula-Vitas Quality of Life Index (MVQOLI). The Family Satisfaction with Advanced Cancer Care (FAMCARE) Scale was administered at discharge. Emergency department (ED) visits and hospital utilization were tracked. Results: Median age was 63 years; more than half had cardiac diagnoses. Majority of members were Hawaiian and other Pacific Islander. Median length of stay in supportive care was 90 days. Five (23%) members enrolled in hospice following supportive care. Symptom improvement occurred in pain (p < 0.0001), anxiety (p = 0.0052), and shortness of breath (p = 0.0447). This model has shown a 79.5% reduction of ED visits per thousand members and a 75% reduction of hospitalizations per thousand. Overall net savings was 36%. Discussions and documentation of end-of-life wishes increased from 23% to 85%. Conclusion: Supportive care is highly effective in reducing costs associated with superutilizers. Our experience demonstrates the effectiveness of supportive care approaches in this population through improved care and lower health care costs overall.

Impact of Financial Incentives on Health Outcomes and Costs of Care among Medicaid Beneficiaries with Diabetes in Hawai'i.

The Hawai'i Patient Reward And Incentives to Support Empowerment (HI-PRAISE) project, part of the Medicaid Incentives for Prevention of Chronic Diseases program of the Affordable Care Act, examined the impact of financial incentives on Medicaid beneficiaries with diabetes. It included an observational pre-post study which was conducted at nine Federally Qualified Health Centers (FQHCs) between 2013 to 2015. The observational study enrolled 2,003 participants. Participants could earn up to $320/year in financial incentives. Primary outcomes were change in hemoglobin A1c, blood pressure, and cholesterol; secondary outcomes included compliance with American Diabetes Association (ADA) standards of diabetes care and cost effectiveness. Generalized estimating equation models were used to assess differences in clinical outcomes and general linear models were utilized to estimate the medical costs per patient/day. Changes in clinical outcomes in the observational study were statistically significant: mean hemoglobin A1c decreased from 8.56% to 8.24% (P < .0001); mean systolic blood pressure decreased from 125.16 to 124.18 mm Hg (P = .0137); mean diastolic blood pressure decreased from 75.54 to 74.78 mm Hg (P = .0005); total cholesterol decreased from 180.77 to 174.21 mg/dl (P < .0001); and low-density lipoprotein decreased from 106.17 to 98.55 mg/dl (P < .0001). Improved ADA compliance was also observed. A key limitation was a reduced sample size due to participant's fluctuating Medicaid eligibility status. HI-PRAISE showed no reduction in total health cost during the project period.

Home Healthcare and Hospice: A Pacific Islands Perspective.

The Pacific Islands Geriatric Education Center of the University of Hawaii conducted situational assessments of caregivers, older adults, and healthcare professionals in the Republic of Palau. The findings revealed an urgent need for a solution to the identified crisis of an aging population, increasing chronic diseases and their corresponding impact on caregivers and society. In 2010, the National Healthcare Financing Act was signed into law, becoming Palau's first step in helping residents and workers in Palau pay for medical expenses. This program is referred to as the Health Care Fund and consists of two parts: National Health Insurance and Medical Savings Account. Advocacy and promotion of home healthcare services in Palau was facilitated by the Pacific Islands Geriatric Education Center. Because of these efforts, systems changed to establish home healthcare services and expand the Health Care Fund with a proposed Home Health Insurance Benefit from the National Health Insurance. This is a huge leap forward to improve access to care for older adults and homebound in Palau.

A Randomized Controlled Trial of Financial Incentives for Medicaid Beneficiaries with Diabetes.

BACKGROUND: The Medicaid Incentives for Prevention of Chronic Diseases program was authorized by the Affordable Care Act to determine the effectiveness of providing financial incentives. OBJECTIVE: To examine the impact of incentives on adult Medicaid beneficiaries' diabetes self-management using the Hawaii Patient Reward And Incentives to Support Empowerment project. METHODS: A randomized controlled trial study was conducted at Kaiser Permanente Hawaii with 320 participants (159 intervention group/161 control group). Participants could earn up to $320/y of financial incentives, distributed in the form of a debit card. Evaluation measures included 1) clinical outcomes of change in hemoglobin A1C, blood pressure, and cholesterol; 2) compliance with American Diabetes Association standards; 3) cost effectiveness; 4) quality of life; 5) self-management activities; and 6) satisfaction with incentives. RESULTS: No significant differences in clinical outcomes were found between groups. There were no differences in observance of American Diabetes Association standards of medical care between the intervention and control group. The project also did not show reduction in health cost. However, participants in the intervention group reported significantly higher adherence with the recommended general diet than those in the control group during the course of the study. They also reported statistically better physical health than their control counterparts at the midpoint of the study; however, the perception of increased physical health didn't sustain to the end of the study. Participants' satisfaction with incentives was high. CONCLUSION: Overall, this study found no conclusive evidence that financial incentives alone had beneficial effects on improving standards of medical care in diabetes.

Financial Incentives for Medicaid Beneficiaries With Diabetes: Lessons Learned From HI-PRAISE, an Observational Study and Randomized Controlled Trial.

PURPOSE: The Hawaii Patient Reward and Incentives to Support Empowerment (HI-PRAISE) project examined the impact of financial incentives on Medicaid beneficiaries with diabetes. DESIGN: Observational pre-post study and randomized controlled trial (RCT). SETTING: Federally qualified health centers (FQHCs) and Hawaii Kaiser Permanente. PARTICIPANTS: The observational study included 2003 Medicaid beneficiaries with diabetes from FQHCs. The RCT included 320 participants from Kaiser Permanente. INTERVENTION: Participants could earn up to $320/year of financial incentives for a minimum of 1 year. MEASURES: (1) Clinical outcomes of change in hemoglobin A1c (HbA1c), blood pressure, and cholesterol; (2) compliance with American Diabetes Association (ADA) standards of diabetes care; and (3) cost effectiveness. ANALYSIS: Generalized estimating equation models were used to assess differences in clinical outcomes. General linear models were utilized to estimate the medical costs per patient/day. RESULTS: Changes in clinical outcomes in the observational study were statistically significant. Mean HbA1c decreased from 8.56% to 8.24% ( P < .0001) and low-density lipoprotein decreased from 106.17 mg/dL to 98.55 mg/dL ( P < .0001). No significant differences were found between groups in the RCT. Improved ADA compliance was observed. No reduction in total health cost during the project period was demonstrated. CONCLUSION: The HI-PRAISE found no conclusive evidence that financial incentives had beneficial effect on diabetes clinical outcomes or cost saving measures.

Risk of Diabetes Mellitus Among Medicaid Beneficiaries in Hawaii.

INTRODUCTION: Medicaid is the largest primary health insurance for low-income populations in the United States, and it provides comprehensive benefits to cover treatment and services costs for chronic diseases, including diabetes. The standardized per capita spending on diabetes by Medicare beneficiaries enrolled in the fee-for-service program in Hawaii increased from 2012 to 2015. We examined the difference in odds of diabetes between Medicaid and non-Medicaid populations in major racial/ethnic groups in Hawaii. METHODS: We used data from 2013 through 2015 from the Hawaii Behavioral Risk Factor Surveillance System in this cross-sectional study to compare the difference in risk for self-reported diabetes between Medicaid (n = 1,889) and non-Medicaid (n = 17,207) beneficiaries. We used multivariate logistic regression models that could accommodate the complex sampling design to examine the difference in odds of diabetes between the 2 populations. RESULTS: In Hawaii, the Medicaid population was younger, was less educated, had more health impairments, and was more likely to be obese and Native Hawaiian/Other Pacific Islander (NH/OPI) than the non-Medicaid population. The unadjusted prevalence of diabetes in the Medicaid population in Hawaii was higher than that for the non-Medicaid population (10.3% vs 8.9%, P = .02). After adjusting for confounding variables, the odds of diabetes in the Medicaid population was still significantly higher than those in the non-Medicaid population (adjusted odds ratio [AOR] = 1.75; 95% confidence interval [CI], 1.33-2.31). Adjusted analysis stratified by race/ethnicity showed that non-Hispanic Asian (AOR = 2.23; 95% CI, 1.31-3.78) and NH/OPI (AOR = 3.17; 95% CI, 1.05-9.54) Medicaid beneficiaries had significantly higher odds of diabetes than their non-Medicaid counterparts. CONCLUSION: The odds of diabetes was significantly higher among the Hawaii Medicaid population than among the non-Medicaid population. Diabetes prevention programs should address the challenges and barriers that the Medicaid population faces. Our findings can be used to promote culturally competent diabetes education programs.

Collaboration between a US Academic Institution and International Ministry of Health to develop a culturally appropriate palliative care navigation curriculum.

Implementation lessons: (1) The development and testing of a culturally appropriate palliative care navigation curriculum for countries facing high cancer and non-communicable diseases burden requires collaboration with the local Ministry of Health. (2) Lay volunteers from non-governmental and faith-based organizations are potential candidates to provide patient navigation services.

Aging and caregiving in the Republic of Palau.

Aging has been an important population trend of the twentieth century, with most elderly people living in developing countries. Little has been published on the healthcare needs of elderly in the Pacific Islands. The Pacific Islands Geriatric Education Center, at the University of Hawaii, has a mission to promote training in geriatric education in the Pacific Islands to improve healthcare to the elderly. The aim of this project was to develop and test a family caregiver training program for Palau and was achieved in two phases: (1) assessing needs by interviewing key informants and surveying elders and (2) evaluating the caregiver training program that was designed based on findings from the assessment. The Ecological Systems Theory provided the theoretical framework for this study. The needs assessment identified training and education of family caregivers as a top priority, with the Palauan culture of family caring for seniors presently threatened by caregiver burnout. Nearly all of the long-term care in Palau is provided by families, and elders have high prevalence of geriatric syndromes. A family caregiver train-the-trainer workshop was subsequently conducted in February 2011. Forty-four trainers, including 12 from other Pacific Islands, attended the workshop. To assess changes in knowledge and confidence to teach, we compared scores on pre- and post-questionnaires using paired t tests. The train-the-trainer workshop resulted in significantly improved self-assessed competence and confidence to teach in all geriatric syndromes, including dealing with difficult behaviors, gait and transfer training, caregiver stress relief, and resources for caregivers (p < 0.0001). This successful intervention identified geriatric care needs in Palau and successfully trained family caregivers to meet these needs, and may be used as a model for similar interventions in other Pacific Islands.

Healthy Heart, Healthy Family: a NHLBI/HRSA collaborative employing community health workers to improve heart health.

Kokua Kalihi Valley, a federally qualified health center in Hawaii, collaborated with the National Heart, Lung, and Blood Institute to test the efficacy of community health workers (CHWs) to deliver the Healthy Heart, Healthy Family curriculum to low-income Filipinos with cardiovascular disease (CVD) risk factors. At 12 months, significant improvements were seen in health behaviors, knowledge, and self-efficacy in managing chronic diseases. We also observed decreases in total cholesterol from 186.25 mg/dl to 170.88 mg/dl (p=.001), low-density lipoprotein from 114.43 mg/dl to 103.04 mg/dl (p=.013), and fasting blood glucose from 117.95 mg/dl to 109.07 mg/dl (p=.034). Although these changes were statistically significant, they are small and not clinically meaningful in reducing CVD risk. The high-density lipoprotein was 3.3 mg/dl lower (worse) at 12 months (p=.003), mean values for blood pressure, BMI, and waist circumference increased. Community health workers can be trained to deliver evidence-based curricula that improve health behaviors and increase self-efficacy in managing chronic diseases.

Home-based palliative care services for underserved populations.

BACKGROUND: Kokua Kalihi Valley is one of the first federally qualified community health centers offering home-based palliative care (HBPC). Kokua Kalihi Valley serves low-income, immigrant populations from Asia and the Pacific Islands, whose end-of-life needs are rarely addressed. Our team includes a palliative medicine physician, nurse, case manager, psychologist, interpreter, and volunteers. OBJECTIVES: The purpose of this Institutional Review Board-approved study was to measure symptom relief and quality of life, resource utilization, and satisfaction with HBPC. METHODS: Over 12 months, 91 people including 46 patients with chronic advanced illnesses and 45 corresponding primary caregivers were enrolled. Data were collected prospectively, upon admission, and repeatedly thereafter, using the Missoula-Vitas Quality of Life Index, the Edmonton Symptom Assessment Scale, and the Palliative Performance Scale. Utilization of resources was tracked, including case management, hospice, emergency department, and hospital visits. RESULTS: The median age was 71 years, and more than half had chronic neurodegenerative conditions. Most patients (98%) were minority, including Samoans, Filipinos, Japanese, Micronesians, and Hawaiians. Median stay in HBPC was 7 months, with a median of 3.5 visits. Approximately 25% of patients enrolled in hospice (median stay 67.5 days). There was a decrease in hospitalizations (p = 0.002) after HBPC admission. Discussions and documentation of end-of-life wishes increased from 50% to 90% (p < 0.01). Caregiver satisfaction with HBPC was high. CONCLUSION: Data on outcomes and quality indicators of HBPC programs are scant, especially among immigrant Asian and Pacific Islanders patients. Our experience demonstrates the effectiveness of palliative care approaches in this population.

Enhancing residents' training in medical ethics: an exploratory study assessing attitudes of internal medicine residents.

Internal medicine residents at the University of Hawai'i were surveyed in 2005 to identify their attitudes regarding ethics consultation based on exposure to ethics education as part of residency training. Our hypotheses were that senior residents are more likely than interns to request an ethics consultation; and providing or forgoing life-sustaining treatment would outrank other situations for requesting a consult. After two mailings, 46 out of 65 residents completed the survey (71% response rate). Statistical methods included Fisher's exact test for categorical variables, and general linear models to compare means between groups. A majority of residents stated that instruction on ethics was received through lectures and rounds. They were most likely to request an ethics consult for issues concerning medical futility and disagreement resolution. Comparing residents by yearof training for reason for ethics consultation, senior residents were more likely to request a consult for questions about artificial nutrition and hydration (p = 0.06). There was no difference between residents with or without previous exposure to ethics consultation or formal instruction in ethics and the likelihood of requesting a consultation in the future. A majority of residents felt it appropriate for any team member to request an ethics consultation. Ethics consultation can potentially be utilized to strengthen post-graduate medical education in keeping with the Accreditation Council for Graduate Medical Education requirements.