 This is Think Tech Hawaii. Community Matters. Good morning. This is Craig Thomas, your host on Much More on Medicine, part of Think Tech Hawaii's live stream series and assisted as always by our engineers, Ray and Rich. And with me today is Annie Chang, Director of Emergency Services at Queen's Health System. Yeah, great. It's nice to see you and thanks for coming. Definitely, thanks for having me. Ah, it's gonna be good. You know, I'm really excited about your project, just so I'm gonna set the stage slightly, but then you're gonna take it away. So, Danny is addressing something that we in the emergency department have failed at since I was a resident in 1980. So that's a long time to fail. And basically, and the problem is people often homeless or at least with some other issue that prevents them from navigating through life and the healthcare system, they end up in the ER. So you've recognized that and are dealing with it. And so this is part of our theme of the spring. We've been dealing with what are health issues that need addressing outside the role of traditional medicine. And this is a perfect example. So why don't you set the stage, tell us what you've launched and kind of what's happening. Yeah, so again, thanks for having me here today, Craig. So I'm an ER physician. I've been back here in Hawaii for about five years now. I work at the Queens Medical Center. And in a couple of minutes, what we've created at Queens with some great support from the legislation, from our president, from insurers like HMSA, is what we call the Queens Care Coalition. Nice. I'm a care physician. I trained in downtown Los Angeles County and the majority of our patients we saw at that time were homeless. And coming back about five years ago is quite a shock to see what the state of the emergency rooms, at least here in downtown Honolulu were like, which was very similar to downtown LA, a high percentage of homeless people. 2014, Governor E. Gay declares a state of emergency. We have the highest homeless per capita of any state in the country since 2014. We still hold that through 2018. And what we found was we are entering a cycle of insanity. We'll see a patient. He's got a skin infection. We give him some antibiotics. We do nothing for his homelessness, his addiction, his behavioral health issues. And you know what I'm saying? Wait, I want to understand something. So are you telling me that if I have a skin infection and I don't feel my prescription and I lie on the sidewalk in a puddle, it's not going to get better? I'm just checking this out. Absolutely, right. So us as a health care institution, we've decided for a long time to put blinders up. We really want to just focus in on this very narrow band of a person's life and that's the medical care and have no regard for their social determinants of health, things like domestic violence, addiction, do they have access to food and water, and of course, housing. And here in Hawaii, we all know housing has become just ridiculously expensive. But yeah, so absolutely. So what we've been seeing is we have these individuals that come in through our emergency room and they have medical disease, but clearly much more significant social issues that need to be addressed. And they're just weren't being addressed in the community, clearly they're not being addressed from the hospital perspective and is of no surprise that we've been having escalating hospital utilization and ERUs. So we saw that we were able to get some numbers and we were able to kind of make a statement to our legislature, our presidents, our individuals that could make decisions that could have impact and they've listened. And we've been so fortunate to have is a model where we know these patients when they're at the near end of their life, when they are really suffering, they come through the ER. They're not coming because they have, you know, 10 minutes of free time and they got nothing better to do. You know, I'm gonna stop you for a second because you just said something really important. Anybody who's been at the ER and my sort of perspective of the ER, it's a little bit like the DMV. Sooner or later, everybody goes there, right? And nobody wants to. Nobody wants to. And the ER is that way too. ER is not a place you go for fun. Absolutely. It's a place you go when you either need the services it's well geared up to provide and I hope we do a good job. Yes. Or when you have no other option. And the problem is if you have no other option, we're probably as currently set up and it's why you're here today to help us do better, not gonna solve the problem. And then everybody's frustrated. Right. The staff, the doctors, the patient, everybody knows we didn't solve anything. Absolutely. And everybody's unhappy. But since it's not solved, they're gonna be back. Sorry, I had to go off on that. Definitely some great insight there. So I mean, I would say our program really focuses on three things. The first and foremost is care for the patient. So we use a model called Care Navigation. It's a model that CMS, that's Medicare and Medicaid, created a publication in 2013 that, because we're not the first place in the United States that have issues of homelessness and high utilization in urban setting, Los Angeles, San Francisco, Baltimore. And what they found were really successful programs linked hospitals with state organizations like the Department of Health, or they linked them with insurers to kind of work together. So, and the model is navigation. And it's very, it sounds so basic, Craig, but it really is at these fundamental needs. I mean, these are individuals that have no house over the head. I mean, they don't really know where they're gonna be the next couple of hours. They don't know where their next meal's gonna be. So it makes sense that some of the solutions need to be fundamental. And it's getting them to their appointment, getting them to pick up their medications. It's getting them to be able to fill out a form so they can get food stamps that they qualify. So they have a ready reliable source of food. That's kind of what the model of Care Navigation that's coming through the hospital. So we assign it based upon the highest utilizers of the system. So the most at risk individuals. And we assign them to a navigator who is a non-clinical individual. So it's not a nurse, it's not a physician. What the studies have shown best that these individuals can link and create a collegial relationship with these patients is through a non-clinical setting. And they create friendships. They create a connection with these patients. And they carry them for 30 to 90 days. And they help them through kind of their most acute need, be it housing, food, addiction, behavioral health, getting them to their appointments. So that's the focus of one of the arms of the Care Coalition. The second one, which has been actually, has impactful, has been communication and just bridging what the legislation's been trying to do to tackle homelessness. So about 20 plus million dollars a year is allocated to homeless services here in Hawaii. And some of it's through housing, some of it's through what's called wrap around services, social support services. But what we've found is that there's just a big lack of communication between community resources and for this population, the hospital resources. In other words, there's homeless persons that's being outreached by let's say Catholic charities or the Institute of Human Services down in Kakaako. They might have a robust plan for this individual. But because we don't communicate through any platform or any type of regular communication, this person enters our system for a skin infection again. Favorite. And we start from scratch. We know nothing about what's going on with this person. We don't know where his application for housing is. We don't know what's been going on with his community partners. And it's like starting... Well, you don't know that he saw me yesterday at Wairoa and didn't take the medicines I gave him. Absolutely. Because he couldn't get them. No. And there is no current process. So that's part of it is working on building bridges with the community, sharing information, HIPAA compliant of course, but really trying to make sure that we're all working as a team for the right outcome for these people. You know, what you're describing is, I think you're touching on the two biggest problems in American healthcare. We're very good at putting tertiary center type specialty services on almost any problem. But most problems, well, first of all, by the time you need that, you're in real trouble usually. But most problems, those aren't the right resources. So we're not good at allocating resource to housing, for example. And the other thing we're not good at is you just talked about coordinating the services. In general, we're terrible at coordinating care and sharing information. When you compare the U.S. to other moderately comparable countries, we spend at least twice as much and we have at best mediocre results. And I'm convinced it's three things. Poor coordination, lack of resource for things that matter is basics. And honestly, paying too much for some of the stuff we do. That's, for what it's worth, that's my belief. Yeah, so I mean, part of it is it's been a journey that's passed three, four years. It's not something we've developed in the past year. Really the culmination right now, I just feel like we're really in the thick of it is getting the buy-in from the legislation after having a very successful session within this past couple of months. So we were able to get some homeless legislation for healthcare past this couple months. Yeah, it was through the Omnus Bill, through both the House and the Senate with some great collaboration. And we were able to get two legislations passed, each for a million funding as a pilot study. Congratulations, that's fabulous. Yeah, and I'm really excited because, you know, it's that kind of buy-in from the state level that we really need in order to have a real tackle. And I really believe this is something that we can change. I mean, I really want, in a really short period of time, I hope even within a year, to really get off this dubious list of being the highest homeless per capita. It's just not a place we should be at. We have some very good national ranking health statistics. Yes. This is the rank we don't want to have. No, it's a definite blight on our report card. And, you know, just talking about absolute numbers, because we're not a big state, but we're talking about 5,000 roughly homeless individuals on Oahu and another 2,000 on the neighbor island. And, you know, it's not an insurmountable amount. It's not something that we can't really, I think, wrap around. But, you know, the two private programs, one is through an ER-based homeless approach. So, providing care navigation through the ER, because we do know that the sickest individuals, on a side note, the average life expectancy of our homeless population is roughly 51 from some of the studies I've done here. And it's a comparison to roughly in the 70s for everyone else. I mean... So, it's one of the reasons the U.S. has terrible worldwide health risks. Absolutely. You know, one of the senators this past session also kind of made a splash, saying homelessness is a healthcare diagnosis. And it's hard to deny that. When I know that they will die about a third earlier than most of us, there's only a few diagnoses that carry that type of impact. That's true. You can be a diagnosis type one diabetic at age two and you'll have a better expectation. You can have HIV. Or HIV and have a near normal lifespan. Absolutely. No, that's huge. Yeah. So, I'm really excited. I'm excited to see where this pilot program goes in terms of just providing data for individuals to see and for the state legislatures to see the impact that we can do from the hospital. The other bill is to actually provide more respite housing. So, that's not necessarily the theme of a shelter, but this is fundamental, more of like a care home kind of setting for these individuals. So, they can land after a pretty significant medical illness. For example, they have a stroke, a homeless person has a stroke and needs some acute care to actually rehabilitate them to maybe actually get them fundamentally functional. That can happen in a care home, but the problem is many of these individuals have very limited insurance. They have a very limited ability to pay. And it's very hard to find a place for these people to be. And part of, rather than using the high cost of an acute care hospital, it's providing them a safe place, not a shelter, not on the street of Pensacola and Ward, but a safe place where they can get the medical resources to be rehabilitated, to actually have the chance to maybe have a functional life. You know, just listening to you and thinking about this, it's so obviously the right thing to do. As far as I know, in Hawaii, we haven't had the disastrous videos that occurred, among other places in LA, of somebody leaving the emergency department still in their gowns, still with their bracelet, without shoes, and getting dumped somewhere. That is so obviously not gonna work. What are we thinking as a country anyway? The other thing I'd like to touch on is, the emergency department has become the problem-solving center of the health system, whether it's a diagnostic situation, whether it's a getting diagnosed and channeled to acute care, but whether it's okay, this person has a pattern of needing help. It's clearly not happening. We need to identify it and establish a resource. And all those things are valuable. I think you're absolutely right, Craig. I think, especially if we're gonna say we have a finite amount of resources, you know, where do we allocate the resources to get the biggest bang for a buck is that we know that, again, kind of touches back to what we kind of mentioned in the beginning, people don't want to be in the ER. They surely don't. And when they do show up in our ERs, we know they are in a moment of crisis in their life. They're truly a moment of crisis, regardless of what others may see of it and how they judge how big of a crisis it is. They really are in a crisis. And we have statistics to show that, you know, if you show up in the ER, that means there's a lot more going on in your life and you're probably a high risk individual. And you're absolutely right. It's a better place to kind of capture and start care for the right population in the ER. Exactly. So, after the break, we're gonna talk a little bit about sort of how to get data, what kind of efforts there are along those lines and how this could be re-engineered. So, I'll look forward to that conversation. This is Craig Thomas, much more on medicine and we'll look forward to seeing you after the break. This is Think Tech Hawaii, raising public awareness. I'm Ethan Allen, host on Think Tech Hawaii of Pacific Partnerships in Education. Every other Tuesday afternoon at 3 p.m., I hope you'll join us as we explore the value, the accomplishments and the challenges of education here in the Pacific. Welcome back, it's Craig Thomas, your host on much more on medicine with Danny Chang, Chief of Emergency Services at the Queen's Health System. Oh, excuse me, I think it's punch-bowl specifically. We don't want to get how we upset. And we've been talking about a diagnosis with real health implications and a strategy to deal with it, namely your housing status or unfortunately lack of housing status. So, before the break, we kind of outlined how we got to this point and you described how the legislature stepped up, Queens has stepped up, HMSA has stepped up. Recognizing that to solve a problem takes resource. I think it also takes data. Let's talk about that. Yeah, absolutely. Again, finite resources and how do we show that there is a need and the impact? So, for our group, how we've selected it is through we can capture who's coming through our ER, obviously, and we can also capture who's homeless. We've also had some access to some really great, robust statewide data through the ER. And what we found is that it's not a small chunk of individuals. We're talking roughly 14 to 20,000 ER visits per year. We're talking about roughly 65 to 70% of them coming through the Queen's System, so that's why it's currently based out of Queens Medical Center. And we can show impact of recidivism and we can show impact of cost. Once we've identified these individuals. So, we generate a ongoing monthly list and that's how we identify. We go about 90 days prior and just for some numbers, we know that at least for the Queen's System, in a 90-day period, we're talking about roughly 500 homeless individuals, unique individuals that equates to roughly 4,000 or so ER visits. So, reflect on that for a moment, gentle listeners, average of eight per individual. And I know, even from statistics from EMS, 25 to 30% of all ER visits are through EMS. 50% total are via EMS or HPD. So, the cost is more than just the medical cost. And we were talking about the layers on top of it, right? But you know what? That wouldn't be so terrible, except we're generally not solving the situation. Yeah. Honestly, and I'll lump EMS and HPD together. They're discreet, they're separate, they have different roles. From the perspective of this population, there's huge overlap. And we're not solving the problem now. I mean, I think there's hope on the horizon, Greg. I mean, there's, there also were some bills passed from the criminal justice process to how to not, you know, decriminalize homelessness. How do you approach it? You know, we have a homeless person enter the criminal justice system. How do you help them, not incarcerate them? So, I mean, there's some hopeful things on that end. Another thing we're also doing and working with on a national level is through again, CMS Medicare and Medicaid is a program that's for the next four years. It's multi-site all the way from Boston, up through Chicago and the West Coast. And we're actually very fortunate, very fortunate to be one of the sites, because it's pumping in about $10 million into the system here to look fundamentally at how does things like a lack of housing, behavioral health, lack of reliable food and domestic violence. So it's very specifically chosen. How does that impact ER utilization? And it's pretty clear from even data before and research before that it has a huge impact on the order of three to four times the utilization. And it's pretty clear that, you know, we're gonna gather some data. We're gonna report to CMS. Queens is the main hospital system here that'll be participating in this study. But it's very clear is CMS is saying, we're gonna gather data to show once and for all on a national scale that if you don't address a person's housing status, if you don't address a person's behavioral health, substance abuse, domestic violence from the hospital system, they're coming to the hospital for a fall. But we realize it's because they drink six beers a day and also the X, Y and Z. If we're not addressing it from the hospital, from the medical system, we're not doing our job. Clearly not. And unfortunately, we have kind of a long history of this, you know, and there are forces that tend to discourage data collection. So obvious examples, tobacco. A more recent and still a little undercover example, alcohol. It probably isn't in your best health interest to have those two glasses of red wine today, even though most people do fine. Firearms, whatever your belief about firearms, we should be studying them and homelessness. If it's 25 plus years off the average life expectancy in the state, gotta study it. And not only study it, but also pilot things and track that and reward it. Or if it doesn't work, try something else. Correct. I think, you know, just even for myself, and this is even here locally, but I can imagine nationally makes sense, is that hospital organizations and hospital systems are pretty well off, I mean, for the most part. They have a better infrastructure. They are just better, I feel, fundamentally run than some of these grassroots community organizations that are often left with the bulk of the responsibility to care for things like rehabilitation of substance abuse, housing for homelessness. And we're talking about organizations that have maybe 20, maybe 30 individuals. Some of them may have a CFO, some of them don't. It's one person that does everything. And what you realize is that, you know, what we've asked of these organizations is tremendous. And the resources that they have are quite sparse. And the coordination between them, there's no infrastructure. There's none. So interestingly, I've been involved locally in a Loha medical mission. And we had a medical clinic years ago, which we ex-nade because it wasn't solving the problem. But the first day I volunteered there, I could hear the nurse doing the little history around the corner. And she asks, do you have a doctor? I couldn't believe what happened next. The guy says, Dr. Thomas at Wahiwa. That was me. I'm like, really? So I go around the corner and it's Lloyd. I know him. So it just demonstrates how hard he was looking for help. It was a mistake, honestly, to replicate that when we really should be focusing on the EDs to solve this. But they need resources to do it. You know, the long-term vision, the long-term hope I have for this kind of nascent program, this program that we're trying to fundamentally drive, how fundamentally change, I should say, how hospitals here in Hawaii address our patients that come in that are either homeless or near homelessness is not just at Queens, but to make it a process. I really hope we do have a system where the state structure of how do we house them, how do we provide support through food stamps or through social security, that to kind of get them bridged to a point where they can maybe have an independence, a job, education for training. That process can begin through the emergency room. I mean, that's my global vision is to have a standing program where we can really just assist any ER here in Oahu on the neighbor island that can struggle it, because it can be difficult. It's a difficult population and it takes training and it takes a well-coordinated system, but again, that number, right? So we're talking 7,000 total for the state. I think it's a very doable number that we can at least chip away at from the hospital-based system. I do too, and clearly there's a whole, so we talk about the homeless. They are anything but homogeneous. There's, you know this, I know this, and even we don't know it, because there's a subset of them that don't go to the emergency department. Correct. And probably they're doing a little better because as we discussed, going to the ER is not a good thing. The weather is good. They're able to kind of, they're the things, at least geographically, that makes it a little bit easier for them. For sure. I've taken care of people on the mainland. You can freeze if you're homeless there. I would, if I had to be homeless, God forbid it would be here. Even so, the idea that the emergency department actually recognizes it as a health issue for which there are interventions and resource and hopefully improved outcomes changes everything. Right now, the patients know we're not solving it. We know we're not solving it. And everybody knows they're gonna be back. And as I said before, nobody's happy. That's unacceptable. Absolutely. You know, one of the positive things at least, again, what I've heard so far is, breath of fresh air have been words of heard. It's like, thank goodness, a hospital system is stepping up because they know it's like, again, that black box I talked about, these individuals are being cared for by the community. They know that once they enter a hospital systems, you know, they can't come into the hospital. They don't have access. These people don't have bad access to queens or polymomy. So they're just relying that, dear God, I hope they're doing the right thing. I hope they're maybe helping fill out the form. I hope they figure out that he's actually become, he relapsed for alcoholism. You know, it's just kind of this guessing game, but now that we're having this open communication, this dialogue, it's been with real positive reception. One of the more statistics, again, just for those who are maybe necessarily skeptics of the value is the 3%, we know that the top 3% of Medicaid, so that's Quest, that's the Medicaid, the top 3% of the state of Hawaii cost the healthcare system about 60% of the budget, and that's about a billion dollars. And we're not solving their problems. Not solving their problems. Danny, I'm delighted you came today. We should have similar conversations in the future. And I mean, oh, I can help. I appreciate it. Because I really think you're doing a great thing. I appreciate it. So thank you all for joining us. We look forward to having more conversations in the future. Again, this is Danny Chang, Chief of Emerged Services at Punchbowl. Thanks a lot. Thank you for having me, Craig. Thank you.