SPM 3 - The number of pediatric and/or behavioral health providers receiving training and support services on pediatric mental health care in underserved communities/counties statewide.

 

Introduction: Children’s Mental Health

For the Cross-Cutting domain, Hawaii has added a new state priority to expand children’s mental health services in response to concerns that emerged due to the COVID pandemic. In the 2020 Needs Assessment, mental health was identified as a concern for children and youth; however, Hawaii decided not to select this issue as a priority due to a lack of program capacity and in recognition of the DOH Child and Adolescent Mental Health Division (CAMHD) that is the lead for this program area.

 

COVID highlighted a growing concern over mental well-being due to pandemic-related health problems, social isolation, and economic hardships that generated widespread stress, anxiety, depression, and other mental health concerns. With the closure of schools and youth activities, and reduced access to outdoor spaces, family stress increased substantially.

 

Data: Mental health issues, particularly for youth suicide depression, was identified as a priority need in the 2020 Title V needs assessment completed before the pandemic. This was reflected in the health data as well as family and stakeholder input.

 

Two of the leading causes of adolescent mortality in Hawaii are unintentional injuries, such as motor vehicle-related injuries and suicide. Unfortunately, Hawaii has a comparatively high rate of adolescent suicidal ideation, and this rate has steadily increased over the years. The suicide death rate for youth ages 15-24 in Hawaii is 19.3, which is high compared to the U.S average of 14.4 for this age range.

 

Emergency Department (ED) Data: Analysis of Hawaii Emergency Department (ED) admissions data conducted by the DOH Injury Prevention program show that prior to COVID, there was an increase in the annual number of emergency room visits related to teen suicide ideation, doubling from 284 in 2016 to 525 in 2019. Although there was a decrease to 460 visits in 2020, this may reflect the general overall decrease in ED visits during COVID. As a proportion of ED visits, the percentage of youth suicide related ED visits increased from 2019 to 2020.

 

Anecdotally, both Hawaii ED doctors and hospital administrators from two of Hawaii’s major hospitals reported in 2020 that they saw more adolescents being held in ED beds for longer periods, too unstable for discharge, waiting for space at Oahu’s two acute care facilities that serve youth.

 

In the rural neighbor island counties, ED data confirms youth have a higher reported rate of suicide-related visits. But this may reflect lower access to mental health services in rural areas and/or greater use of emergency room services by neighbor island residents. On Oahu, there are more options for behavioral health services, and residents may elect to go to a private physician or behavioral health provider for support.

 

The need to support youth after ED visits for any mental health illness is crucial. According to Hawaii Medicaid quality assurance 2019 data, only 34% of youth ages 6-17 who were admitted to an ED for mental illness received follow-up care within seven days following ED discharge.

 

Provider Shortage: COVID has also exacerbated the provider shortage. Of the 989 medical provider offices surveyed in 2020 (all disciplines), 44% said that the pandemic has disrupted their practice in the form of temporary and permanent clinic closures, early retirement, increased telehealth practice, altered operating hours and locations, and reduced patient volume. The loss of providers and increase in provider shortage estimates are seen in every county.

 

While there are currently 153.4 FTE active psychiatrists in the state, there is an estimated shortage of 17.9 FTE providers and not all psychiatrists specialize in serving children and adolescents. Shortages of psychiatrists are especially critical in rural communities on Oahu and in the counties of Hawaii, Maui, and Kauai.

 

According to the Centers for Disease Control and Prevention (CDC), a 2015 report shows that while Honolulu County (the island of Oahu) may have the highest number of psychiatrists, it still has a relatively low rate of providers in comparison to the estimated 306,000 children aged 0-17 who may need to access their services.

 

In rural areas of Oahu as well as neighbor islands, where the provider shortages are higher, residents also confront geographic and transportation barriers to accessing behavioral healthcare. Most tertiary healthcare facilities, specialty and subspecialty services, and healthcare providers are located in urban Oahu. Consequently, residents on Hawaii Island, Kauai, Maui, Molokai, and Lanai (collectively the “neighbor islands”) are usually required to travel to Oahu for specialty care. With the onset of COVID, there have been limited flights to and from certain islands, such as Molokai and Lanai. Airfare costs can be volatile as prices are based on fluctuating fuel costs, which creates a financial barrier for neighbor island residents; roundtrip airfare can range from $130 to $300. Also problematic now is the shortage of rental cars on all islands for transportation, adding to the costs of accessing care.

 

Access to emergency care on neighbor islands may also require the use of helicopters or fixed-wing aircrafts. Access to healthcare on the rural neighbor islands is also challenging because public transportation is limited, so residents must rely on cars to travel to the major population centers for healthcare. In many areas of the neighbor islands, the terrain is mountainous and roadways are limited to a single lane. A traffic accident, fallen tree, or treacherous driving conditions caused by weather can result in lengthy delays in accessing healthcare.

 

Funding Opportunity: With the 2021 announcement of the HRSA Pediatric Mental Health Care Access (PMHCA) grant, FHSD had an opportunity to build program capacity around mental health. With the PMHCA grant, Hawaii will establish a statewide system of behavioral health teleconsultation and care coordination for children, especially those in underserved areas and rural communities where there are severe shortages of behavioral health providers as well as other barriers to care.

 

This project will provide pediatric healthcare providers access to a pediatric mental health care team that will support their work with children and youth. Trainings on pediatric mental health care and on the pediatric mental health team model will be provided in the communities so that there will be statewide access to the pediatric mental health care team(s). Overall, the goal is to promote integration of primary care and behavioral health in order to better services children, youth, and their families in their communities

 

Evidence: HRSA recently provided additional funding to support all Title V agencies to implement the Pediatric Mental Health Care Access Program, which promotes behavioral health integration into pediatric primary care using telehealth delivery. State or regional networks of pediatric mental health teams provide teleconsultation, training, technical assistance, and care coordination so that pediatric primary care providers can better diagnose, treat, and/or refer children and youth with behavioral health conditions. The overarching goal of the program is to use telehealth modalities to provide timely detection, assessment, treatment, and referral of children and adolescent with behavioral health conditions, using evidence-based practices and methods such as web-based education and training sessions. The MCH Evidence Center has provided ample evidence to show that telehealth services can improve access to healthcare for underserved MCH populations.

 

Title V lead/funding: The PMHCA grant is administered by FHSD and will allow FHSD to fund two staff positions to help maintain and build the program. Although no Title V funds will be used to support the program, Title V-funded staff will assist with data, contractual, and media support.

 

Key Partners: This new project is a unique collaboration between the Department of Health, John A. Burns School of Medicine (JABSOM), Project ECHO Hawaii, Hawaii Primary Care Association, and University of Hawaii Pacific Basin Telehealth Resource Center. This multi-agency collaboration will ensure that pediatric providers can access needed mental health consultation services in underserved communities statewide. The project will also coordinate with DOH efforts to establish a statewide mental health services/referral system led by the DOH Child and Adult Mental Health programs.

 

Objective: By July 2025, provide training and support services on pediatric mental health care to 80 pediatric and/or mental health care providers in underserved communities statewide.

 

Strategies: The strategies to implement the project will focus on three key areas:  

• Refine, develop and implement a pediatric mental health care access model
• Promote Workforce development and training on pediatric mental health care
• Support services and linkages in underserved communities

 

Activities for implementation for each of the strategic areas is described in the application plans for this new state mental health priority.

 

The funding for the new project is anticipated to be awarded by September 29, 2021. FHSD staff will prepare administrative requests needed to secure approvals to establish accounts, budgets, new position descriptions, as well as needed procurement with grant partner contracts.

 

Current Activities FY 2021 through June 2021

Although mental health was not selected as a state priority, FHSD strategically utilized partnerships to support work in this area.

 

Partnerships within DOH: FHSD and CAMHD continued discussions to help clarify the distinct roles for both programs regarding child mental health. CAMHD has traditionally been identified as the lead for children and youth’s mental health as they service the 3- to -21-years-of-age population with identified mental health concerns. FHSD’s role has traditionally been focused more on prevention and early identification and partnering with the primary care workforce through the Office of Primary Care and Rural Health.

 

CAMHD’s role has been focused on building the referral and treatment system for high-end treatment services for children and youth, and it works primarily with the mental health and behavioral health system providers. Opportunities to build collaboration between the two divisions focused on workforce training efforts and legislation to promote trauma informed-care practices.

 

Infant/Early Child Mental Health: The development of Hawaii’s Integrated Infant and Early Childhood Behavioral Health Plan was completed through a partnership with FHSD and:

• Hawaii Community Foundation,
• Early Childhood Action Strategy collaborative,
• Association for Infant Mental Health Hawaii (AIMH-HI), and
• Executive Office on Early Learning.

 

The plan addresses four areas: Systems and Policy; Marketing, Outreach, and Community Education; Workforce Development; and Programs and Services. It was commissioned at the request of the state Early Learning Board (ELB), a public-private governing board tasked with formulating statewide policy relating to early learning. ELB recognized that children’s social emotional/behavioral health issues may be adversely affected by the COVID pandemic restrictions. FHSD provided resources and leadership for the plan and continues to support implementation. Partnerships established during the plan development helped support the PMHCA grant efforts. Also, elements of the infant/early childhood behavioral health plan were integrated and will coordinate with strategies in the PMHCA grant.

 

Data: SSDI grant funding was used to conduct a preliminary review of data regarding child/youth mental health and disparities. The information was used for the HRSA PMHCA grant and is being used to develop a data publication. With limited FHSD epidemiologist support, a contractor is being secured to complete the project.

 

 

 

SPM 4 - Establish new telehealth access points with health and digital navigators in public libraries located in underserved communities statewide.

 

Introduction: Telehealth Access

For the Cross-Cutting domain, Hawaii added this new state priority to expand telehealth services to underserved communities in response to health and digital equity issues that emerged because of the COVID pandemic.

 

As reported in the final report of the State Performance Measure 1 (Increase the use of telehealth across Title V activities to improve access to services and education for families and providers) from 2015, 100% of the Hawaii Title V programs adopted the use of telehealth prior to and during the pandemic. However, the pandemic highlighted the health and digital inequity experienced by many underserved families. Some families do not have the digital literacy to access online information and services or do not have devices and/or adequate internet or cellular service, even if they know how to use the internet. Before COVID-19, FHSD setup telehealth access at all of the neighbor island District Health Offices to provide some access for families. But during the statewide COVID emergency, these sites were closed to all outside visitors.

 

This new project will provide individuals and families with the ability to access health and digital navigators, computers with internet, and telehealth rooms in public libraries located in underserved communities statewide.

 

Evidence: A review of the MCH Evidence Center shows evidence is fairly strong for use of telehealth to increase access to underserved populations for women’s preventative health services; pregnancy and post-partum health messaging; adolescent health; parenting support for infant and toddler health; raising awareness about child mental health and health insurance access; reaching underserved children via teledentistry; and supporting child/adolescent mental health via teleconsultation.

 

Title V lead/funding: Within FHSD, the Genetics Program continues to serve as the telehealth lead for the Title V agency. After successfully integrating the use telehealth technology throughout the Title V agency, this project focuses on addressing telehealth access issues to reach underserved communities in the state. Funding for this project is from a Centers for Disease Control and Prevention grant: National Initiative to Address COVID-19 Health Disparities Among Populations at High-Risk and Underserved, Including Racial and Ethnic Minority Populations and Rural Communities awarded June 2021.

 

Key Partners: This new project is a unique collaboration of the Hawaii State Department of Health (DOH), State Public Library System, and the University of Hawaii (UH) Pacific Basin Telehealth Resource Center and University John A. Burns School of Medicine. The project will provide individuals and families with the ability to access health and digital navigators, computers with internet, and telehealth rooms in libraries located in underserved communities statewide.

 

Objective: By July 2023, establish 15 new telehealth access points with health and digital navigators in public libraries located in underserved communities statewide.

 

Strategies: The strategies to implement the project focus on three key areas:

 

• Telehealth Library Access Project infrastructure development

• Workforce development

• Service Provision

 

Activities for implementation for each of the strategic areas is described in the application plans for this new state priority.

 

The funding for the new project was awarded to DOH on June 1, 2021. By September 30, 2021, FHSD staff will complete the paperwork to set up the project; get approvals from the governor and director of health as needed; create position descriptions; procure equipment; and set up the collaboration with the state public library, UH, community-based organizations, and families in the 15 communities near each library in the project.

 

 

 

SPM 1 - The degree to which Title V programs utilize telehealth to improve access to services, education, and training for families and providers (count).

 

Introduction: Telehealth

Expanded use of telehealth technology was identified as a priority in the 2015 Title V five-year needs assessment. The objective stated that by July 2020, 100% of Hawaii Title V programs would use telehealth to provide services, education, and/or training.

 

Data: This SPM goal was met at 100%. The COVID-19 pandemic compelled all Title V programs throughout 2020 and into 2021 to fully utilize the telehealth investments in training, software, and equipment to facilitate telework, virtual client services, and expand networking with agency and community partners through video conferencing. This priority will be retired in 2020 since it has been fully achieved. No further objectives are set.

 

Title V Lead/Funding: Within the Family Health Services Division (FHSD), there is ongoing support for efforts to implement or increase telehealth activities for genetics, newborn screening, early intervention, and home visiting program activities. These efforts are led by the Genomics Section, which is the grantee for the HRSA Western States Regional Genetics Network (WSRGN). WSRGN is a leader in the use of telegenetics and has many resources that FHSD can leverage for the Title V telehealth initiatives. Although Title V does not fund telehealth activities directly, key management and support staff funded by Title V help facilitate the telehealth expansion activities described in this narrative.

 

Key Partners/Policies: Prior to the pandemic, Hawaii’s governor and legislature identified telehealth as a top priority for the state. Hawaii has progressive telehealth statutes and congressional representatives had secured major funding to expand telehealth resources for Hawaii and the Pacific. Thus, telehealth continued to increase including programs within the Hawaii State Department of Health (DOH), hospitals statewide, community organizations, and the University of Hawaii. These efforts are supported by the HRSA-funded Pacific Basin Telehealth Resource Center (PBTRC) that works to help stakeholders collaborate on telehealth activities.

 

Strategies: There are four strategies for this measure: Infrastructure development, workforce development, service provision, and education/training. The strategies were developed by the FHSD staff and led by the CSHNB Genomics Section Supervisor, who serves as the FHSD lead for the telehealth priority.

 

Report FY 2020 through June 2021

Here are some highlights of current telehealth activities for FY 2021, including the impacts and changes due to the COVID-19 pandemic in Hawaii.

 

Since 2015, FHSD invested resources for telehealth in Title V programs. The planning, infrastructure development, and training employed to build telehealth capacity prepared the Title V programs to quickly move to virtual activities during the COVID-19 public health emergency and into the present.

 

Prior to the pandemic, most FHSD programs were using videoconferencing largely for meetings and trainings. The use of Zoom videoconferencing was the norm throughout division program operations and activities. However, the pandemic compelled FHSD programs to exclusively use videoconferencing for the majority of the work with so many employees mandated to telework from home.

 

The trend supporting provider and family adoption of telehealth continued and has since expanded to include collaboration with federal and state government agencies and community partners. The Genetics Program continued to maintain and expand telehealth resources and technical assistance (TA) that quickly increased in the first few months of the pandemic and initial lock down in Hawaii. The resources and activities included:

• Updating and maintaining a five-minute animated video, Best Practices for Providers, demonstrating best online practices for healthcare providers that’s usually presented in a more extensive training course.
• Updating and maintaining the English and Spanish versions of an eight-minute video, What to Expect from a Telehealth Visit, for families and patients to explain telehealth and also what to do to receive telehealth services in one’s home.  Versions were also created with increased volume and no background music at the request of families who have hearing impaired family members.
• Working with PBTRC to update and maintain telehealth resources, including quick start guides, billing policies, information for patients, checklists, and locations/providers on the PBTRC website.
• Updating and maintaining the videos and resources used by the HRSA Office for the Advancement Telehealth and the new Health and Human Services telehealth website. The resources Hawaii developed were adopted nationally, with local contact information switched to the National Consortium for Telehealth Resource Centers for national dissemination.
• From April 1, 2020 to June 30, 2021:
  • Best Practices Video views: 14,074
  • What to Expect Video views (English): 12,025
  • What to Expect Video views (Spanish): 112
  • What to Expect Video views (Vietnamese): 33
  • What to Expect Video views (Chinese Mandarin): 1,699
  • What to Expect Video views (Samoan): 20
• The Genomics Program collaborated with PBTRC and continued telehealth TA webinars weekly for all providers, including the Title V programs, from June to August 2020. The webinars shifted to a monthly schedule from August to December 2020 and then were offered as needed starting in January 2022.
• The Genomics Program received additional CARES Act funding through the Association of Maternal and Child Health Programs (AMCHP) to increase telehealth resources for families in the Western States Region (Washington, Idaho, California, and Hawaii). This funding allowed the program to:
  • Transconvert (translation and conversion of the video for language and visual elements to meet cultural needs) the What to Expect from a Telehealth Visit video into Vietnamese, Samoan, Chinese (Mandarin), Tagalog, and Korean.  The Chinese (Cantonese), Ilocano, Korean, and Russian versions are currently under development.
  • Develop and maintain a seven-module online telehealth training for family advocates, Title V staff, and other community program staff that work with families. The training provides a foundation to help advocates and staff navigate families to telehealth services and resources. The training is free, and a certificate of completion is provided.
  • Developed a dedicated section of the Western States Regional Genetics Network (WSRGN) website (https://www.westernstatesgenetics.org/family-telehealth-resource-project/) to help advocates, staff working with families, and families to centralize different types of resources to help families.

 

Factors Contributing to Success

The major factors contributing to the success in expanding telehealth throughout Title V programs continue to be support from the governor, state legislature, DOH administration, FHSD/program leadership, program staff, and other public sector agencies such as the University of Hawaii and HRSA-funded PBTRC. The legislature approved funding since 2017 for a State Telehealth Coordinator position within DOH and development and maintenance of a State Telehealth Plan. DOH also consolidated the individual Zoom videoconferencing licenses into one HIPAA-compliant corporate license to allow more efficient expansion for telehealth for all public health programs.

 

Having telegenetics activities developed and implemented as part of the HRSA-funded WSRGN, which is administered within the Hawaii Title V agency, really helped harmonize expansion of telehealth activities in FHSD programs. The long-standing partnership with the HRSA-funded PBTRC also greatly supported telehealth activities, especially with the advent of the COVID pandemic.

 

As a state, we have developed a Statewide Telehealth Hui and Statewide Broadband Hui (“hui” is the Hawaiian word for group). Both of these groups are working towards developing policies, programs, and funding to support digital and health equity as well as access for all families in Hawaii. In the 2021 legislature, the creation of a Broadband Coordinator was approved. This coordinator is tasked to sustain development efforts for digital equity in Hawaii.

 

Challenges

Hawaii was fortunate to quickly adopt the use of telehealth for Title V programs during the pandemic. However, there are still issues with ensuring adequate internet or cellular connections especially for staff, clients, and families in rural areas of the state.

 

A major disparity continues for families who are not able to receive telehealth services in their homes due to a lack of devices and/or adequate internet or cellular service. Before COVID-19, FHSD setup telehealth access at the neighbor island District Health Offices to address this concern. However, during the COVID lockdown, these sites were closed to outside visitors. FHSD programs continue to work with state programs, community-based organizations, healthcare providers, and internet/cellular carriers to expand the availability of devices and internet/cellular services.