Health neglect strains main medical facility
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Video: Wai'anae homeless, workers tell their stories |
| • | Interactive map: Demographic profile of the Wai'anae Coast |
| • | Interactive graphic: Key facts and figures |
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Reader polls: What do you think is the primary cause for the homeless problem on the Wai'anae Coast, and what would be the most effective first steps to take to solve it? |
| • | Many remain gripped by addiction |
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By Rob Perez
Advertiser Staff Writer
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They usually show up at the doctor's office — if they show up at all — with multiple health problems.
They suffer from diabetes, obesity, hypertension or an assortment of other ills.
For some, substance abuse also is a problem, aggravating what already is a disturbing health picture.
Mental illness and depression often are part of the mix, too.
The homeless crisis that is gripping the Wai'anae Coast has spawned a crisis of another sort, this one slowly eroding the health profile of a community already dealing with serious health issues.
Many of the hundreds of homeless along the coast are living in conditions so atrocious that some liken them to Third World or war-torn regions.
Filth, cramped quarters, lack of running water, no electricity — it is an environment that is not conducive to healthy, sanitary living.
"This is Beirut, Hawai'i," said Dr. John Myhre, a Native Hawaiian health psychologist at Wai'anae Coast Comprehensive Health Center. "It's very sad."
At the epicenter of this growing crisis is the health center, which treats about 25,000 patients annually and is the main source of medical care for the region's residents, especially low-income ones.
Physicians, counselors and others at the center not only are seeing a dramatic increase in the number of homeless patients, but their cases tend to be more complicated and more acute than those from only a few years ago.
In just the past year, the center treated 1,002 homeless patients, a 44 percent jump from the previous 12 months. As recently as 2003, it treated only 429 homeless.
"In the whole time I've been here, we have never had over 1,000," said Mary Oneha, who is the center's director of quality and performance and has worked at the facility for 14 years.
The 1,002 homeless patients treated from August 2005 through July 2006 actually understates the extent of the problem. Some of those who live in makeshift quarters don't acknowledge being homeless when they get medical care, partly because of the stigma historically linked to the issue. So the actual number treated by the center was higher, but no one knows how much higher.
Contributing to the understated picture, many homeless don't even bother getting care. They neglect their problems until the problems become too painful or troublesome to ignore.
Jamie Calarruda, 46, is a case in point.
Calarruda, a Hawaiian, has high blood pressure but doesn't see a doctor regularly. "I've got to be just about dying for me to go," she said.
Calarruda became homeless earlier this year after the pig farm where she and her husband worked in exchange for room and board went out of business. She is unemployed and, like many of her beach neighbors, has no medical insurance.
Calarruda said she knows others on the beach who have serious health problems but don't get care. "There's a lot of people out there. They need medical help. It's sad, really sad."
The center is trying to reach those people by taking treatment directly to the beaches.
Twice a week, a nurse, social worker and an insurance-eligibility specialist board a van and stop at key points along the coast, providing basic services to the beach dwellers.
The nurse checks vital signs, changes bandages and looks for conditions that should be assessed by a physician. The workers also arrange follow-up appointments, help with insurance forms, make referrals to social-service agencies and provide other basic services.
They also distribute toothpaste, toothbrushes, first-aid kits and other essentials. On one of the two days, a Legal Aid attorney joins the group.
Even before the homeless population surged along the coast, the health center had been struggling for years to improve one of the worst community health profiles in the state.
Diseases ranging from diabetes to heart disease are major problems, especially among the Hawaiian population. The situation is compounded by widespread poverty in the region, and the rise in homelessness has only added to the woes.
The challenge facing healthcare providers is reflected in cases like these:
Wong and Avelino were among the patients who were treated during one of the beach runs by the health center van in late August.
Oneha, the center director who oversees the van program, said the cases involving homeless patients have become more complex and acute over the past five years.
The sheer numbers, especially when many are crowded into small areas along the beach, make the spreading of ailments more common, according to Oneha and other healthcare workers who deal with the homeless.
Also more common, they say, is the tendency for some of the homeless to wait until their health problems are particularly acute before they see a physician.
The rise in substance abuse, they add, only compounds the situation.
"It's much more of a problem today than it was four or five years ago," Oneha said.
Because cases tend to be more complicated and serious, healthcare workers say they have to spend more time on average with each patient.
Oneha recalled one case in which she spent three hours with a couple on the beach because they had so many issues to deal with and needed lots of guidance and information. She invested the time because she realized she might not see the couple again, a not uncommon happening when dealing with a transient population like the homeless.
Despite the complexity of the cases, the center is treating the homeless with little or no increase in resources, officials say.
In Oneha's department, which does all the center's outreach services for the homeless, it has had the equivalent of only four full-time case managers for several years — despite dealing with so many more patients.
"It stretches what little we do have," said Joyce O'Brien, associate director of the center. "Things have to give here and there."
The center treats all patients, regardless of ability to pay. If a homeless patient is uninsured, the facility gets a set amount from the state to treat that person — as long as the center's annual cap for the number of uninsured patients hasn't been exceeded, center officials say. But the cap usually is exceeded each year, which means the center gets no reimbursement for those treated beyond the limit.
Like other healthcare facilities in Hawai'i and across the country, the center is struggling to rein in the mounting cost of providing care, and the homeless crisis only adds to that pressure. Also like other facilities elsewhere, the center has had to trim services, not in direct medical care but in secondary areas such as support services and some preventative care.
In the latter area, the center reduced its medical nutrition therapy and laid off a dietitian even though such treatment is effective in fighting diabetes and obesity, two of the more common ailments on the coast. Center officials said the reduction was driven largely by inadequate reimbursement by the state — a charge state officials dispute.
Doing more, not less, preventative care and treating patients in a more holistic sense — looking at underlying issues such as cultural and socioeconomic ones that contribute to a person's ailments — are the keys to making lasting, widespread changes on the coast, center officials say, and the state has to provide adequate support to do that.
"The problem is, if you really want to change the health outcomes, if you really want to change the (health profile) over time, you need to provide more than just medical care," said Richard Bettini, the center's chief executive officer.
Lillian Koller, director of the state's Department of Human Services, said the state has taken steps to boost preventative coverage and achieve better outcomes statewide.
The state, for instance, is expanding preventative coverage under its new contracts for the Quest insurance program for the poor. The new coverage, which takes effect in February, includes smoking-cessation classes for the first time.
The new contracts also for the first time will reward health plans that exceed minimum benchmarks in fighting certain diseases, such as diabetes and obesity, and penalize those plans that fall short, in effect putting a greater emphasis on preventative measures, according to Koller.
The changes mark the first time in more than a decade that the state has been able to substantially revise the Quest program. The state had to negotiate the changes with the federal government, which helps pay for the insurance.
"We're putting our money where our mouths are," Koller said. "This is something that is long overdue."
Whether this approach will result in significant health changes along the coast remains to be seen.
Skeptics note that little progress has been made in recent years despite millions of dollars in state spending on care for the homeless and poor.
Bettini, the center's chief executive, believes the government bureaucracy responds too slowly to the coast's pressing needs.
"There is a disconnect between the urgency in this community to solve some of these problems and the bureaucracy that takes so long to move to address them," he said. "We work in a degree of panic. And we wait and we wait and we wait for a response. When you talk to people Downtown, you don't get the feeling there's this same sense of urgency."
Reach Rob Perez at rperez@honoluluadvertiser.com.
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