Molokai General Hospital Community Health Needs Assessment

March 29, 2013

Table of Contents

Executive Summary ...... 4 Introduction ...... 4 Approach ...... 4 Data Sources and Methods ...... 4 Areas of Need ...... 5 Selected Priority Areas ...... 6 Note to the Reader ...... 6 1 Introduction ...... 7 1.1 Summary of CHNA Report Objectives and context ...... 7 1.1.1 Healthcare Association of Hawaii ...... 7 1.1.2 Molokai General Hospital ...... 7 1.1.3 Advisory Committee ...... 7 1.1.4 Consultants ...... 8 1.2 Definition of Community + Map ...... 9 2 Methods ...... 10 2.1 Core Indicator Summary ...... 10 2.1.1 Data Sources ...... 10 2.1.2 Comparisons: Analytic Approach ...... 10 2.1.3 dIndicator an Topic Area Scoring ...... 11 2.1.4 Shortage Areas ...... 11 2.2 Hospitalization Rates ...... 12 2.3 Key Informant Interviews ...... 12 2.4 Community Survey ...... 14 3 Community Health Needs Assessment Findings ...... 15 3.1 Demographics ...... 15 3.1.1 Population...... 15 3.1.2 Economy ...... 19 3.1.3 Education ...... 20 3.2 Overview of Needs Assessment ...... 20 3.2.1 Access to Health Services ...... 24 3.2.2 Cancer ...... 25 3.2.3 Diabetes ...... 26 3.2.4 Disabilities ...... 28 3.2.5 Economy ...... 28 3.2.6 Education ...... 30 3.2.7 Environment ...... 31 3.2.8 Exercise, Nutrition & Weight ...... 31 3.2.9 Family Planning ...... 33 3.2.10 Heart Disease & Stroke ...... 33 3.2.11 Immunizations & Infectious Diseases ...... 34 3.2.12 Injury Prevention & Safety ...... 35 3.2.13 Maternal, Fetal & Infant Health ...... 36 3.2.14 Mental Health & Mental Disorders ...... 37 3.2.15 Older Adults & Aging ...... 39

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3.2.16 Oral Health ...... 40 3.2.17 Respiratory Diseases ...... 42 3.2.18 Social Environment ...... 42 3.2.19 Substance Abuse & Lifestyle ...... 44 3.2.20 Transportation ...... 45 4 Community Health Needs Summary ...... 47 4.1 Findings/Conclusions ...... 47 4.1.1 Disparities Highlights ...... 49 4.1.2 Identified Data Gaps ...... 50 4.2 Limitations and Other Considerations ...... 50 5 Selected Priority Area ...... 52 Appendix A: Core Indicator Data ...... 54 About HCI Provided Data ...... 54 Framework for Indicator/Data and Topic Selection ...... 54 Core Indicator Data Summary: Analytic Approach and Scoring Methodology ...... 55 Core Indicator Data ...... 58 Appendix B: Hospitalization Data ...... 66 Hospitalization Rates ...... 66 Appendix C: Key Informant Interview Participants ...... 69 Completed Interviews ...... 69 Attempted Interviews ...... 69 Appendix D: Identified Community Resources ...... 70 Appendix E: Referenced Reports ...... 92 Appendix F: Road map to IRS Requirements in Schedule H Form ...... 93 Appendix G: Authors ...... 94

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Tables

Table 3.1: Population Density and Change ...... 15 Table 3.2: Core Indicator Summary Scores ...... 20 Table 3.3: Composite Hospitalization Rates due to Preventable Causes in Molokai, 2011 ...... 21 Table 3.4: Core Indicators – Access to Health Services ...... 24 Table 3.5: Core Indicators – Cancer ...... 26 Table 3.6: Core Indicators ‐ Diabetes ...... 27 Table 3.7: Core Indicators – Economy ...... 29 Table 3.8: Core Indicators – Education ...... 30 Table 3.9: Core Indicators – Exercise, Nutrition & Weight ...... 32 Table 3.10: Core Indicators – Family Planning ...... 33 Table 3.11: Core Indicators – Heart Disease & Stroke ...... 34 Table 3.12: Core Indicators – Immunizations & Infectious Diseases ...... 35 Table 3.13: Core Indicators – Injury Prevention & Safety ...... 36 Table 3.14: Core Indicators – Maternal, Fetal & Infant Health ...... 36 Table 3.15: Core Indicators – Mental Health & Mental Disorders ...... 37 Table 3.16: Core Indicators – Oral Health ...... 41 Table 3.17: Core Indicators – Respiratory Diseases ...... 42 Table 3.18: Core Indicators – Social Environment ...... 42 Table 3.19: Core Indicators – Substance Abuse & Lifestyle...... 44 Table 3.20: Core Indicators – Transportation ...... 45

Figures

Figure 1.1: Service Area Map ...... 9 Figure 2.1: Comparison Methods ...... 11 Figure 3.1: Census Tracts and Population on Molokai Island, 2006‐2010 ...... 15 Figure 3.2: Population Change, 2000‐20101 ...... 15 Figure 3.3: Population by Age: Molokai and Hawaii, 2006‐2010 ...... 16 Figure 3.4: Population by Age: Molokai Census Tracts, 2006‐2010 ...... 16 Figure 3.5: Population by Race/Ethnicity: Molokai and Hawaii, 2006‐2010 ...... 17 Figure 3.6: Breakdown of Molokai Population Reporting Race of Native/Other P.I. Only, 2006‐2010 ...... 17 Figure 3.7: Breakdown of Molokai Population Reporting Race of Asian Only, 2006‐2010 ...... 17 Figure 3.8: Population by Race/Ethnicity: Molokai Census Tracts, 2006‐2010 ...... 18 Figure 3.9: Linguistic Isolation, 2006‐2010 ...... 18 Figure 3.10: Per Capita Income, 2006‐2010 ...... 19 Figure 3.11: People Living in Poverty, 2006‐2010 ...... 19 Figure 3.12: Poverty by Race/Ethnicity, 2006‐2010 ...... 19 Figure 3.13: Educational Attainment: Molokai Census Tracts, 2006‐2010 ...... 20 Figure 3.14: PQI Composite Hospitalization Rates, 2011 ...... 21 Figure 3.15: Percent of Hospitalizations by Age Group and Gender, 2009‐2011 ...... 22 Figure 3.16: Key Informant Interview Word Cloud ...... 22 Figure 3.17: High‐Risk Race/Ethnicity Groups Identified through Community Survey...... 23 Figure 3.18 Percent of Population Living Below Poverty ...... 29 Figure 3.19: Mental Health Hospitalization Rates by Year ...... 38 Figure 3.20: Percent of Mental Health Hospitalizations by Age Group and Gender, 2009‐2011 ...... 38 Figure 3.21: Unadjusted Composite Hospitalization Rates, 2009‐2011 ...... 39 Figure 4.1: Areas of Disparity for Race/Ethnicity Groups ...... 49

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Executive Summary

Introduction Molokai General Hospital is pleased to present the 2012‐2013 Molokai Community Health Needs Assessment (CHNA). This CHNA report was developed through a collaborative process and provides an overview of the health needs on the Island of Molokai. The goal of this report is to offer a meaningful understanding of the health needs in the community, and help guide the hospital in its community benefit planning efforts and development of an implementation strategy to address prioritized needs. Special attention has been given to identify health disparities, the needs of vulnerable populations, and unmet health needs or gaps in services. The report fulfills the IRS 990 Schedule H requirements to conduct a community health needs assessment for tax year 2012‐2013. Although this report focuses on needs within the community, there are also innumerable community assets and a true aloha spirit that provide ample foundation for community health improvement. Approach In Fall 2012, the Healthcare Association of Hawaii partnered with Healthy Communities Institute to conduct a CHNA for Maui County. As a subset of the larger project, data relevant to Molokai was assessed separately, in order to better understand the unique needs and concerns of the island. Our approach followed the public health model of assessing and understanding community health holistically. A framework for analysis was constructed based on determinants of health; the framework included a broad definition of community health that considers extensive secondary data on the social, economic, and physical environments, as well as health risks and outcomes. The influence of mauka (“toward the mountains”), or upstream factors, and the resulting makai (“toward the ocean”), or downstream impacts, on health is a transcending theme. Key informant interviews with those having special knowledge of health needs, health disparities, and vulnerable populations provided vital information that increased the understanding of the health needs on Molokai. A small set of community residents provided additional insights on the health needs on Molokai. It is hoped that this report will provide a foundation for community health improvement efforts and that community health partners will build on this report. Data Sources and Methods An extensive array of secondary and primary data was collected and synthesized for this report. Core Indicators: Secondary data was analyzed using Hawaii Health Matters (www.HawaiiHealthMatters.org), a publicly available data platform with a dashboard of over 100 indicators from over 20 sources; much of the data comes from Hawaii Department of Health, allowing for Hawaii‐specific race, age and gender details. Data specific to Molokai residents was provided by Hawaii Department of Health, along with state comparison values for equivalent time periods of measurement. This extensive core data was analyzed using a highly systematic and quantitative approach that incorporated multiple benchmarks and comparisons to understand the question: How is Molokai performing? Hospitalization Indicators: Four indicators on preventable causes of hospitalization, specific to Molokai residents, supplemented the core indicators. This data was provided by Hawaii Health Information Corporation (HHIC) and enabled valuable insights into utilization patterns.

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Supplemental Information: Recently published reports on Molokai’s health and access to care were reviewed for additional key information on important topics such as health disparities, primary care needs, and mental health. Key Informant Interviews: Storyline Consulting, a local partner of the project, interviewed 4 key informants who had knowledge ofh the healt needs in Molokai. The selection of the key informants was guided by preliminary core indicator data findings and followed a structured nomination and selection process by the HAH Advisory Committee. These 4 Molokai‐specific interviews were supplemented by relevant information provided by additional key informants who were interviewed for the State of Hawaii. The input by local key informants was invaluable and greatly enhanced the understanding of health needs and offered insight into health resources and health improvement approaches. Community Survey: A small sample of community residents, via an online survey, supplemented the key informant interviews. Highlights of these surveys, or “Voices from the Community,” are incorporated throughout the report. Areas of Need This report provides an overview of Molokai’s community health needs. Community health was assessed for Molokai as a whole, and for race sub‐groups and sub‐geographies as possible. The findings revealed community needs in the following areas:

Access to Health Services Exercise, Nutrition, & Weight Mental Health & Mental Cancer Family Planning Disorders Diabetes Heart Disease & Stroke Older Adults & Aging Disabilities Immunizations & Infectious Oral Health Economy Diseases Respiratory Diseases Education Injury Prevention & Safety Social Environment Environment Maternal, Fetal & Infant Substance Abuse & Lifestyle Health Transportation

Several overarching themes emerged across the topic areas: All groups experience adverse health outcomes due to chronic disease and health risk behaviors While there are significant disparities in chronic disease, it is important to note that areas such as heart disease and stroke, cancer, diabetes, and asthma affect many residents of Molokai. Moreover, key health behaviors that impact chronic disease, including optimal exercise, nutrition, and weight need attention across all age, gender, and race/ethnic groups. Attention to this area at many levels could have an enormous positive impact on the long‐term health of the community. As a chronic condition that significantly influences overall health, mental health and associated substance abuse is a concern for Molokai residents. The suicide death rate is high, and many injury‐ related hospitalizations and deaths may be attributable to substance abuse. A lack of mental health care providers almost certainly contributes to the island’s mental health burden, and there are inadequate resources available for residents with substance abuse problems. Increasing services may require creative solutions that will cater to Molokai’s unique culture.

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Greater socioeconomic need and health impacts are found among certain groups in Molokai Repeatedly throughout this needs assessment, key informants stressed that Molokai residents who are low‐income are the most affected by health problems and often the most difficult to help. Financial constraints, such as the high cost of travel due to gas prices on Molokai, affect residents’ access to health services. Low‐income residents are less likely to get care available on Molokai, less likely to be able to afford the cost of travelling to Oahu for specialty treatment, and more likely to engage in unhealthy behaviors such as smoking. Cultural and language barriers inhibit effective intervention for the most impacted populations Because of the strong correlation between poverty and race/ethnicity, some of the groups most impacted by health issues often face cultural barriers to health improvement. Language differences, including limited English proficiency, and poor health behaviors that are common within a culture are challenges that must be overcome in order to effectively prevent disease. Interventions must consider these cultural and language barriers in order to be effective. Limited access to care results in greater health impacts Despite needs that exist, services are difficult to provide on Molokai due sto it small population. While some primary and specialty care services are available, the island is federally designated as medically underserved. Molokai residents must travel to Oahu to access many types of care, and the expense of travel is unaffordable for many. Specific services with limited availability on Molokai include but are not limited to: educational programs, cancer treatment, substance abuse programs, services for victims of domestic violence, and long‐term care for older adults. Schools are key community assets for effective interventions Implementing school‐based interventions can also be a method of positively impacting health in Molokai. Health interventions for children and teens can have a two‐fold benefit of establishing healthy life‐long behaviors among Molokai’s youth, as well as influencing the health of their families.

Selected Priority Areas Diabetes is the priority area selected by Molokai General Hospital. Note to the Reader Beyond the Executive Summary, readers may choose to study the entire report or alternatively focus on a particular topic area. An overview is provided for each key type of data included in the report: core indicators, hospitalization rates, key informant interviews, and on‐line community survey. To more deeply understand a topic area, the reader can turn to any of the 20 topic area presentations and find all data for the topic and summary conclusions. Each topic‐specific section is organized in the following way: • Core Indicators and Supplemental Information • Key Informant Interview Information • Summary of Topic Area

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1 Introduction

1.1 Summary of CHNA Report Objectives and context The state of Hawaii is unique in that all of its community hospitals and hospital systems joined efforts to fulfill new requirements under the Affordable Care Act, which the IRS developed guidelines to implement. The Healthcare Association of Hawaii (HAH) led a collaboration to conduct state‐ and county‐wide assessments for its members. Building on this collaboration, Molokai General Hospital developed a Molokai Island‐specific CHNA to meet IRS requirements. 1.1.1 Healthcare Association of Hawaii HAH is the unifying voice of Hawaii’s health care providers and an authoritative and respected leader in shaping Hawaii’s health care policy. Founded in 1939, HAH represents the state’s hospitals, nursing facilities, home health agencies, hospices, durable medical equipment suppliers, and other health care providers who employ about 20,000 people in Hawaii. HAH works with committed partners and stakeholders to establish a more equitable, sustainable health care system driven to improve quality, efficiency, and effectiveness for patients and communities. 1.1.2 Molokai General Hospital Molokai General Hospital (MGH), a member of The Queen’s Health Systems, is a 15‐bed Critical Access Hospital located on the island of Molokai. MGH is the lone hospital on the island providing the only 24/7 care for a population of 7,500 residents. Services include a blood‐banking laboratory, digital CT, digital x‐ray, digital mammography, outpatient chemotherapy, acute care, skilled nursing, physical therapy, and a full service midwifery program. 1.1.3 Advisory Committee The collaborative CHNA process has been informed by hospital leaders and other key stakeholders from the community who constitute the Advisory Group. The following individuals shared their insights and knowledge about health care, public health, and their respective communities as part of this group.

Howard Ainsley ‐ Hawaii Health Systems Corporation Bruce Anderson, PhD – Hawaii Health Systems Corporation Joy Barua – Kaiser Permanente Hawaii Maile Ballesteros – St. Francis Home Care Kauai Wendi Barber, CPA, MBA – Castle Medical Center Rose Choy ‐ Kahi Mohala Behavioral Health Kathleen Deknis, RN, MPH – Home Health by Hale Makua Karen Fernandez – Wahiawa General Hospital Mark Forman, JD – Hawaii Medical Service Association Foundation Loretta J. Fuddy, ACSW, MPH – State of Hawaii Department of Health Robert Hirokawa, DrPH – Hawaii Primary Care Association Mari‐Jo Hokama – Kahi Mohala Behavioral Health Fred Horwitz – Life Care Center of Hilo Susan Hunt, MHA – Hawaii Island Beacon Community Richard Keene – The Queen’s Health Systems Jeannette Koijane, MPH – Kokua Mau Jay Kreuzer ‐ Hawaii Health Systems Corporation Greg LaGoy, ND, MBA – Hospice Maui

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Bernadette Ledesma, MPH – Pearl City Nursing Home Vince Lee, ACSW, MPH ‐ Hawaii Health Systems Corporation Wesley Lo ‐ Hawaii Health Systems Corporation Pat Miyasawa – Shriners Hospitals for Children‐Honolulu R. Don Olden – Wahiawa General Hospital Quin Ogawa – Kuakini Health System Jason Paret, MBA – North Hawaii Community Hospital Ginny Pressler, MD, MBA, FACS – Hawaii Pacific Health Hilton Raethel, MBA, MHA – Hawaii Medical Service Association Hardy Spoehr ‐ Papa Ola Lokahi Jerry Walker ‐ Hawaii Health Systems Corporation Katherine Werner Ciano, MS, RN – North Hawaii Hospice Ken Zeri, RN, MSN – Hospice Hawai`i Lori Miller – Kauai Hospice Marie Ruhland, RN – Home Healthcare Services of Hilo Medical Center Neill Schultz – Castle Medical Center Corinne Suzuka, RN, BNS, MA – St. Francis Home Care Peter Sybinsky, PhD – Hawaii Health Information Corporation Ty Tomimoto – Rehabilitation Hospital of the Pacific Sharlene Tsuda – The Queen’s Health Systems Stephany Vaioleti, LSW, JD ‐ Kahuku Medical Center Sharon Vitousek, MD – North Hawaii Outcomes Project

1.1.4 Consultants Healthy Communities Institute The Healthy Communities Institute (HCI) mission is to improve the health, environmental sustainability and economic vitality of cities, counties and communities worldwide. The company is rooted in work started in 2002 in concert with the Healthy Cities Movement at the University of California at Berkeley.

HCI offers a spectrum of technology and services to support community health improvement. HCI’s web‐ based dashboard system makes data easy to understand and visualize. The web system and services enable planners and community stakeholders to understand all types and sources of data, and then take concrete action to improve target areas of interest. HCI has over 100 implementations of its dashboard for clients in 40+ states.

The HCI team is composed of experts in public health, health informatics, and health policy. The services team provides customized research, analysis, convening, planning and report writing to meet the organizational goals of health departments, hospitals, and community organizations.

To learn more about Healthy Communities Institute please visit www.HealthyCommunitiesInstitute.com. Storyline Consulting Storyline Consulting is dedicated to serving and enhancing Hawaii’s nonprofit and public sectors. Storyline provides planning, research, evaluation, grant writing, and other organizational development support and guidance. By gathering and presenting data and testimonies in a clear and effective way, Storyline helps organizations to improve decision‐making, illustrate impact, and increase resources. To learn more about Storyline Consulting please visit www.StorylineConsulting.com.

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1.2 Definition of Community + Map The hospital service area is defined by a geographical boundary of the island of Molokai, which is one of three inhabited islands in Maui County. Molokai will serve as the unit of analysis for this Community Health Needs Assessment. Hence, the health needs discussed in this assessment will pertain to individuals living within this geographic boundary. When possible, highlights for sub‐geographies within Molokai are provided. The specific area served by Molokai General Hospital is Molokai island, indicated in Figure 1.1.

Figure 1.1: Service Area Map

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2 Methods

The starting point for this needs assessment is a summary of secondary or core indicator data, which applies a systematic and quantitative method of comparing the relative severity of health indicators across 20 topic areas. When possible, other data are considered, including rates of hospitalization due to preventable causes, to more closely examine the most severe health needs and their impact on health care utilization. The secondary data findings are further informed by collected primary data. Individuals with special knowledge regarding the health needs of the community, including those with expertise in public health and community health, were interviewed through a key informant interview process. An online survey collected additional opinions from community residents. The quantitative, secondary data is then combined with the knowledge of key informants who have awareness of health needs specific to their community and highlighted with resident opinions on community health concerns. 2.1 Core Indicator Summary 2.1.1 Data Sources The core indicators included in this summary originated from Hawaii Health Matters (www.HawaiiHealthMatters.org), a publicly available data platform with a dashboard of over 100 indicators from over 20 sources. Hawaii Health Matters (HHM) was developed as a partnership between Hawaii Health Data Warehouse and Hawaii Department of Health, with technology provided by Healthy Communities Institute. The core indicators cover health outcomes, behaviors that contribute to health, and other factors that are correlated with health. The secondary data available on HHM is continuously updated as sources release new data. Data specific to Molokai was provided by the Hawaii Department of Health or calculated from census tract values from national data sources, when possible. Each eof th indicators was categorized into one of 20 topic areas, spanning both health and quality of life issues. All indicators, including measurement date, sources and topic area assignment, are included in the Appendix of this report. 2.1.2 Comparisons: Analytic Approach The status of Molokai was assessed one indicator at a time using up to four comparison methods. 1. First, Molokai was compared geographically, to the rest of the State of Hawaii. If the Molokai value was worse than the state value, the geographic comparison was considered poor. 2. The second comparison examined the trend of the data. If more than one value was available, the percent change per year was calculated. If Molokai’s indicator value had worsened by at least 2.5% of the baseline value per year, the trend for the indicator was considered poor. 3. A third comparison measured disparities among sub‐populations in Molokai. If one sub‐ population had a value at least two times worse than another for the indicator, then the disparity measurement was considered poor. If only a single sub‐population value was available due to data suppression of low counts, the disparity measurement was considered epoor if th value was at least 50% worse than the average value for Molokai. 4. Finally, the indicator value was compared to nationally recognized Healthy People 2020 (HP2020) benchmarks. The indicator was considered poor if Molokai had not yet met the target set by the federal Health and Human Services agency.

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Figure 2.1: Comparison Methods As many comparisons as possible were applied to each indicator. The possible comparisons varied for each indicator depending on the availability of data. Geographic comparisons were only possible when state data was available for the same indicator and time period. Trend comparisons were only possible when at least two periods of measure were available. The availability of sub‐ population data varied by indicator, and so disparity comparisons were incorporated whenever possible. Finally, HP2020 benchmarks only exist for a subset of the indicators included in the summary. Please see Appendix A for more details and examples of this process.

2.1.3 Indicator and Topic Area Scoring After the status of all possible comparisons was assessed, indicators were aggregated into their respective topic areas. The total number of poor comparisons was divided by the total possible comparisons within the topic area to calculate the topic area score. This score, measuring the proportion of poor comparisons within the topic, ranges from zero to one. Scores were not calculated for topic areas that had one or zero indicators, as these areas were deemed to lack an adequate number of indicators. Please see Appendix A for more details and an example of this process. 2.1.4 Shortage Areas The Health Resources and Services Administration (HRSA) develops shortage designation criteria and uses them to decide whether or not a geographic area, population group or facility is a Health Professional Shortage Area or a Medically Underserved Area or Population. Molokai currently has the following designations: • Medically underserved area • Primary health care professional shortage group area • Mental health professional shortage area Criteria for medically underserved areas and populations can be found at: http://bhpr.hrsa.gov/shortage/muaps/index.html Criteria for health professional shortage areas can be found at: http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/designationcriteria.html

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2.2 Hospitalization Rates Risk‐adjusted hospitalization rate indicators were provided by Hawaii Health Information Corporation (HHIC). The indicators are defined by the Agency for Healthcare Research and Quality (AHRQ) as a set of measures that can be used to identify quality of outpatient care that can potentially prevent the need for hospitalization. Risk adjustment attempts to account for differences in indicators across providers and geographic areas that are attributable to variations in patient mix. AHRQ’s risk adjustment methodology employs multivariate ordinary least squares regression to estimate an expected value of each indicator an area would exhibit with an “average” case‐mix. The model adjusts for patient demographics, including age, sex, all age‐sex combinations, All‐Payer Refined DRGs (a refinement of CMS’s DRGs that additionally classifies non‐Medicare cases) and severity‐of‐illness. HHIC applies AHRQ’s risk adjustment methodology to further control for the top four dominant races in Hawaii, as determined by the Hawaii State Department of Health’s Hawaii Health Survey. Risk adjustment coefficients are estimated using the Healthcare Cost and Utilization Project’s (HCUP) State Inpatient Databases (SID). Please see http://qualityindicators.ahrq.gov/Modules/pqi_resources.aspx for a complete definition of indicators. Due to the small population and case counts in Molokai, hospitalization rates for causes defined by the AHRQ preventable causes of admission are aggregated into composite rates. The following causes are included in each composite rate presented in this report: PQI Composite – Dehydration, Bacterial Pneumonia, Urinary Tract Infection Acute Conditions Short‐term Complications of Diabetes, Long‐term Complications of PQI Composite – Diabetes, Uncontrolled Diabetes, Rate of Lower‐extremity Amputation, Chronic Conditions COPD or Asthma in Older Adults (ages 40+), Asthma in Younger Adults (ages 18‐39), Hypertension, Heart Failure, and Angina without Procedure PQI Composite All causes listed above Because the area of mental health was not well represented in the Core Indicator Summary, HHIC also provided unadjusted rates of hospitalization for any mental health‐related primary diagnosis. HHIC provided unadjusted hospitalization rates by age and gender sub‐populations for each indicator. Unadjusted rates are not compared to state or county values due to uncertainties in the comparability of the respective populations. Counts for age and gender sub‐populations are used to compare the proportion of hospitalizations attributed to each group relative to the proportion of Molokai’s population represented by the group. All rates are based upon patient residence, and values were suppressed if there were fewer than 10 cases. Population estimates are based on the U.S. Census Bureau, Population Division, Intercensal Estimates of the Resident Population for Counties of Hawaii and Hawaii State Department of Health, Office of Health Status Monitoring, Hawaii Health Survey. Sub‐county demographic counts are based on estimates/projections provided by Pitney Bowes Business Insight, 2008‐2011. Please see Appendix B for a table of all hospitalization rates for Molokai along with the corresponding state value for comparison. 2.3 Key Informant Interviews In order to supplement the quantitative findings, key informants were interviewed to further assess the underlying drivers for health outcomes, current community efforts, and obstacles to health. These key informants were chosen by the HAH Advisory Committee on November 7‐8, 2012 through a structured

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nomination and selection process, which followed a thorough review of the preliminary core indicator data for Maui County. Advisory members nominated community members with expertise in public health, in the top ten topic areas from the core indicator analysis, and in those topic areas where there were data gaps. Key informants were also nominated for their knowledge of vulnerable populations, such as low‐income or more adversely impacted racial/ethnic groups. After the nomination process, the advisory members prioritized the list through a voting process.

The key informant interview process was part of a larger statewide CHNA effort in which a total of 105 community experts were nominated, then prioritized down to a list of 75. The remaining 30 nominated key informants were maintained on an alternate list, in the event that a key informant was not available. Roughly 15 key informants were allotted for each of the four counties and for the overall state perspective. For Maui County, 11 key informants were interviewed for their specific knowledge of the health needs within the county; four of these informants represented Molokai. Some findings from state perspective interviews were included when relevant for Molokai.

The Maui County interviews were conducted by local consultants, Storyline Consulting. The interviews took place between November 19, 2012 and January 2, 2013 and lasted 30‐60 minutes in length. Storyline subcontracted most Molokai interviews to Ka Honua Momona International, which has existing relationships with many of the local key informant nominees. Most interviews took place by phone; a few took place in person. Storyline Consulting typed notes from the interviews during the conversation, capturing the bulk of the conversation verbatim. Interview notes were then condensed and entered into a data collection spreadsheet.

The information obtained from these interviews was incorporated into this report in three ways. A summary qualitative analysis tool called a “word cloud” was produced using TagCrowd.com to identify the most common themes and topics. Words or phrases that were mentioned most often display in the word cloud in the largest and darkest font (see Figure 3.16). Next, input from the key informants was included in each relevant topic area in Section 3.2. If available, information specific to the health of Molokai residents is listed in the first section of each interview summary table; information gathered on the general population of Hawaii for each topic area is also presented in the tables. Any recommended community programs or resources are included in the last column titled “Opportunities/Strengths.”

A Key Informant Interview Guide was developed to guide the interviews. Storyline Consulting adapted the interview guide to best suit Hawaii’s context, unique ethnic/racial profile, and culture. The questions used in the guide are listed below:

Q1: Could you tell me a little bit about yourself, your background, and your organization?

Q2: You were selected for this interview because of your specialized knowledge in the area of [topic area]. What are the biggest needs or concerns in this area?

Q3: What is the impact of this health issue on low income, underserved/uninsured persons?

Q4: Could you speak to the impact on different ethnic groups of this health concern?

Q5: Could you tell me about some of the strengths and resources in your community that address [topic area]?

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Q6: Are their opportunities for larger collaboration with hospitals and/or the health department that you want us to take note of?

Q7: What advice do you have for a group developing a community health improvement plan to address these needs?

Q8: What are the other major health needs/issues you see in the community?

Q9: Is there anything else you’d like us to note?

2.4 Community Survey An online survey was used to collect community opinions on the greatest health needs for Maui County. The survey link was virally distributed by members of the HAH Advisory Committee and was posted on several local websites, including www.HawaiiHealthMatters.org. The survey was open from November 28 to December 24, 2012. Because the survey sample is a convenience sample, it is not expected to be representative of the population as a whole. Survey respondents provided select personal characteristics, including gender, age, sex, and zip code of residence and whether or not the resident works in the health field. Responses that indicated a zip code residence on the Island of Molokai are included in this report. Molokai residents were asked to rank the top ten topic areas from the Maui County core indicator analysis in order of importance for their community, as well as informing us about other topic areas of concern. Respondents were also asked which racial/ethnic groups they felt experienced more health problems than average. Lastly, there was an open‐ended question asking the resident if there was anything else they would like to share with us, in terms of health concerns in their community. Opinions gathered with this survey are included in this report as highlights, called “Voices from the Community,” in describing notable areas of need.

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3 Community Health Needs Assessment Findings

3.1 Demographics The demographics of a community significantly impact its health profile. Different ethnic, age, and socioeconomic groups may have unique needs and take varied approaches to health. This section provides an overview of the demographics of Molokai, both island‐wide and by census tract. Figure 3.1 illustrates the census tracts located on the Island of Molokai and their respective population sizes as of 2006‐2010. In this report, “Western Molokai” refers to Census Tract 318.01 Figure 3.1: Census Tracts and Population on Molokai Island, of Maui County, “Eastern Molokai” 2006‐2010 refers to Census Tract 317 of Maui County, and Kalawao County refers to the entirety of Census Tract 319. Comparisons to the State of Hawaii are provided in this section for reference. All estimates are sourced from the U.S. Census Bureau’s American Community Survey unless otherwise indicated. 3.1.1 Population In 2010, Molokai Island had a total population of 7,345. As measured by the decennial Census, the Table 3.1: Population Density and Change island had a much lower population density than the State of Hawaii. Although the state’s overall population grew faster than the national average (9.7%) between 2000 and 2010, the population on Molokai Island decreased 0.8% over the decade. Within the island, the population of Kalawao County decreased the most drastically, at ‐38.8% over the decade.1 Figure 3.2: Population Change, 2000‐20101

1 2010 U.S. Census

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Age As seen in Figure 3.3, Molokai Island has a proportionally larger population of children under age 18 (26.1%) than the state overall (22.6%). However, Figure 3.4 shows that the age breakdown varies greatly across the island, with a much older population in Kalawao County. Figure 3.3: Population by Age: Molokai and Hawaii, 2006‐2010

Figure 3.4: Population by Age: Molokai Census Tracts, 2006‐2010

Racial/Ethnic Diversity Compared to the state, Native Hawaiians and Other Pacific Islanders constitute a much larger proportion of Molokai’s population, at 34.3% (contrasted with just 9.6% of the state). Native Hawaiians make up almost the entirety of this population, the largest race/ethnicity group on the island (see Figure 3.5 and Figure 3.6). The population on Molokai Island reporting a race of Asian only makes up just 15.4% of the population, less than half of the state’s 39.4%. Of the Asian population, two‐thirds are Filipino, as seen in Figure 3.7 (which includes all residents reporting a race of Asian only regardless of Hispanic/Latino ethnicity).

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White, Black/African American, Hispanic/Latino, and other race/ethnicity groups are also smaller than Hawaii overall. In Figure5 3. and Figure 3.8 below, the race groups displayed to the left of the blue line include residents reporting one race only, while residents reporting two or more races and Hispanic/Latino ethnicity (of any race) are shown to the right of this line.

Figure 3.5: Population by Race/Ethnicity: Molokai and Hawaii, 2006‐2010

Figure 3.6: Breakdown of Molokai Figure 3.7: Breakdown of Molokai Population Reporting Race of Population Reporting Race of Asian Native/Other P.I. Only, 2006‐2010 Only, 2006‐2010

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Within the island, Kalawao County has, proportionally, the largest White and mixed race populations and the smallest Native Hawaiian/Other Pacific Islander population.

Figure 3.8: Population by Race/Ethnicity: Molokai Census Tracts, 2006‐2010

Figure 3.9: Linguistic Isolation, 2006‐2010

A substantially lower percent of Molokai Island households were linguistically isolated compared to the state in 2006‐2010: just 2.1% of households reported that all of its members ages 14 and over had some difficulty speaking English, contrasted with 6.2% of households in Hawaii. Within the island, linguistic isolation is heavily concentrated in Kalawao County.

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3.1.2 Economy Figure 3.10: Per Capita Income, 2006‐2010 Per capita income in 2006‐2010 for Molokai was $23,662, lower than the state’s $28,882. Per capita income levels varied across the island, ranging from $18,281 in Western Molokai to $43,308 in Kalawao County (Figure 3.10). The island has higher levels of poverty than the state, at 17.8% compared to the state’s 9.6%. As with per capita income, Western Molokai is performing worse than the rest of the island on this economic indicator (Figure 3.11).

Figure 3.11: People Living in Poverty, 2006‐2010 Certain race/ethnicity groups are also more affected by poverty, as seen in Figure 3.12. Residents reporting a race/ethnicity of Other or Hispanic/Latino make up a nsmall portio of the island’s population (as seen in Figure 3.8 above), but experience high levels of poverty. The White, Black/African American, American Indian/Alaska Native, and mixed race population have lower levels of poverty than average on the island. However, it is important to note that federal definitions of poverty are not geographically adjusted, so the data may not adequately reflect the proportion of Hawaii residents who struggle to provide for themselves due to the high cost of living in the state.

Figure 3.12: Poverty by Race/Ethnicity, 2006‐2010

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3.1.3 Education Figure 3.13: Educational Attainment: Molokai A lower percentage of Molokai Island Census Tracts, 2006‐2010 residents ages 25 and older have at least a high school degree (86.7%) compared to the state (89.8%). The proportion of island residents who have at least a bachelor’s degree (22.0%) also falls short of the state’s 29.4%.

3.2 Overview of Needs Assessment Secondary Data Summary Fifty‐five indicators of health drivers and outcomes were included in the systematic review of secondary data. Table 3.2 shows the weighted ranking scores for each topic area, from most severe to least. Table 3.2: Core Indicator Summary Scores Topic Area Indicators Score Rank Substance Abuse & Lifestyle 2 0.86 1 Respiratory Diseases 2 0.80 2 Injury Prevention & Safety 3 0.80 2 Economy 9 0.71 4 Education 2 0.67 5 Family Planning 2 0.67 5 Cancer 5 0.59 7 Oral Health 5 0.58 8 Exercise, Nutrition, & Weight 6 0.53 9 Heart Disease & Stroke 4 0.50 10 Immunizations & Infectious Diseases 2 0.50 10 Mental Health & Mental Disorders 2 0.50 10 Maternal, Fetal & Infant Health 4 0.43 13 Transportation 3 0.40 14 Access to Health Services 2 0.29 15 Diabetes 1 n/a n/a Social Environment 1 n/a n/a Disabilities 0 n/a n/a Older Adults & Aging 0 n/a n/a Environment 0 n/a n/a

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The ranking of scores for the topic areas provides a systematic way to assess a large number of indicators across many topic areas. Because the absolute and relative scores are influenced by the number of available inputs for the scoring equation, scoring differences can arise due to availability of data, so it is important to consider the scores in the context of the primary data and the interrelatedness of many of the topic areas. Findings of both quantitative and qualitative nature are presented below by topic area, along with a discussion of what can be learned from these results. For a complete list of indicators included in the core indicator summary, see Appendix A. Hospitalization Rates Risk‐Adjusted Composite Hospitalization Rates due to Preventable Causes in Molokai for the most recent year available, 2011, are presented in Table 3.3. Prevention Quality Indicator (PQI) Composite Rates are a summary of preventable causes as described in the table footnote. All hospitalization rates are listed in Appendix B. Table 3.3: Composite Hospitalization Rates due to Preventable Causes in Molokai, 2011 Risk‐Adjusted Rate per 100,000 Composite Hospitalization Rates Hospitalizations (95% CI) PQI Composite – Acute Conditions* 11 172.2 (70.4‐274.0) PQI Composite – Chronic Conditions** 30 470.9 (302.4‐639.4) PQI Composite*** 41 642.9 (446.1‐839.7) * Includes hospitalizations due to dehydration, bacterial pneumonia, and urinary tract infection **Includes hospitalizations due to short‐term complications of diabetes, long‐term complications of diabetes, uncontrolled diabetes, rate of lower‐extremity amputation, COPD or asthma in older adults (ages 40+), asthma in younger adults (ages 18‐ 39), hypertension, heart failure, and angina without procedure ***Includes all causes listed for acute and chronic composite rates Compared to the State of Hawaii and Maui County, Molokai had lower rates of preventable hospitalizations for both acute and chronic conditions. Figure 3.14: PQI Composite Hospitalization Rates, 2011

Although making up only 22.3% of Molokai’s population, residents ages 65 and older made up for 78.4% of preventable hospitalizations for acute conditions and 58.3% of preventable hospitalizations for chronic conditions in 2009 through 2011. The breakdown of acute hospitalizations by gender (males: 52.9%; females: 47.1%) closely resembled the population distribution, while chronic hospitalizations were disproportionately made up of females (61.1%).

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Figure 3.15: Percent of Hospitalizations by Age Group and Gender, 2009‐2011

Key Informant Interviews The word cloud below illustrates the needs mentioned most often by the key informants whose interviews were included in this CHNA analysis, where the size and shading of the word reflects the frequency of its use. The concerns include both those pertaining to the informants’ specific areas of expertise, as well as other issues they see in the community as a whole. Interviews are summarized by the topic area covered by the interviewees’ expertise in sections 3.2.1 through 3.2.20. Figure 3.16: Key Informant Interview Word Cloud

Community Survey During the period of November 28 to December 24, 2012, 20 surveys were completed online by Molokai residents. Of these, 80% were female, 20% male. As the survey was a convenience sample, it was not expected to be representative of the population as a whole. Of respondents, 45% were between the

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ages of 45 and 64; 20% were between the ages of 35 and 44; 35% were 65 or older; and no respondents were younger than 35. 40% of respondents were Community Health or Public Health Professionals.

Highest Ranked Topic Areas From the topics that scored highest Other Areas of Concern • Access to Health Services in the core indicator data summary • Cancer • Education for Maui County, Molokai residents • Diabetes • Substance Abuse & ranked the topic areas to the left • Older adults & Aging Lifestyle highest. • Exercise, Nutrition, & • Heart Disease & Stroke From the topic areas that did not Weight • Mental Health & Mental score high based on Maui County • Economy Disorders core indicator data, five were • Disabilities selected as also being a concern by • Environment at least 50% of Molokai respondents.

Nearly all respondents identified Native Hawaiians as experiencing more health problems than average. Please see highlights throughout this report of respondent opinions titled “Voices from the Community.” Figure 3.17: High‐Risk Race/Ethnicity Groups Identified through Community Survey

The sections below, 3.2.1 – 3.2.20, will describe the findings by topic area in the following format: Core Indicators and Supplemental Information The need in the topic area is first described with the poor comparisons found in the core indicator analysis. For all topics with at least one core indicator, highlights are followed by a table including the indicators, most recent value, and how Molokai fared across ther fou comparison methods. Green checkmarks indicate that the comparison was good, red X’s indicate a poor comparison, and a blank cell indicates no comparison was possible. Further information about core indicators is included in Appendix A. When possible, data is supplemented by hospitalization data and additional information obtained from previous needs assessments and reports.

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Key Informant Interviews The information gleaned from key informants who were interviewed for their expertise in the relevant topic area is summarized in a table. Main points made by interviewees are organized by the needs and concerns for Molokai; the impact on low‐income, underserved or uninsured, and/or race or ethnic groups; and the opportunities and strengths that they have identified in their community. Findings from interviews specific to Molokai are distinguished from those with a statewide perspective with a table sub‐header. Summary All findings are summarized for the topic with a focus on common themes.

3.2.1 Access to Health Services Core Indicators and Supplemental Information There were two poor comparisons in this area: • In 2006‐2010, more adults had no health insurance in Molokai (10.0%) compared to the state (8.4%) • Adults ages 35‐44 were the age group most likely to have no health insurance (13.8%), followed by adults ages 18‐24 (11.5%) and adults ages 45‐54 (10.4%) Table 3.4: Core Indicators – Access to Health Services

Molokai has been designated as a Medically Underserved Area by the Health Resources and Services Administration (HRSA), as well as a Primary Care Health Professional Shortage Group Area. Key Informant Interviews Needs/Concerns Impact on Low‐Income, Opportunities/Strengths Underserved/Uninsured, Race/Ethnic Groups Molokai

*Use of ER for non‐urgent visits *Colonization still has an effect on *Higher awareness of health issues drives up hospital costs Native Hawaiian people; the around smoking, exercise, healthy renaissance of Hawaiian language lifestyle *Need better access to services for and holding on to the cultural substance abuse and victims of *Strong connection to cultural practices are important and can’t be domestic violence on Molokai values on Molokai; ability of overlooked community to identify needs, come *Elderly population need long‐term *Impacts on underserved include together and fill them; it is a care services on Molokai teen pregnancy, obesity, tooth community that really cares and is *Huge problem with kupuna care, decay, diabetes, alcohol, smoking passionate including access to specialists and and substance abuse recruitment and retention of

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providers *Integrated health model would be helpful; need better electronic records and access to information and tracking data so we can see if we’re doing a better job *No pediatrician on island *Lack of education to inform community of what's available *Shortage of specialty services

State of Hawaii

*Rural areas lack critical care units *Transportation is an issue‐‐how do that can respond quickly; hospitals you get patients to hospitals that not equipped to handle array of have capacity? concerns

Summary Access to health services is a particular challenge for Molokai. The shortage of healthcare providers has been recognized by HRSA with the designation of the island as medically underserved and having a shortage of primary care providers. Specialty care in Voices from the Community Molokai is also extremely limited, and key informants state that recruitment and retention of specialty physicians is difficult. “[One community need is] Residents living in poverty face additional difficulty with access to specialists or transportation and poor health outcomes. The strong community transportation to other spirit of Molokai is an asset that may prove beneficial in improving islands.” access to services for all residents of Molokai.

3.2.2 Cancer Core Indicators and Supplemental Information Molokai compared poorly to the state values for all available cancer indicators: • In 2006‐2010, only 62.3% of Molokai women ages 40 and older had a mammogram in the previous two years, compared to 77.5% of all women in the state. The HP2020 target for mammogram history (81.1%) is unmet • The breast cancer death rate was higher in Molokai in 2006‐2010 (33.4 deaths/100,000 population) versus the state rate (19.6 deaths/100,000 population); the rate was especially high among Native Hawaiians or Other Pacific Islanders (113.6) • Of women 18 and older, a lower proportion had a pap test in the previous three years in Molokai (74.7%) compared to all women in the state (79.8%). The HP2020 target for pap test history (93.0%) is unmet • Of adults ages 50 and older, the proportion that had a blood stool test in the past two years decreased from 30.1% in 2001‐2005 to 22.1% in 2006‐2010 and is lower than the state value (27.4%)

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• The death rate due to colon cancer was higher in Molokai (18.1 deaths/100,000 population) than the state (17.0) in 2006‐2010, and was especially high among Asians (45.6) Table 3.5: Core Indicators – Cancer

Key Informant Interviews Needs/Concerns Impact on Low‐Income, Opportunities/Strengths Underserved/Uninsured, Race/Ethnic Groups State of Hawaii

*Increasing aging population means *Cancer treatment centers are *American Cancer Society provides increased number of people concentrated on Oahu and are materials in Spanish, Tagalog, and diagnosed with cancer costly to access from other islands Ilocano *Obesity is a big issue because we *People with lower incomes and know there is a link between lack of less education will be hardest hit good nutrition and cancer with cancer for a variety of reasons, and care provision needs to be altered to reach them *Need personal health managers to help people follow up with appointments and treatments

Summary The cancer burden in Molokai can be lessened with improved screening and health behaviors. Cancer screening for women has not met national targets, and colon cancer screening has decreased in recent years. Reducing obesity may help to lower the future burden of cancer. The higher breast cancer death rate andn colo cancer death rate in Molokai indicates that the cancer burden is greater here than for Hawaii overall. Furthermore, the concentration of treatment centers on Oahu makes accessing specialty care difficult and costly for Molokai residents. 3.2.3 Diabetes Core Indicators and Supplemental Information One core indicator measured diabetes prevalence among adults in Molokai:

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• A higher proportion of Molokai adults have been diagnosed as having diabetes (10.3%) compared to the state (8.2%) • Diabetes prevalence increased from 9.0% in 2001‐2005 and was higher than average, as of 2006‐ 2010, among the following groups of adults: ages 45‐54 (15.4%), ages 55‐64 (15.4%), ages 65‐74 (17.9%), ages 75 and older (18.8%), Filipinos (16.0%), Japanese (14.5%), and Native Hawaiians (10.7%) Table 3.6: Core Indicators ‐ Diabetes

Key Informant Interviews Needs/Concerns Impact on Low‐Income, Opportunities/Strengths Underserved/Uninsured, Race/Ethnic Groups Molokai

*Grant funding has allowed for dialysis program; treatment provided on the island is now less stressful on patients

State of Hawaii

*National trend is that 1:3 children *Native Hawaiians have a higher *Work with American Heart and will have Type II diabetes; in Hawaii, rate of diabetes, and those living in American Cancer Associations to much higher rate of 1:2 children rural areas have little access to combat obesity specialists *Childhood obesity will lead to *Ask legislature to put physical diabetes becoming an even bigger *Higher prevalence for diabetes education back in schools problem in the future; the amount among Native Hawaiians, other of resources spent on diabetes will Pacific Islanders, Japanese, and double Filipinos and we have such a blend of those bloodlines in Hawaii *Diabetes is going undiagnosed in many Hawaii residents *Difficulties in translating messages to Samoan and other Pacific Island

languages *Education and outreach efforts to Molokai is a challenge

Summary The prevalence of diabetes in Molokai currently affects a large number of adults and is likely to increase in severity due to poor nutrition and activity habits (see Section 3.2.8, Exercise, Nutrition & Weight). Diabetes prevalence is highest among Filipino, Japanese, and Native Hawaiian residents in Molokai and

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is projected to increase if childhood obesity is not controlled. Reducing the impact of diabetes in Molokai will require universal and effective primary care management of those with disease and preventing new disease by combatting obesity through a multi‐level approach that can effectively include, schools, employers, city planning, and community based organizations that promote physical activity across generations.

3.2.4 Disabilities There was no data included in the core indicator summary specific to disabilities (please see Section 4.1.2 for a discussion on data gaps). One consideration of this needs assessment should be the identification of two priorities for children with special health care needs in a recent statewide needs assessment of Maternal and Child Health Needs:2 • Promote the identification of children with developmental delay • Promote the transition of adolescents with special health care needs to adult health care

3.2.5 Economy Core Indicators and Supplemental Information Nearly all economic indicators compared poorly for Molokai: • The proportion of Molokai residents living below poverty increased from 17.3% in 2005‐2009 to 17.8% in 2006‐2010 and was higher than the state poverty rate (9.6%) • By age, the highest poverty rates in Molokai were among children less than 6 years of age (47.7%), children 6‐11 years old (25.9%), and adolescents 12‐17 years old (19.1%). By race/ethnicity, poverty rates were highest for those of “other” race (56.1%), Hispanic or Latino ethnicity (33.4%), Native Hawaiian or Other Pacific Islander descent (24.3%), and Asian descent (18.0%) • Per capita income was lower in Molokai ($23,666) compared to the state ($28,882); by race/ethnicity, per capita income was lowest for those of “other” race ($5,888), two or more races ($12,898), Hispanic or Latino ethnicity ($13,088), and Native Hawaiian or Other Pacific Islander descent ($13,927) • The proportion of households with cash public assistance income was higher in Molokai (7.6%) compared to the state (3.3%) and the homeownership rate was lower (46.9% in Molokai v. 51.2% in the state) • Unemployment in Molokai increased from 9.9% in 2005‐2009 to 13.6% in 2006‐2010 and was higher than the state value (5.6%)

2 From the Family Health Services Division, Hawaii Department of Health Report: State of Hawaii Maternal & Child Health Needs Assessment Summary, November 2010. http://hawaii.gov/health/doc/MCH‐NASummary2010

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Table 3.7: Core Indicators – Economy

Within the island, the poverty rate is highest in Western Molokai and lowest in Kalawao County3. Figure 3.18 Percent of Population Living Below Poverty3

Map created with Community Issues Management tool: http://www.cim‐network.org/CIM/ Key Informant Interviews Although no key informants were interviewed specifically for their knowledge on the economy of Molokai, the effects of poverty on health were mentioned in several interviews spanning many topics. Please see a discussion of the impact of socioeconomics in Section 4.1.

Summary Molokai’s economy is a driving force of community health, along Voices from the with education and the social environment. The economy was Community mentioned many times by key informants for its relevance to patterns of health access, health behaviors, and health outcomes. “[One community concern The necessity of addressing the health needs and quality of life is] affordable housing and issues of the 1,352 persons who have income below the federal the high cost of utilities.” poverty level4 is critical in order to realize a healthy community.

3 U.S. Census, American Community Survey, 2006‐2010 Estimates 4 U.S. Census, American Community Survey, 2006‐2010 Estimates

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Furthermore, because federal definitions of poverty do not adjust for geographic variations in the cost of living, the data likely does not adequately reflect the proportion of residents who struggle to provide for themselves due to the high cost of living in Hawaii.

3.2.6 Education Core Indicators and Supplemental Information Core indicators include two measures of education among adults: • The proportion of adults ages 18 and older without a high school degree was higher in Molokai (5.5%) compared to the state (5.3%) in 2006‐2010, and was particularly high among adults ages 75 years and older (19.1%), ages 65‐74 (8.6%), ages 18‐24 (6.5%), ages 25‐34 (5.7%), Filipino adults (8.0%), and Native Hawaiian adults (6.6%) • The proportion of adults ages 25 and older with a Bachelor’s degree in 2006‐2010 was lower in Molokai (22.0%) compared to the state (29.4%) and was lowest among adults ages 25‐34 years (13.8%), ages 45‐64 (18.8%), ages 35‐44 (21.5%), Native Hawaiian or Other Pacific Islander adults (8.6%), adults of two or more races (9.4%), and Hispanic or Latino adults (17.6%) Table 3.8: Core Indicators – Education

Key Informant Interviews Needs/Concerns Impact on Low‐Income, Opportunities/Strengths Underserved/Uninsured, Race/Ethnic Groups Molokai

*Molokai education needs are not *Low‐income students at UH, *On Molokai, people work together always met because of rurality Molokai Education Center to maximize a grant, project, sometimes lack appropriate meeting, or event *University of Hawaii (UH), Molokai preparation for college; back‐ Education Center not able to offer *Molokai Middle School excelling, tracking to help them with basic all classes to complete some winning awards skills is frustrating for students degrees; hoping to expand facilities, but must await funding; hard to *Cultural and language issues for keep someone employed full‐time Native Hawaiians given small population *Education programs are grant‐ based; when funding is interrupted some good programs end

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Summary Measures among adults show that Molokai is behind the state in educational attainment, especially among Filipino and Native Hawaiian/Pacific Islander adults. The disparity in education may be a result of unmet needs for youth; interruptions in grant funding interfere with the continuity of successful programs. Although Molokai Middle School thrives, key informants feel that Molokai students are not well prepared for college upon high school completion. Secondary education is further challenged by the difficulty in securing funding for facilities and staff.

3.2.7 Environment Core Indicators and Supplemental Information There was no data included in the core indicator summary specific to the natural environment of Molokai (please see Section 4.1.2 for a discussion on data gaps). In a document prepared by Molokai residents defining local visions and goals for the island,5 several environmental priorities were outlined including reforestation, watershed protection, soil reclamation, and development of renewable energy sources. Summary Despite the lack of readily available data on Molokai’s environment, this treasured asset of the island is a great concern for residents. All future community planning efforts should take care to maintain stewardship of Molokai’s environment. Air and water quality has the strongest health effect on the most vulnerable in the community, including children and older adults.

3.2.8 Exercise, Nutrition & Weight Core Indicators and Supplemental Information Several indicators demonstrate a need for improving physical activity and diet in Molokai: • While 19.2% of Molokai adults did not engage in physical activity between 2001‐2009, this proportion was highest among adults ages 75 years and older (29.1%), ages 45‐54 (25.4%), ages 55‐ 64 (20.6%), ages 35‐44 (20.5%), Filipino adults (31.3%), and Japanese adults (25.3%) • The percent of adults in Molokai who are obese increased from 31.0% in 2001‐2005 to 37.9% in 2006‐2010; the obesity rate was higher than the state value (22.3%) and had not met the HP2020 target of 30.6% • Only 27.6% of Molokai adults have a healthy body weight (compared to 40.3% among all adults in Hawaii); subpopulations with the lowest rates of healthy body weight include adults ages 45‐54 (19.5%), ages 35‐44 (22.1%), ages 25‐34 (25.9%), and Native Hawaiian adults (14.0%)

5 Molokai: Future of a Hawaiian Island, 2008. http://molokai.org/fileadmin/user/pdf/molokai.pdf

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Table 3.9: Core Indicators – Exercise, Nutrition & Weight

Furthermore, a recent statewide needs assessment of Maternal and Child Health Needs identified reducing the rate of overweight and obesity in young children ages 0‐5 as a priority for children in the state.6 Key Informant Interviews Needs/Concerns Impact on Low‐Income, Opportunities/Strengths Underserved/Uninsured, Race/Ethnic Groups State of Hawaii

*Kids are getting driven to structured activities instead of playing outside *Parents don’t have time to cook at home and end up eating less healthy but faster food *Food is an important component of many cultural events, but many times the food being served is unhealthy

Summary Given its large impact on health outcomes, Molokai residents would benefit from improved exercise patterns, eating habits, and weight control. Data shows that the prevalence of obesity among Molokai adults is increasing, and key informants note that changing patterns in family life are resulting in unhealthy eating habits and lower activity levels among children.

6 From the Family Health Services Division, Hawaii Department of Health Report: State of Hawaii Maternal & Child Health Needs Assessment Summary, November 2010. http://hawaii.gov/health/doc/MCH‐NASummary2010

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3.2.9 Family Planning Core Indicators and Supplemental Information Two core indicators demonstrate a need for family planning services in Molokai: • The teen birth rate was higher in Molokai (42.9 births/1,000 women aged 15‐19) than the state (39.9) in 2006‐2010; the rate was very high among Native Hawaiian and Other Pacific Islanders (200 births/1,000 women aged 15‐19) • In 2006‐2010, more infants in Molokai were born to mothers with less than 12 years of education (14.6%) compared to the state (8.9%); by maternal age the rate is highest among 15‐19 year old mothers (44.4%) Table 3.10: Core Indicators – Family Planning

Furthermore, a recent statewide needs assessment of Maternal and Child Health Needs identified reducing the rate of unintended pregnancy (including a focus on teen pregnancy) as a priority for women and infants.7 Summary Evidence is strong that Molokai needs improvement in the area of family planning. The high proportion of births to mothers with less than 12 years of education is problematic, as there is a strong relationship between parents’ educational attainment and poverty, literacy, and educational attainment rates for children. The particularlyh hig teen birth rate among Native Hawaiians in Molokai signals that there are cultural factors influencing family planning. Providing effective sex education and ensuring access to affordable contraceptives are vital steps towards improving this area.

3.2.10 Heart Disease & Stroke Core Indicators and Supplemental Information Measures of heart health in Molokai include several poor comparisons: • A larger percentage of adults had high blood pressure in Molokai (31.0%) in 2001‐2009 compared to the state (26.2%); the rate was particularly high for adults ages 55‐64 (49.9%), ages 65‐74 (47.5%), ages 75 years and older (42.3%), and ages 45‐54 (39.0%) • While 32.4% of adults in Molokai had high cholesterol in 2001‐2009, the rate was even higher for adults ages 65‐74 (53.2%), ages 55‐64 (43.8%), and ages 75 years and older (43.3%) • Based on 2001‐2009 data, Molokai has not met HP2020 targets for high blood pressure prevalence (26.9%) or high cholesterol prevalence (13.5%)

7 From the Family Health Services Division, Hawaii Department of Health Report: State of Hawaii Maternal & Child Health Needs Assessment Summary, November 2010. http://hawaii.gov/health/doc/MCH‐NASummary2010

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• Although lower than the state value (103.9 deaths/100,000 population), the 2006‐2010 coronary heart disease death rate in Molokai (92.9) was highest for men (129.4) and Native Hawaiian or Other Pacific Islander adults (194.7 deaths/100,000 population) Table 3.11: Core Indicators – Heart Disease & Stroke

Key Informant Interviews Needs/Concerns Impact on Low‐Income, Opportunities/Strengths Underserved/Uninsured, Race/Ethnic Groups State of Hawaii

*Need to look toward primary *Storytelling is an important way of *A lot of resources are available, it’s prevention and wellness, developing communicating among the Pacific a matter of leveraging and awareness and healthy habits Island populations, and health collaborating information should be shared with *Ability to collaborate when this in mind everyone brings their strengths, *Access to technology and resources, expertise, and knowledge computer illiteracy may be barriers to the table to utilizing online tools

Summary Driven by the poor health behaviors chronicled throughout this report, heart disease is an area of health that needs improvement in Molokai. Although some core indicators compare favorably to the state, Native Hawaiians have a very high death rate due to heart disease (and it should be noted that data suppression may be masking other groups with high values). Of all death rates included in the core indicator summary, the coronary heart disease death rate was exceedingly high in Molokai. Key informants attribute at least some of the disparity in heart disease to cultural factors and unhealthy behaviors, and recommend focusing efforts towards improvement in this area on preventative measures.

3.2.11 Immunizations & Infectious Diseases Core Indicators and Supplemental Information Vaccination rates among older adults need improvement in Molokai:

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• A lower proportion of adults ages 65 and older were vaccinated for influenza in Molokai (71.1%) compared to the state (75.4%) in 2006‐2010; the HP2020 target for influenza vaccination (90.0%) is not met • A lower proportion of adults ages 65 and older were vaccinated for pneumonia in Molokai (64.9%) compared to the state (67.0%) in 2006‐2010; the HP2020 target for pneumonia vaccination (90.0%) is not met Table 3.12: Core Indicators – Immunizations & Infectious Diseases

Summary While core indicators show that vaccination rates among older adults are significantly lower in Molokai compared to the rest of Hawaii, barriers to immunization may affect all Molokai residents. The transportation and access issues outlined throughout this report are prohibitive to providing vaccines to Molokai’s rural communities. The unavailability of data for Molokai regarding sexually transmitted infections, tuberculosis, and other communicable illnesses prevalent in Hawaii limits the assessment of the burden of infectious disease on the island.

3.2.12 Injury Prevention & Safety Core Indicators and Supplemental Information Injury related death rates indicate that this area is a concern for Molokai: • The motor vehicle collision death rate was higher in Molokai in 2006‐2010 (15.7 deaths/100,000 population) than the state (9.7) and had not met the HP2020 target (12.4); the rate among men (32.1) was over twice the overall rate • The death rate due to unintentional injuries increased from 30.3 deaths/100,000 population in 2001‐2005 to 48.3 deaths/100,000 population in 2006‐2010; although the unintentional injury death rate had met the HP2020 target (53.3), it remained higher than the state value (34.5) sand wa very high among men (85.6) • The death rate due to all injuries was higher in Molokai (62.0 deaths/100,000 population) than the state (53.8) in 2006‐2010 and was particularly high for men (108.9)

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Table 3.13: Core Indicators – Injury Prevention & Safety

Summary A large number of accidental deaths could be prevented by improving safety measures in Molokai. The injury death rate was the second highest death rate among all causes included in the core indicator summary. Injury, unintentional injury, and motor vehicle collision deaths are more common in Molokai compared to the state. Additionally, falls among the elderly have been identified as a statewide priority (see Section 3.2.15, Older Adults & Aging). In planning interventions, issues that are common to rural areas of Hawaii should be considered, including transportation, substance abuse, and cultural factors that may increase the risk of injury deaths for Molokai residents.

3.2.13 Maternal, Fetal & Infant Health Core Indicators and Supplemental Information Several large age disparities were found in core indicators for maternal, fetal, and infant health: • In 2006‐2010, a higher proportion of mothers in Molokai received late or no prenatal care (20.7%) compared to the state (17.3%); the rate was highest among mothers ages 15‐19 (29.8%), ages 35‐44 (25.9%), and ages 20‐24 (23.4%) • Although the preterm birth rate in Molokai (9.2%) was lower than the state (10.6%), among mothers ages 15‐19 the rate was 16.3% • The percent of babies with low birth weight (7.1%) was lower than the state value (8.2%), but was highest among mothers ages 15‐19 (17.4%) • The percent of births delivered by Cesarean section increased from 13.9% in 2001‐2005 to 16.1% in 2006‐2010; the rate was highest for mothers ages 35‐44 (29.5%) and ages 15‐19 (17.4%) Table 3.14: Core Indicators – Maternal, Fetal & Infant Health

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Furthermore, a recent statewide needs assessment of Maternal and Child Health Needs identified reducing the use of alcohol during pregnancy as one of its priorities for Women and Infants.8 Key Informant Interviews Needs/Concerns Impact on Low‐Income, Opportunities/Strengths Underserved/Uninsured, Race/Ethnic Groups Molokai

*Successful midwives program on Molokai, started in response to no OB/GYNs, allows for births on island

Summary Although birth outcomes generally compare favorably to the state for the population of Molokai as a whole, babies born to young mothers are more likely to be born prematurely or underweight. Furthermore, the increasing proportion of cesarean births may be putting mothers and infants at risk of complications in instancese where th surgery is not necessary. As discussed in the Family Planning topic area (section 3.2.9), teen births are more common in Native Hawaiians and this group may be more impacted by the poor birth outcomes among young mothers. While the successful midwives program has allowed for mothers to give birth without having to travel to another island, lowering the teen birth rate and increasing prenatal care would further improve health for babies born on Molokai.

3.2.14 Mental Health & Mental Disorders Core Indicators and Supplemental Information There were two poor comparisons for the suicide death rate in Molokai: • The death rate due to suicides was over twice as high in Molokai in 2001‐2005 (20.4 deaths/100,000 population) compared to the state (9.8); among men, the suicide death rate was 36.1 deaths/100,000 males • The HP2020 target for suicide death rate (10.2 deaths/100,000 population) is unmet in Molokai Table 3.15: Core Indicators – Mental Health & Mental Disorders

8 From the Family Health Services Division, Hawaii Department of Health Report: State of Hawaii Maternal & Child Health Needs Assessment Summary, November 2010. http://hawaii.gov/health/doc/MCH‐NASummary2010

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A lack of services for mental health is a contributing factor to Molokai’s poor outcomes. The Health Resources and Services Administration designated Molokai as a mental health professional shortage area. Between 2009 and 2011, mental health accounted for 58 hospitalizations among Molokai residents. The mental health hospitalization rate per 100,000 fluctuated slightly by year (Figure 3.19). The majority of mental health admissions were among ages 18‐64 (84.5%), slightly more than the proportion of the population made up by this age group (77.7%). A disproportionate percentage of mental health admissions were for males (67.4%) compared to the percentage of residents in Molokai who are male (50.1%). Figure 3.20 presents the proportion of mental health hospitalizations by age group and gender. Because mental health hospitalization rates are not risk or age adjusted, the mental health admission rates are not compared across geographies due to uncertainties in varying population characteristics. All 2011 valuesd are include in Appendix B. Further data on mental health hospitalizations can be found in the State of Hawaii Primary Care Needs Assessment Data Book 2012.9

Figure 3.19: Mental Health Hospitalization Rates Figure 3.20: Percent of Mental Health Hospitalizations by Year by Age Group and Gender, 2009‐2011

Key Informant Interviews Needs/Concerns Impact on Low‐Income, Opportunities/Strengths Underserved/Uninsured, Race/Ethnic Groups State of Hawaii

*Highest needs in capacity are *Mental health stigma across *One opportunity is continuing to around acute psychiatric care, for cultures and ethnicities‐‐a lot of build capacity around statewide hospitals in rural areas and also on shame attached with behavioral tele‐access Oahu health.

9 Family Health Services Division, Hawaii Department of Health Report: State of Hawaii Primary Care Needs Assessment Data Book 2012, July 2012. http://hawaii.gov/health/doc/pcna2012databook.pdf

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*Lack of psychiatrists available to *Native Hawaiians have a lot of community complications due to access issues, social determinants of health *Need to integrate physical and mental health areas; increase *Micronesian new arrivals don't comfort level of our healthcare know how to access system system with addressing behavioral health needs

Summary The lack of adequate mental health care in Molokai has led to a great need in this area. The suicide death rate is much higher compared to the state, and a noteworthy number of hospitalizations (58) were attributed to mental health in 2009 through 2011. Barriers to mental health care include cultural stigmas and a lack of psychiatrists, which has been recognized with Molokai’s designation as a mental health provider shortage area. Those interviewed for this topic suggest integrating physical and mental health care and utilizing creative solutions such as tele‐access to bring mental health services to hard‐to‐ reach populations.

3.2.15 Older Adults & Aging Core Indicators and Supplemental Information Core indicators pertaining to older adults were included in other topic areas of this Figure 3.21: Unadjusted Composite Hospitalization Rates, report. Findings include: 2009‐2011 • Vaccination rates for influenza and pneumonia for adults 65 and older have not met Healthy People targets (Immunizations & Infectious Diseases, Section 3.2.11) • A larger percentage of adults 65 and older have had all of their natural teeth extracted (14.5%) compared to the state value of 9.6% (Oral Health, Section 3.2.16) Overall, most hospitalizations occurred among older adults between 2009 and 2011. The unadjusted hospitalization rates are much higher for adults aged 65 and older for both acute and chronic conditions. Key Informant Interviews Needs/Concerns Impact on Low‐Income, Opportunities/Strengths Underserved/Uninsured, Race/Ethnic Groups Molokai

*Chronically ill on Molokai that * Lack of transportation on Molokai, *The increase in communication need full‐time care have to move off gas prices are so high, if the between health agencies within the commute is too far they are less community is helping to maximize

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island for nursing care and homes likely to come to an appointment the resources *Need resources for senior citizens *The continuous paper work *A lot of people in Molokai want to and those who are not healthy needed to receive free insurance is help enough to live on their own hard to stay on top of and there is a need for more advocacy for support *All people should have optimal mental, physical, and spiritual *Filipino population definitely has a health language barrier and cultural differences *The cultural imbalance that has happened in Hawaii has big ramifications and seems to play a huge part in health disparities

Summary Health needs for seniors living on Molokai include improved vaccination coverage, dental care, and living assistance. Currently, there is not enough nursing care or nursing homes available on Molokai, and older adults with special care needs are often forced to Voices from the Community relocate. Older adults also need assistance with transportation and support in managing paperwork involved with receiving health care. “Molokai needs nursing Key informants cite the asset of community spirit among Molokai homes for our kupuna who residents, and propose increased communication between health need all kinds of services.” agencies within the community to maximize resources. Integration and coordination of physical and mental health care for seniors could help reduce the burden of managing advice and medications from multiple providers and more effectively deliver health services for this growing population.

3.2.16 Oral Health Core Indicators and Supplemental Information All oral health indicators for adults compare poorly to the state based on data for 2002 through 2010: • A lower percentage of adults had at least one dental cleaning in the prior year (64.8%) compared to the state (71.0%), and fewer adults visited a dentist or dental clinic for any reason in the prior year (66.5%) compared to the state (71.3%) • Among all adults, a higher proportion had one or more tooth extractions (49.7%) compared to the state (43.2%); among adults ages 45‐64, 62.1% had one or more tooth extractions (compared to the state value of 50.7%) • A larger percentage of Molokai adults 65 and older have had all of their natural teeth extracted (14.5%) compared to the state value of 9.6%; total tooth loss was most common in women (21.4%) and Whites (18.2%)

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Table 3.16: Core Indicators – Oral Health

Although no oral health indicators in the summary addressed children, a report by the Pew Research Center gave the State of Hawaii a grade of “F” for meeting only one out of eight benchmarks for key policy indicators. In The State of Children’s Dental Health: Making Coverage Matter,10 Hawaii compared poorly to the nation due to several factors, including: • Sealant programs were in place in 0% of high‐risk schools in 2010 • Optimally fluoridated water was provided to only 10.8% of citizens on community systems in 2008 • As of 2010, the Medicaid program does not reimburse medical care providers for preventive dental health services

Key Informant Interviews Needs/Concerns Impact on Low‐Income, Opportunities/Strengths Underserved/Uninsured, Race/Ethnic Groups Molokai

*Adults on Medicare should have dental coverage; state only covers teeth removal

Summary Given the large impact oral health has on overall health and well‐being, it is important that Molokai residents have access to and utilize preventative dental care. Both insurance coverage and access to dental care are necessary to maintain good oral health. Strengthening Medicaid coverage to include preventative dental care has potential for improving oral health. While children’s oral health has been noted to be poor statewide, unavailability of data specific to Molokai limits assessment of preventative care and education among Molokai’s youth.

10 From the Pew Research Center’s The State of Children’s Dental Health: Making Coverage Matter, May 2011. http://www.pewstates.org/uploadedFiles/PCS_Assets/2011/The_State_of_Childrens_Dental_health.pdf

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3.2.17 Re1piratory Diseases Core Indicators and Supplemental Information Asthma is an increasing concern for Molokai: • The proportion of adults who currently have asthma increased from 6.2% in 2001‐2005 to 11.5% in 2006‐2010 and is higher than the state value (8.9%); the age groups most likely to have asthma include ages 18),‐24 (16.4% ages 65‐74 (14.4%), and ages 45‐54 (13.6%) • Although a slightly lower proportion of children have current asthma in Molokai (11.6%) compared to the state (11.9%), the rate is higher among Native Hawaiian children (13.5%) Table 3.17: Core Indicators – Respiratory Diseases

Summary Asthma is more prevalent among adults in Molokai than the state average, and has been increasing over recent years. Subpopulations that are more affected by poverty, including Native Hawaiian residents, are also the most impacted by respiratory disease. Controlling asthma is particularly important for children, whose education can be negatively affected by the disease if the school environment is not able to provide asthma medication support.

3.2.18 Social Environment Core Indicators and Supplemental Information One core indicator measured the proportion of children living in single‐parent households: • In 2006‐2010, a much higher percentage of children in Molokai lived in single‐parent households (49.1%) compared to the state (29.0%); this value had increased in Molokai from 40.6% in 2005‐ 2009 Table 3.18: Core Indicators – Social Environment

Of further note, certain race/ethnicity groups are more affected by poverty, as seen in Figure 3.12.11

11 U.S. Census, American Community Survey, 2006‐2010 Estimates

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An additional consideration for the Social Environment is the inclusion of two priorities in a recent statewide needs assessment of Maternal and Child Health Needs:12 • Reduce the rate of child abuse and neglect with special attention on ages 0‐5 years • Prevent bullying behavior among children with special attention on adolescents age 11‐18

Key Informant Interviews Needs/Concerns Impact on Low‐Income, Opportunities/Strengths Underserved/Uninsured, Race/Ethnic Groups Molokai

*Need to get people working again *Lack of access to childcare for and out of poverty those in poverty

State of Hawaii

*Most chronic disease areas can be *Stress factor is incredibly high in traced back to lifestyle, education, terms of basic living, having enough and nutrition resources to just make it; stress factors lead to abusive situations, poor health *Compliance issues caused by lack of access to transportation *Societal priorities, things we value may not lend themselves to a healthy lifestyle *Native Hawaiians more likely to live in poverty and have social environment issues to confront

Summary Largely driven by economic insecurity, social issues such as unemployment, education, alcoholism, and domestic violence all influence a community’s health. The relatively high proportion of children living in single‐parent households and the lack of affordable childcare are examples of factors that limit opportunities for economic and social advancement in Molokai. Although measures of Molokai’s social environment are limited, the heavy impact that this topic has on health makes this area a key priority in addressing community health. Chronic disease is heavily influenced by lifestyle and stress levels that are direct results of the social environment.

12 From the Family Health Services Division, Hawaii Department of Health Report: State of Hawaii Maternal & Child Health Needs Assessment Summary, November 2010. http://hawaii.gov/health/doc/MCH‐NASummary2010

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3.2.19 Substance Abuse & Lifestyle Core Indicators and Supplemental Information Core indicators signal strong need in this area: • The percent of adults who binge drink was higher in Molokai (24.9%) than the state (17.8%) in 2006‐ 2010 and had not met the HP2020 target (24.3%); binge drinking was most common among men (34.1%), and adults ages 25‐34 (38.3%), ages 18‐24 (32.6%), and ages 35‐44 (31.7%) • The percent of adults who smoke was higher in Molokai (21.4%) than the state (15.9%) in 2006‐2010 and had not met the HP2020 target (12.0%); smoking was most common among adults ages 35‐44 (27.8%), ages 45‐54 (26.4%), ages 25‐34 (24.6%), and ages 18‐24 (22.6%)

Table 3.19: Core Indicators – Substance Abuse & Lifestyle

In Molokai in 2006‐2010, the overall percent of hospital admissions that were associated with a substance related disorder (8.0%) was lower than the state average of 8.9%.13

Key Informant Interviews Needs/Concerns Impact on Low‐Income, Opportunities/Strengths Underserved/Uninsured, Race/Ethnic Groups Molokai

*Need for more drug abuse *Lack of resources and consistent *The increase in communication services, rehabilitation and ongoing jobs all add to poverty and sense of between health agencies within the help to stay clean and sober hopelessness community is helping to maximize the resources *Need options for chronic pain *Filipino population definitely has a management without high doses of language barrier and cultural *A lot of people in Molokai want to prescription drugs which end up on differences help the streets *The cultural imbalance that has *Substance abuse is a problem, no happened in Hawaii has big inpatient services ramifications and seems to play a huge part in health disparities

State of Hawaii

*Significant need in drug and *With Marshallese population and *Hawaii Primary Care Association is

13 From the Family Health Services Division, Hawaii Department of Health Report: State of Hawaii Primary Care Needs Assessment Data Book 2012, July 2012. http://hawaii.gov/health/doc/pcna2012databook.pdf

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alcohol addiction and related others, there are issues related to required to do a lot of things around problems like accidents and psycho‐ language and culture; need for language and services and will have social disorders translation a good handle on this *Struggle to support a substance *With Hawaiians, cultural issues abuse treatment center in an area come into play and comes down to with small population that how we offer services and what nonetheless has need services we offer *Providers are reluctant to make diagnoses when there is no place to make a referral *Highest drug use for youth is marijuana followed by alcohol *Ice/Crystal Meth is big problem for both youth and adults

Summary While alcohol and tobacco use problems among adults in Molokai are evident in data, the problem of substance abuse extends to other addictive and harmful drugs that contribute to health issues. Developing a substance abuse program in Molokai is difficult given the small population; nevertheless, there is a clear need, as providers may currently be under‐diagnosing substance abuse due to the lack of options available for treatment following diagnosis. Cultural barriers further complicate intervention, and must be considered in program planning. While some efforts to treat and prevent substance abuse can lessen the burden on health, intervening on mental health and socioeconomic issues that feed substance abuse problems may have longer‐lasting impacts.

3.2.20 Transportation Core Indicators and Supplemental Information Transportation is an essential component of access to health services: • A lower proportion of workers used public transportation to commute to work (1.9%) compared to the state (6.0%) in 2006‐2010; Molokai residents least likely to use public transportation include men (0.6%), adults ages 45‐ 54 (1.5%), and adults of two or more races (0.8%) • Although a higher proportion of Molokai workers walked to work (5.9%) compared to the state (4.7%) in 2006‐2010, the rate was lower for women (3.0%), Whites (3.5%), workers ages 16‐19 (1.5%), ages 20‐24 (1.5%), ages 65 and older (2.4%), and ages 45‐54 (2.6%) Table 3.20: Core Indicators – Transportation

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Key Informant Interviews Needs/Concerns Impact on Low‐Income, Opportunities/Strengths Underserved/Uninsured, Race/Ethnic Groups State of Hawaii

*Student transportation is especially *Low‐income students that rely on *Communities need to get past challenging the bus, and their families, are existing laws and regulations that affected by cuts to funding block creative partnerships, for

example using senior transportation during the mornings for students

Summary Transportation is a challenge for small communities such as those on Molokai, particularly for low‐ income residents. The low level of public transportation use among workers likely reflects the limited availability of bus service on the island. Key informants recommend creative solutions, such as using shared vehicles to meet the needs of multiple groups.

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4 Community Health Needs Summary

4.1 Findings/Conclusions The community health needs of Molokai span across all of the topics included in this report. Some health issues impact a larger proportion of the population, while others are of greatest impact to particular groups or sub‐geographies. In order to assess the health needs in Molokai, both objective indicator data and subjective interviews were considered. While indicator data provided a good starting point for determining where attention should be focused, sometimes the data was lacking in depth or breadth on important topics. Interviewing key informants who have local knowledge on the topics helped to fill in details and bring attention to data gaps. Surveying residents elicited health concerns from a small proportion of the community and added highlights. Planners will want to consider how to impact these areas, as many areas can be addressed concurrently with appropriate primary and holistic interventions. Several common themes emerge in this assessment that can guide community health improvement planning: All groups experience adverse health outcomes due to chronic disease and health risk behaviors While there are significant disparities in chronic disease, it is important to note that some areas—such as heart disease and stroke, cancer, diabetes, and asthma—affect many residents of Molokai. Moreover, key health behaviors that impact chronic disease, including optimal exercise, nutrition, and weight need attention across all age, gender, and race/ethnic groups. While some core indicators in the area of physical activity and body weight compared favorably to the state, it is important to remember that obesity and inactivity is a problem statewide. Although a slightly lower percent of Molokai residents are overweight compared to the state (32.5% in Molokai v. 34.8% in Hawaii), a higher percent are obese (37.9% in Molokai v. 22.3% in Hawaii) and the rates are at hazardous levels for both geographies. Attention to this area at many levels could have an enormous positive impact on the long‐term health of the community. As a chronic condition that significantly influences overall health, mental health and associated substance abuse is a concern for Molokai residents. The suicide death rate in Molokai is double the state value and is far from meeting the Healthy People 2020 target. In addition, many injury‐related hospitalizations and deaths may be attributable to substance abuse, including motor vehicle collision deaths caused by driving under the influence of alcohol and poisoning deaths caused by addictive pain management drugs. A lack of mental health care providers almost certainly contributes to the island’s mental health burden, and there are inadequate resources available for residents with substance abuse problems. Expanding services may require creative approaches that will cater to Molokai’s unique culture. Greater socioeconomic need and health impacts are found among certain groups in Molokai Repeatedly throughout this needs assessment, key informants stressed that Molokai residents who are low‐income are the most affected by health problems and often the most difficult to help. The rate of poverty in Molokai is nearly twice that of the state, and all but one of the economic core indicators compared poorly to the state. Furthermore, because Census estimates of poverty do not adjust for the higher cost of living in Hawaii, the number of Molokai residents impacted by poverty is likely underestimated. Financial constraints, such as the high cost of travel due to gas prices on Molokai, affect residents’ access to health services. Low‐income residents are less likely to get proper cancer screening,

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and if diagnosed with cancer may not be able to afford the cost of travelling to Oahu for treatment. Additionally, those living in poverty are less likely to engage in healthy behaviors that can prevent chronic disease and are more likely to smoke. Barriers to improving socioeconomic status include a lack of affordable childcare and under‐preparation for college among low‐income students. Cultural and language barriers inhibit effective intervention for the most impacted populations Because of the strong correlation between poverty and race/ethnicity, some of the groups most impacted by health issues often face cultural barriers to health improvement. Language differences, including limited English proficiency, and poor health behaviors that are common within a culture are challenges that must be overcome in order to effectively prevent disease. Key informants cited challenges in effective communication and intervention to particular race/ethnic groups in the areas of access to health services; diabetes; education; heart disease and stroke; mental health and mental disorders; older adults and aging; and substance abuse. Disparities in the teen birth rate suggest that cultural factors may also be an issue in providing effective family planning services. See Section 4.1.1 for further discussion of health disparities by race/ethnicity. Limited access to care results in greater health impacts Despite needs that exist, services are difficult to provide on Molokai due to its small population. The island has been designated as a medically underserved area, a primary care health professional shortage groupd area, an a mental health professional shortage area by the Health Resources and Services Administration. Key informants cite a shortage of specialty care physicians and services available to Molokai residents. Molokai residents must travel to Oahu to access many types of care, and the expense of travel is unaffordable for many. Specific services of limited availability on Molokai include but are not limited to: educational programs, cancer treatment, substance abuse programs, services for victims of domestic violence, and long‐term care for older adults. Schools are key community assets for effective interventions School‐based interventions can also be a method of positively impacting health in Molokai. Health interventions for children and teens can have a two‐fold benefit of establishing healthy life‐long behaviors among Molokai’s youth, as well as influencing the health of their families. Schools may play an important role in addressing childhood obesity, oral health, family planning, and substance abuse among teens.

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4.1.1 Disparities Highlights Although the root causes of health disparities are attributable to socioeconomics, race/ethnicity is a correlate for which data is more often available. The topic areas for which each race/ethnic group was noted to have a severe disparity (either by a key informant or for at least one indicator) are listed in Figure1 4. below. Note that some race/ethnic category definitions differ between secondary data sources, and the degree to which disparities could be assessed depend on data availability. A significant finding is that Native Hawaiians and Pacific Islanders are faring worse across more topic areas than any other group. This population also has one of the highest poverty rates in Molokai. Figure 4.1: Areas of Disparity for Race/Ethnicity Groups

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4.1.2 Identified Data Gaps There were five topic areas for which so little data was available that a core indicator summary score was not calculated: Diabetes, Disabilities, Older Adults & Aging, Environment, and Social Environment. Diabetes prevalence data is only available for adults, and more data is needed on the disease regarding children and teens. Obesity indicators, while correlated with diabetes, are not necessarily predictive of diabetes’ impact. While the American Community Survey has estimates of the population affected by disabilities, this data is only available at the county level and therefore was unavailable for Molokai. The health needs of Older Adults can be further described with data from other topics such as tooth loss, immunization rates for adults 65 and older, and age‐specific hospitalization rates, but data describing the social isolation, disability, and care needs faced by this population is lacking. Secondary data failed to reflect the needs surrounding Molokai’s natural and social environment, despite the importance that these areas hold culturally for residents. While some secondary data shed light on the topic of mental health, primary data brought further attention to this critical area that impacts many other health behaviors and outcomes. Across all topic areas, sub‐population data is limited due to data suppression for small counts, and little data specific to children and teens is available for Molokai. In particular, Exercise, Nutrition & Weight, Oral Health, and Injury Prevention & Safety are areas that affect children but are not represented well in secondary data. 4.2 Limitations and Other Considerations This needs assessment is subject to limitations of the methods used for summarizing secondary data and key informant interview findings. Topic areas to which core indicators were assigned are not truly independent of each other, and the scoring system used could not account for the inherent relationships between health and wellness topics. The number of indicators available for each topic area varied, and while the scoring system numerically accounted for this variation, the impact of a given indicator on the final scoring for a topic area was greater if fewer indicators and/or comparisons were available. Nonetheless, this needs assessment utilized an extensive data set, derived from the best public health data made available by the Hawaii State Department of Health and the Hawaii Health Data Warehouse; core indicators included the most recent time periods and most detailed race/ethnicity disparity data possible. Race and ethnicity breakout data from this source provides information on the numerous subgroups in Hawaii (Japanese, Filipino, Native Hawaiian, Pacific Islander), allowing this report to understand health needs and disparities for groups that together compose a majority of the population in Molokai. Indicators from national data sources had limitations, including combining important race and ethnic groups together and thus masking disparities. Importantly, in assessing poverty and economic measures, data sources did not account for the higher cost of living on the islands, resulting in an underestimation of poverty in Molokai. The variability in accuracy and precision of secondary data indicators, as well as the comparisons used, are further limitations. Some indicators, such as those from vital statistics, are based on accurate counts and are the most exact. Other indicators that are based on surveys are subject to variability due to sampling error and accuracy of self‐reported data. Because no more than 2 periods of measurement are available for each indicator, trend comparisons may not accurately reflect long‐term trends. For indicators for which the state as a whole is doing very poorly, a favorable geographic comparison for Molokai did not necessarily reflect good health; examples of this include high cholesterol prevalence and physical activity measures. Healthy People 2020 benchmarks were used for comparisons, when available, though some of these can be ambitious targets for communities to meet.

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While preventable hospitalization rate indicators provided by HHIC were invaluable for their insight into the underlying health of the community, it should also be considered that the comparison to state values may reflect geographic differences in access and timeliness of care. Further analysis may be needed to better understand Molokai’se preventabl hospitalization patterns, perhaps by aggregating years of data to enable examination of preventable hospitalizations due to specific causes. One challenge in conducting this community health needs assessment was the condensed timeline. All of this work was compressed into a 6‐month time frame, overlapping the winter holidays, which impacted primary data collection strategy. However, key public health officials and community health leaders of Molokai were successfully included in the key informant process (See Appendix C for a full list of key informants interviewed). The online community survey was aimed to further complete the understanding of the local needs in Molokai,e although th limited participation makes it difficult to assess if findings accurately reflect the broader community’s perspective. While invaluable data was provided through the primary data collected for this report, a future CHNA process would benefit from a longer time horizon and would allow for expanded involvement and input from the community. Regardless of the limitations, this report provides a snapshot of the health and quality of life challenges in Molokai. The needs outlined provide a guide for community benefit planning, but subsequent efforts may be needed to delve deeper into specific areas of need and the most effective methods of intervention. While there are many areas of need, there are also innumerable community assets and a true aloha spirit that provide ample foundation for community health improvement activities.

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5 Selected Priority Area

Queen’s mission is to fulfill the intent of Queen Emma and King Kamehameha IV to provide in perpetuity quality health care services to improve the well‐being of Native Hawaiians and all of the people of Hawaii.

Senior management of The Queen’s Health Systems (Queen’s), the nonprofit parent company of a family of health care‐related companies that includes The Queen’s Medical Center (QMC) and Molokai General Hospital (MGH), discussed the community health needs identified in this assessment and selected Diabetes as the priority area to be addressed by both nonprofit hospitals. (Queen’s senior management team includes the president and chief executive officer, chief operating officer, operating entity heads, clinical leaders [physicians and service lines], and those responsible for system‐wide functions such as human resources, finance, endowment, legal, corporate development, information technology, and community development.)

The compelling reasons considered in selecting Diabetes include:

Diabetes… • One of the most serious, common, and costly diseases in Hawaii and the U.S. • Disease on the rise, projected to increase in severity due to the obesity epidemic • Often leads to additional health issues and complications (e.g., heart disease and stroke, kidney disease, hypertension, blindness and eye problems, etc.).

United States… • 25.8 million children and adults with diabetes (8.3% of the population) • 1.9 million new cases per year • $176 billion to treat/care for diagnosed diabetes • 7th leading cause of death Source: American Diabetes Association

Statewide… • 113,000 children and adults with diabetes (8.5% of the state population) • Diabetes prevalence greatest for Native Hawaiians (11.4%) and Filipinos (10.1%) • Projected that 1 in 2 children born in the year 2000 will have diabetes in their lifetime • 5th leading cause of death Source: American Diabetes Association

Additionally… • Nationally, 25%‐30% of patients waiting for a kidney transplant have diabetes. In Hawaii, it is closer to 45%. This is of significance to QMC, as it opened the state’s only organ transplant center in early 2012 in response to community need when the previous center closed in December 2011. • The Department of Native Hawaiian Health (DNHH) at the University of Hawaii’s John A. Burns School of Medicine conducted a needs assessment of Native Hawaiians, other Pacific Islanders (e.g., Samoan, Marshallese, Guamanian, Chuukese), and Filipinos (collectively identified as Native Hawaiians and other Pacific Peoples [NHPP]). Through interviews with leaders in DNHH’s Ulu Network member organizations, the top medical concern, identified by 93% of the

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organizations, was cardiometabolic disease, which is defined as the collective of conditions of diabetes, cardiovascular disease, and obesity. Of these cardiometabolic conditions, diabetes was specifically identified by 83% of the organizations. • Native Hawaiians have the highest prevalence of diabetes in the state (11.4%); in Honolulu County, the prevalence isn eve higher (12.3%). With its significant impact on Native Hawaiians, focusing on Diabetes aligns with our mission. • Diabetes often leads to other complications that have been identified as community health needs (e.g., cardiac, stroke). By having a more focused effort to address Diabetes in our community, reducing the impact of Diabetes may also reduce the impact of other areas of need.

Management’s recommendation was presented to the joint boards of trustees, and the boards supported the selection of Diabetes as the priority health need to be addressed by QMC and MGH.

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Appendix A: Core Indicator Data

About HCI Provided Data Healthy Communities Institute (HCI), in partnership with the Hawaii Department of Health and the Hawaii Health Data Warehouse, provides demographic and secondary indicator data on health, health determinants, and quality of life topics. Data is typically presented in comparison to the distribution of counties, state average, national average, or Healthy People 2020 targets. Data is primarily derived from state and national public health sources. HCI also provides a database of promising practices from a variety of sources, including the Centers for Disease Control and Prevention. All of the HCI content is presented in a public web platform that also serves as a publishing tool for components of Community Health Needs Assessments. Framework for Indicator/Data and Topic Selection The framework for indicator selection within the Health category is based on the Department of Health and Human Services (DHHS) Healthy People initiative. Healthy People establishes science‐based national objectives for improving the health of the nation. The initiative establishes benchmarks every ten years and tracks progress toward these achievable goals. This framework encourages collaboration across sectors and allows communities to track important health and quality of life indicators focusing on general health status, health‐related quality of life and well‐being, determinants of health and disparities. The Health subcategories are based on the Healthy People framework, and multiple indicators across the health sub‐topics that correspond with Healthy People targets have been chosen (based on data availability, reliability and validity from the source). Indicators in the other categories were selected according to national consensus and feedback from a wide set of advisors, public health officials, health departments, and local stakeholders from various sectors in the community. For example, the education indicators are based on the National Center for Health Research and Statistics and United Way of America, and the standards and goals they set forth to help track educational attainment in the U.S. Economic indicators were selected in conjunction with economic development and chamber of commerce input. All of the selected indicators have gone through a vetting process where HCI’s advisory board, as well as stakeholders in communities who have implemented HCI systems, provide feedback to refine the core indicators in order to best reflect local priorities. The indicator selection process evolves over time with changing health priorities, new research models and national benchmarks. HCI continues to incorporate models and standards from nationally recognized institutions such HHS’s Healthy People, AHRQ’s PQI’s, EPA Air Quality standards, National Center for Education Research and Statistics’ priorities, United Way, and United States Department of Agriculture’s Food Atlas, among many others.

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Core Indicator Data Summary: Analytic Approach and Scoring Methodology As discussed in Section 2.1, the selection of topic areas for primary data collection relied on four types of Core Indicator comparisons: geographic, trend, disparity, and benchmark. A four‐point system was used to evaluate each indicator on these four comparison methods, as illustrated in the examples below.

Geographic Comparison The core indicator was assigned a geographic comparison point if it was worse than the state value for the same indicator. For example, because the percent of Molokai adults with diabetes was higher than the state value for the same time period, this indicator was assigned one point. X = 1 point

Trend Comparison The indicator was assigned a point if the value was worsening by at least 2.5% of the baseline value per year on average. Because all indicators have measurement periods of aggregated years, the percent change between two time periods was divided by the difference in the ending year of each period of measure. In this example of Adults who are Obese, a point would be assigned because the value increased by 4.5% per year on average: 2010 – 2005 = 5 years difference

Average % change per year = X 22.3% ÷ 5 years = 4.5% = 1 point

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Disparity Analysis The indicator was assigned a point if there were large disparities among subpopulations. The method used to identify large disparities depended on the number of subpopulation values available: Method 1: Two or more sub‐population values If at least two subpopulation values were available for an indicator, the disparity was considered large if the ratio between the worst and best value was 2 or higher. In this example, children with current asthma received one point because the worst value was 2.3 times greater than the best value: X 13.5 ÷ 5.8 = 2.3 = 1 point Method 2: One sub‐population value If only one subpopulation value was available for an indicator due to data suppression, the disparity was considered large if the subpopulation value was at least 50% worse than the average value. In this example, teen birth rate received one point because the subpopulation value available was over four times as high as the average value: X 200.0 ÷ 42.9 = 4.7 = 1 point

If an indicator had a large disparity by age, gender, or race, it was assigned a maximum of one point.

Healthy People 2020 Target Comparison The indicator was assigned a point if it did not meet a Healthy People 2020 target. In this mammogram history example, a point would be assigned because Molokai did not meet the target of 81.1%: X = 1 point

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Scoring The total earned points and total possible points were tallied for each indicator. In this example of a mammogram history indicator, four points were possible since all four comparisons were available. Out of the four potential points, the indicator earned two points, for a poor comparison to the state value and for not meeting the Healthy People 2020 target:

The total earned points and total possible points were then tallied for all indicators in a topic area to calculate the topic area summary score. In this cancer topic area example, 10 points were assigned out of 17 possible points, giving the topic area a summary score of 0.59.

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Core Indicator Data Most of the core indicator data included in this report can be found on Hawaii Health Matters (www.HawaiiHealthMatters.org).

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Appendix B: Hospitalization Data

The following zip codes are included in Molokai hospitalization rates: Molokai 96729 96742 96748 96757 96770

Hospitalization Rates Risk‐adjusted hospitalization rate indicators were provided by Hawaii Health Information Corporation (HHIC). The indicators are defined by the Agency for Healthcare Research and Quality (AHRQ) as a set of measures that can be used to identify quality of outpatient care that can potentially prevent the need for hospitalization. Risk adjustment attempts to account for differences in indicators across providers and geographic areas that are attributable to variations in patient mix. AHRQ’s risk adjustment methodology employs multivariate ordinary least squares regression to estimate an expected value of each indicator an area would exhibit with an “average” case‐mix. The model adjusts for patient demographics, including age, sex, all age‐sex combinations, All‐Payer Refined DRGs (a refinement of CMS’s DRGs that additionally classifies non‐Medicare cases) and severity‐of‐illness. HHIC applies AHRQ’s risk adjustment methodology to further control for the top four dominant races in Hawaii, as determined by the Hawaii State Department of Health’s Hawaii Health Survey. Risk adjustment coefficients are estimated using the Healthcare Cost and Utilization Project’s (HCUP) State Inpatient Databases (SID). Please see http://qualityindicators.ahrq.gov/Modules/pqi_resources.aspx for a complete definition of indicators. Due to the small population and case counts in Molokai, hospitalization rates for causes defined by the AHRQ preventable causes of admission are aggregated into composite rates. The following causes are included in each composite rate presented in this report: PQI Composite – Dehydration, Bacterial Pneumonia, Urinary Tract Infection Acute Conditions Short‐term Complications of Diabetes, Long‐term Complications of PQI Composite – Diabetes, Uncontrolled Diabetes, Rate of Lower‐extremity Amputation, Chronic Conditions COPD or Asthma in Older Adults (ages 40+), Asthma in Younger Adults (ages 18‐39), Hypertension, Heart Failure, and Angina without Procedure PQI Composite All causes listed above Because the area of mental health was not well represented in the Core Indicator Summary, HHIC also provided unadjusted rates of hospitalization for any mental health‐related primary diagnosis.

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For all indicators HHIC provided unadjusted rates for age and gender sub‐populations. Unadjusted rates are not compared to state or county values due to uncertainties in the comparability of the respective populations. Counts for age and gender sub‐populations are used to compare the proportion of hospitalizations attributed to peach grou relative to the proportion of Molokai’s population the group represents. All rates are based upon patient residence, and values were suppressed if there were fewer than 10 cases. Population estimates are based on the U.S. Census Bureau, Population Division, Intercensal Estimates of the Resident Population for Counties of Hawaii and Hawaii State Department of Health, Office of Health Status Monitoring, Hawaii Health Survey. Sub‐county demographic counts are based on estimates/projections provided by Pitney Bowes Business Insight, 2008‐2011. The table below includes case counts and risk‐adjusted hospitalization rates with 95% confidence intervals for Molokai. Risk‐adjusted state rates are also provided for comparison. Sub‐population case counts are summed for 2009, 2010, and 2011 for stability and patient privacy; unadjusted sub‐ population rates are calculated using all three years of data. All mental health hospitalization rates are unadjusted. Use caution when comparing unadjusted rates, as they may represent populations of varying age and gender distributions.

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Appendix C: Key Informant Interview Participants

Completed Interviews

Key Informant Date of Topics Covered Title, Organization Interview Loretta Fuddy Mental Health & Mental Disorders 12/12/2012 Director, Hawaii State Department of Health Substance Abuse & Lifestyle Dr. Josh Green State Senator Diabetes Executive Medical Director, Hawaii Independent 11/28/2012 Substance Abuse & Lifestyle Physicians Association Emergency Room Physician Donna Haytko‐Paoa Education 12/17/2012 Professor/Site Coordinator, Maui College ‐ Molokai Leslie Lam Executive Director, American Diabetes Association Diabetes 12/28/2012 Hawaii Kathy Matayoshi Superintendent of Education, Hawaii State Transportation 12/26/2012 Department of Education Access to Health Services Desiree Puhi Oral Health 12/11/2012 Executive Director, Molokai Community Health Center Social Environment Substance Abuse & Lifestyle Access to Health Services Lynette Schaefer Diabetes 12/4/2012 Chaplain, Maui Police Department, Moloka'I Hospice Maternal, Fetal & Infant Health Hardy Spoehr Access to Health Services 12/19/2012 Executive Director, Papa Ola Lokahi Social Environment Dr. Traci Stevenson Older Adults & Aging Co‐Medical Director/Family Physician, Molokai 12/11/2012 Substance Abuse & Lifestyle Community Health Center Lori Suan Exercise, Nutrition, & Weight Executive Director, American Heart Association, 12/10/2012 Heart Disease & Stroke Hawaii Chapter Dr. Jackie Young Chief Staff Officer, High Plains Division, American Cancer 12/26/2012 Cancer Society Hawaii Site

Attempted Interviews Following the nomination and voting process, individuals from the following organizations were attempted to be reached but were unavailable for interview. Organization Expertise Molokai Family Health Center Access to Health Services

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Appendix D: Identified Community Resources

Statewide Health‐Related Resources Identified from Aloha United Way14 The following list includes selected resources available to residents of the State of Hawaii, as identified from Aloha United Way. However, it is not an exhaustive directory of all statewide programs. To find more resources for Molokai, please visit http://www.auw211.org/.  Topic Area(s) Organization/Program URL Phone Access to Health Services DISABILITY & COMMUNICATION ACCESS BOARD http://www.state.hi.us/health/dca (808)586‐8121 b/home/index.htm Access to Health Services DISABLED RIGHTS LEGAL PROJECT (808)585‐0920 Access to Health Services; EYE OF THE PACIFIC GUIDE DOGS FOUNDATION www.eyeofthepacific.org  (808)941‐1088 Transportation Access to Health Services; HAWAII TOBACCO QUITLINE www.callitquitshawaii.org Substance Abuse Cancer AMERICAN CANCER SOCIETY www.cancer.org (808)595‐7544 Cancer BCCCP ‐ BREAST AND CERVICAL CANCER CONTROL PROGRAM www.queens.org Cancer THE LEUKEMIA & LYMPHOMA SOCIETY www.lls.org/aboutlls/chapters/sd/ (808)534‐1222 Cancer US TOO INTERNATIONAL AND NATIONAL ALLIANCE OF STATE www.naspcc.org/hawaii  (808)521‐2630 PROSTATE CANCER COALITIONS Cancer; Access to Health CANCER INFORMATION SERVICE www.cancer.gov 1‐800‐4‐CANCER Services (1‐800‐422‐6237) Children's Health CHILD & FAMILY SERVICES www.childandfamilyservice.org Children's Health HAWAII KIDS COUNT http://uhfamily.hawaii.edu/projec ts/kidscount/home.aspx  Children's Health PREVENT CHILD ABUSE HAWAII www.preventchildabusehawaii.org (808)951‐0200 Diabetes AMERICAN DIABETES ASSOCIATION ‐ HI www.diabetes.org  Diabetes NATIONAL KIDNEY FOUNDATION OF HAWAII ‐ OAHU www.kidneyhi.org (808)593‐1515 Diabetes; Children's JUVENILE DIABETES RESEARCH FOUNDATION INTERNATIONAL ‐ www.jdrfhawaii.org (808)988‐1000 Health HAWAII CHAPTER Education OUTREACH COLLEGE www.outreach.hawaii.edu (808)956‐7221

14 Data was accessed February 2013

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Topic Area(s) Organization/Program URL Phone Exercise, Nutrition, & EXPANDED FOOD & NUTRITION EDUC‐OAHU www.ctahr.hawaii.edu/site/Extpro (808)956‐7138 Weight grams.aspx Exercise, Nutrition, & OVEREATERS ANONYMOUS ‐ HAWAII www.oa.org (808)737‐3469 Weight Heart Disease & Stroke REHABILITATION HOSPITAL OF THE PACIFIC ‐ STROKE PROGRAM www.rehabhospital.org (808)531‐3511 Heart Disease & Stroke; LAST MINUTE CPR & FIRST AID www.lastminutecpr.com (808)671‐4100 Education Immunizations & HIV EARLY INTERVENTION SERVICES www.waikikihc.org (808)926‐0742 Infectious Diseases (808)791‐9387 Injury Prevention & Safety BRAIN INJURY ASSOCIATION OF HAWAII http://www.biausa.org/hawaii  (808)791‐6942 Injury Prevention & HAWAII STATE COALITION AGAINST DOMESTIC VIOLENCE www.hscadv.org  Safety; Social Environment Injury Prevention & MADD HAWAII http://www.madd.org/local‐ (808)532‐6232 Safety; Substance Abuse offices/hi/  Injury Prevention & OHIA DOMESTIC VIOLENCE SHELTER http://www.pacthawaii.org/ohia.h (808)526‐2200 Safety; Social tml  Environment Maternal, Fetal & Infant H‐KISS http://hawaii.gov/health/family‐ (808)594‐0066 Health child‐health/eis  Maternal, Fetal & Infant LA LECHE LEAGUE www.lllnorcal.org/groups/Hawaii. (808)325‐3055 Health html Maternal, Fetal & Infant PARENT LINE www.theparentline.org (808)526‐1222 Health Mental Health NAMI (NATIONAL ALLIANCE ON MENTAL ILLNESS) ‐ HAWAII www.namihawaii.org (808)591‐1297 Mental Health WARM LINES www.unitedselfhelp.org (808)931‐6444 Older Adults & Aging AGING, EXECUTIVE OFFICE ON www.hawaii.gov/health/eoa/inde (808)586‐0100 x.html Older Adults & Aging ALZHEIMER'S ASSOCIATION ‐ ALOHA CHAPTER http://www.alz.org/hawaii/  (808)591‐2771 Older Adults & Aging CTR ON AGING, OFFICE OF PUBLIC HEALTH STUDIES www.hawaii.edu/aging (808)956‐5001 Older Adults & Aging LEJ DISABILITY VETERANS PROJECT www.lejdisability.org  (888) 557‐9789 Oral Health HAWAII DENTAL ASSOCIATION www.hawaiidentalassociation.net/ (808)593‐7956 Organ Donation LEGACY OF LIFE HAWAII www.legacyoflifehawaii.org  (808)599‐7630 Other Chronic Conditions ARTHRITIS FOUNDATION, HAWAII BRANCH www.arthritis.org  (808)596‐2900

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Topic Area(s) Organization/Program URL Phone Other Chronic Conditions AUTISM SOCIETY OF HAWAII www.autismhi.org/ (808)228‐0122 Other Chronic Conditions EPILEPSY FOUNDATION OF HAWAII www.hawaiiepilepsy.com  (808)528‐3058 Other Chronic Conditions LUPUS FOUNDATION, HAWAII www.lupushawaii.org  Social Environment OFFICE OF HAWAIIAN AFFAIRS ‐ OAHU www.oha.org (808)594‐1888 Social Environment; HAWAI`I HOTEL & LODGING ASSOCIATION www.hawaiihotels.org (808)923‐0407 Economy Substance Abuse COALITION FOR A DRUG‐FREE HAWAII www.drugfreehawaii.org Substance Abuse; Teen & COALITION FOR A TOBACCO‐FREE HAWAII www.tobaccofreehawaii.org Adolescent Health  Health‐Related Resources Identified through Hawaii Department of Health Contracts The following list includes organizations within Maui and Honolulu Counties that have active contracts with the Hawaii Department of Health in 2013.  Geography Topic Area(s) Organization/Program Maui County Access to Health Services PHARMACY CORPORATION OF AMERICA DBA PHARMERICA Maui County Access to Health Services UNIVERSITY, CLINICAL, EDUCATION AND RESEARCH ASSOCIATES Maui County Access to Health Services; Family Planning MAUI AIDS FOUNDATION Maui County Children's Health; Access to Health Services IMUA FAMILY SERVICES ‐ LANAI Maui County Children's Health; Access to Health Services IMUA FAMILY SERVICES ‐ MAUI Maui County Environment CENTRAL MAUI SOIL & WATER CONSERVATION DISTRICT Maui County Environment COUNTY OF MAUI Maui County Environment KAHOOLAWE ISLAND RESERVE COMMISSION Maui County Environment LANAI INSTITUTE FOR THE ENVIRONMENT Maui County Environment MAUI DEPARTMENT OF WATER SUPPLY Maui County Environment RRR RECYCLING SERVICES HAWAII Maui County Environment WEST MAUI LAND COMPANY, INC. Maternal, Fetal & Infant Health; Access to Health Maui County LANAI WOMEN'S HEALTH CENTER Services; Family Planning Maternal, Fetal & Infant Health; Access to Health Maui County MAUI COMMUNITY COLLEGE Services; Family Planning Maui County Maternal, Fetal & Infant Health; Access to Health MOLOKAI GENERAL HOSPITAL

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Geography Topic Area(s) Organization/Program Services; Family Planning Maui County Maternal, Fetal & Infant Health; Children's Health MAUI FAMILY SUPPORT SERVICES Maternal, Fetal & Infant Health; Exercise, Maui County MAUI FAMILY SUPPORT SERVICES, INC. Nutrition, & Weight Maternal, Fetal & Infant Health; Exercise, Maui County MOLOKAI OHANA HEALTH CARE, INC. Nutrition, & Weight Maui County Mental Health ALAKAI NA KEIKI, INC (MAUI) Maui County Mental Health MAUI YOUTH AND FAMILY SERVICES, INC. Maui County Mental Health PARENTS AND CHILDREN TOGETHER (MAUI) Maui County Substance Abuse MAUI COUNTY POLICE DEPT. Maui County Substance Abuse MAUI ECONOMIC OPPORTUNITY, INC. Maui County Substance Abuse; Teen & Adolescent Health MAUI YOUTH AND FAMILY SERVICES Honolulu County Access to Health Services ALOHA HOUSE, INC. Honolulu County Access to Health Services LIFE FOUNDATION Honolulu County Children's Health; Access to Health Services ACES Honolulu County Children's Health; Access to Health Services ALAKAI NA KEIKI, INC. Honolulu County Children's Health; Access to Health Services B.C.P., INC. DBA BAYADA HOME HEALTH CARE Honolulu County Children's Health; Access to Health Services CARE HAWAII, INC. Honolulu County Children's Health; Access to Health Services COMPREHENSIVE AUTISM SERVICES & EDUCATION, INC. DBA C.A.S.E., INC. Honolulu County Children's Health; Access to Health Services DEBORAH T. TOM DBA DEBORAH T. TOM, MS, PT Honolulu County Children's Health; Access to Health Services DR. BRENDA LOVETTE DBA LOKAHI CONSULTING GROUP, INC. Honolulu County Children's Health; Access to Health Services EASTER SEALS OF HAWAII ‐ HONOLULU CENTRAL Honolulu County Children's Health; Access to Health Services EASTER SEALS OF HAWAII ‐ HONOLULU EAST Honolulu County Children's Health; Access to Health Services EASTER SEALS OF HAWAII ‐ KAILUA Honolulu County Children's Health; Access to Health Services EASTER SEALS OF HAWAII ‐ KAPOLEI Honolulu County Children's Health; Access to Health Services HAWAII BEHAVIORAL HEALTH, LLC Honolulu County Children's Health; Access to Health Services HELPING HANDS HAWAII Honolulu County Children's Health; Access to Health Services IMUA FAMILY SERVICES Honolulu County Children's Health; Access to Health Services JIHEE KIM NGUYEN Honolulu County Children's Health; Access to Health Services JUNE UYEHARA ISONO, INC. DBA AUDIOLOGY CONSULTANT AND SERVICES Honolulu County Children's Health; Access to Health Services KAPIOLANI MEDICAL SPECIALISTS MARY MARASOVICH DBA OAHU SPEECH LANGUAGE PATHOLOGY Honolulu County Children's Health; Access to Health Services CONSULTANTS Honolulu County Children's Health; Access to Health Services PACIFIC GATEWAY CENTER

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Geography Topic Area(s) Organization/Program Honolulu County Children's Health; Access to Health Services QUALITY BEHAVIORAL OUTCOMES, LLC Honolulu County Children's Health; Access to Health Services SAYURI'S NUTRITIONAL CONSULTATION, LLC Honolulu County Children's Health; Access to Health Services THE INSTITUTE FOR FAMILY ENRICHMENT, LLC Honolulu County Children's Health; Access to Health Services WAIANAE COAST EARLY CHILDHOOD SERVICES, INC. ‐ WAIANAE Honolulu County Environment CITY & COUNTY OF HONOLULU Honolulu County Environment HUI O KO'OLAUPOKO Honolulu County Environment OAHU RESOURCE CONSERVATION & DEVELOPMENT COUNCIL Honolulu County Environment SUSTAINABLE RESOURCES GROUP INTERNATIONAL, INC. Honolulu County Environment TOWNSCAPE, INC. Immunizations & Infectious Diseases; Children's Honolulu County NA KAHU MALAMA NURSES, INC. Health Maternal, Fetal & Infant Health; Access to Health Honolulu County CHILD AND FAMILY SERVICE Services; Family Planning Maternal, Fetal & Infant Health; Access to Health Honolulu County COMMUNITY CLINIC OF MAUI Services; Family Planning Maternal, Fetal & Infant Health; Access to Health Honolulu County KALIHI PALAMA HEALTH CENTER Services; Family Planning Maternal, Fetal & Infant Health; Access to Health Honolulu County KOKUA KALIHI VALLEY Services; Family Planning Maternal, Fetal & Infant Health; Access to Health Honolulu County KOOLAULOA HEALTH AND WELLNESS CENTER Services; Family Planning Maternal, Fetal & Infant Health; Access to Health Honolulu County MOLOKAI GENERAL HOSPITAL Services; Family Planning Maternal, Fetal & Infant Health; Access to Health Honolulu County WAIANAE COAST DISTRICT COMPREHENSIVE Services; Family Planning Maternal, Fetal & Infant Health; Access to Health Honolulu County WAIKIKI HEALTH CENTER Services; Family Planning Honolulu County Maternal, Fetal & Infant Health; Children's Health CHILD AND FAMILY SERVICE Honolulu County Maternal, Fetal & Infant Health; Children's Health THE INSTITUTE FOR FAMILY ENRICHMENT Maternal, Fetal & Infant Health; Exercise, Honolulu County WAIANAE COAST COMPREHENSIVE HEALTH SERVICES Nutrition, & Weight Maternal, Fetal & Infant Health; Exercise, Honolulu County WAIMANALO HEALTH CENTER Nutrition, & Weight Honolulu County Mental Health ALAKAI NA KEIKI, INC (CENTRAL OAHU)

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Geography Topic Area(s) Organization/Program Honolulu County Mental Health ALAKAI NA KEIKI, INC (HONOLULU) Honolulu County Mental Health ALAKAI NA KEIKI, INC (LEEWARD OAHU) Honolulu County Mental Health ALOHA HOUSE, INC Honolulu County Mental Health ALOHA HOUSE, INC (CR ‐ CRISIS MOBILE) Honolulu County Mental Health BENCHMARK BEHAVIORAL HEALTH, INC. (ANCILLARY) Honolulu County Mental Health BOBBY BENSON CENTER Honolulu County Mental Health BREAKING BOUNDARIES Honolulu County Mental Health CARE HAWAII, INC. Honolulu County Mental Health CARE HAWAII, INC. (CR ‐ CRISIS MOBILE) Honolulu County Mental Health CASTLE MEDICAL CENTER Honolulu County Mental Health CHILD AND FAMILY SERVICE (CR ‐ CRISIS MOBILE) Honolulu County Mental Health CHILD AND FAMILY SERVICE Honolulu County Mental Health CHILD AND FAMILY SERVICE (CR ‐ CRISIS MOBILE) Honolulu County Mental Health COMMUNITY EMPOWERMENT RESOURCES Honolulu County Mental Health HALE KIPA, INC. Honolulu County Mental Health HAWAII BEHAVIORAL HEALTH, LLC Honolulu County Mental Health HAWAII BEHAVIORAL HEALTH, LLC (CR ‐ MTFC) Honolulu County Mental Health HAWAII FAMILIES AS ALLIES (BG30&31) Honolulu County Mental Health HAWAII FAMILIES AS ALLIES(PK) Honolulu County Mental Health HELPING HANDS HAWAII Honolulu County Mental Health HOPE SERVICES OF HAWAII, INC. Honolulu County Mental Health MARIMED FOUNDATION FOR ISLAND HEALTH CARE TRAINING Honolulu County Mental Health MENTAL HEALTH KOKUA Honolulu County Mental Health NORTH SHORE MENTAL HEALTH, INC. Honolulu County Mental Health PARENTS AND CHILDREN TOGETHER (CR ‐ FFT) Honolulu County Mental Health PARENTS AND CHILDREN TOGETHER (EAST OAHU) Honolulu County Mental Health PARENTS AND CHILDREN TOGETHER (WEST OAHU Honolulu County Mental Health PO'AILANI, INC. Honolulu County Mental Health SPECIAL EDUCATION CENTER OF HAWAII Honolulu County Mental Health STEADFAST HOUSING DEVELOPMENT CORP. Honolulu County Mental Health SUSANNAH WESLEY COMMUNITY CENTER Honolulu County Mental Health TALAVERA, ELSA Honolulu County Mental Health THE INSTITUTE FOR FAMILY ENRICHMENT (TIFFE) Honolulu County Mental Health TIFFE

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Geography Topic Area(s) Organization/Program Honolulu County Mental Health TIFFE‐ COST REIMB (FFT) Honolulu County Mental Health WAIANAE COAST COMMUNTY MENTAL HEALTH CENTER, INC. Honolulu County Substance Abuse ALOHA HOUSE, INC. Honolulu County Substance Abuse BRIDGE HOUSE Honolulu County Substance Abuse C&C OF HONOLULU POLICE DEPT. Honolulu County Substance Abuse CARE HAWAII Honolulu County Substance Abuse CITY AND COUNTY OF HONOLULU Honolulu County Substance Abuse HINA MAUKA Honolulu County Substance Abuse HO'OMAU KE OLA Honolulu County Substance Abuse HOA AINA O MAKAHA Honolulu County Substance Abuse KA HALE POMAIKAI Honolulu County Substance Abuse KLINE WELSH Honolulu County Substance Abuse KU ALOHA OLA MAU Honolulu County Substance Abuse OXFORD HOUSE Honolulu County Substance Abuse PARENTS AND CHILDREN TOGETHER Honolulu County Substance Abuse SALVATION ARMY ATS Honolulu County Substance Abuse WAIKIKI HEALTH CENTER Honolulu County Substance Abuse WAIMANALO HEALTH CENTER Honolulu County Substance Abuse; Family Planning MALAMA NA MAKUA Honolulu County Substance Abuse; Mental Health ALOHA HOUSE, INC. Honolulu County Substance Abuse; Mental Health HINA MAUKA Honolulu County Substance Abuse; Mental Health KLINE WELSH Honolulu County Substance Abuse; Mental Health OHANA MAKAMAE Honolulu County Substance Abuse; Mental Health QUEENS MEDICAL CTR Honolulu County Substance Abuse; Teen & Adolescent Health ALOHA HOUSE, INC. Honolulu County Substance Abuse; Teen & Adolescent Health ALU LIKE, INC. Honolulu County Substance Abuse; Teen & Adolescent Health BISAC Honolulu County Substance Abuse; Teen & Adolescent Health CARE HAWAII Honolulu County Substance Abuse; Teen & Adolescent Health FAMILY EDUCATION CENTER OF HAWAII Honolulu County Substance Abuse; Teen & Adolescent Health HALE HO'OKUPA'A Honolulu County Substance Abuse; Teen & Adolescent Health HINA MAUKA Honolulu County Substance Abuse; Teen & Adolescent Health MYFS Honolulu County Substance Abuse; Teen & Adolescent Health OHANA MAKAMAE Honolulu County Substance Abuse; Teen & Adolescent Health PO'AILANI

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Geography Topic Area(s) Organization/Program Honolulu County Substance Abuse; Teen & Adolescent Health TIFFE Honolulu County Substance Abuse; Teen & Adolescent Health YMCA  Licensed Health Care Facilities Reported by the Centers for Medicare & Medicaid Services15 The following lists include the places of service reported by the Centers for Medicare & Medicaid Services (CMS) for Maui and Honolulu Counties. However, it is not an exhaustive directory of all facilities in the counties.

Licensed Facilities Reported by CMS: Maui County  Facility Type Facility Sub‐Type Facility Name Address 239 EAST WAKEA AVENUE KAHULUI Ambulatory Surgical Center AMBULATORY SURGICAL CENTER ALOHA EYE CLINIC LTD HI 96732 239 HO'OHANA STREET KAHULUI HI Ambulatory Surgical Center AMBULATORY SURGICAL CENTER ALOHA SURGICAL CENTER, LP 96732 80 MAHALANI STREET WAILUKU HI Ambulatory Surgical Center AMBULATORY SURGICAL CENTER KAISER WAILUKU CLINIC ‐ ASC 96793 Comprehensive Outpatient Rehab MAUI COMPREHENSIVE 140 HOOHANA ST, STE 201 KAHULUI COMPREHENSIVE OUTPATIENT Facility REHABILITATION CTR HI 96732 10 HOOHUI STREET, SUITE 100 End Stage Renal Disease Facility END STAGE RENAL DISEASE KAHANA DIALYSIS SATELLITE FACI LAHAINA HI 96761 End Stage Renal Disease Facility END STAGE RENAL DISEASE LANAI COMMUNITY DIALYSIS CENTE 628 7TH STREET LANAI CITY HI 96763 LIBERTY DIALYSIS ‐ HAWAII LLC, 1831 WILI PA LOOP WAILUKU HI End Stage Renal Disease Facility END STAGE RENAL DISEASE WAILUKU DIALYSIS 96793 LIBERTY DIALYSIS ‐HAWAII LLC‐ 28 KAMOI STREET SUITE 400 End Stage Renal Disease Facility END STAGE RENAL DISEASE MOLOKAI DIALYSIS KAUNAKAKAI HI 96748 LIBERTY DIALYSIS HAWAII LLC ‐ 10 HOOHUI STREET, SUITE 100 End Stage Renal Disease Facility END STAGE RENAL DISEASE KAHANA DIALYSIS FACI LAHAINA HI 96761 LIBERTY DIALYSIS‐MAUI DIALYSIS 105 MAUI LANI PARKWAY, SUITE 105 End Stage Renal Disease Facility END STAGE RENAL DISEASE FACILITY WAILUKU HI 96793

15 The Centers for Medicare & Medicaid Services published this list in the 4th Quarter of 2012.

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Facility Type Facility Sub‐Type Facility Name Address 255 MAHALANI STREET WAILUKU HI End Stage Renal Disease Facility END STAGE RENAL DISEASE MAUI HEMODIALYSIS SATELLITE FA 96793 28 KAMOI STREET SUITE 400 End Stage Renal Disease Facility END STAGE RENAL DISEASE MOLOKAI DIALYSIS FACILITY KAUNAKAKAI HI 96748 HEALTHSOUTH REHABILITATION 180 DICKENSON SQUARE, SUITE 119 Extension or Branch OPT EXTENSION CENTER OF HAWAII LAHAINA HI 96761 HEALTHSOUTH REHABILITATION 1325 SOUTH KIHEI ROAD, SUITE 108 Extension or Branch OPT EXTENSION CENTER OF HAWAII WAILUKU HI 96793 HEALTHSOUTH REHABILITATION 1043 MAKAWAO AVENUE, SUITE 107 Extension or Branch OPT EXTENSION CENTER OF MAKAWAO MAKAWAO HI 96768 FEDERALLY QUALIFIED HEALTH 670 WAIALE DRIVE WAILUKU HI Federally Qualified Health Center COMMUNITY CLINIC OF MAUI CENTER 96793 FEDERALLY QUALIFIED HEALTH 4590 HANA HIGHWAY HANA HI Federally Qualified Health Center HANA COMMUNITY HEALTH CENTER CENTER 96713 FEDERALLY QUALIFIED HEALTH 478 LAUHALA STREET LANAI CITY HI Federally Qualified Health Center LANAI COMMUNITY HEALTH CENTER CENTER 96763 FEDERALLY QUALIFIED HEALTH 1881 NANI STREET WAILUKU HI Federally Qualified Health Center MALAMA I KE OLA HEALTH CENTER CENTER 96793 FEDERALLY QUALIFIED HEALTH 15 IPU AUMAKUA LANE LAHAINA HI Federally Qualified Health Center MALAMA I KE OLA HEALTH CENTER CENTER 96761 FEDERALLY QUALIFIED HEALTH MOLOKAI COMMUNITY HEALTH 28 KAMOI STREET, SUITE 600 Federally Qualified Health Center CENTER CENTER KAUNAKAKAI HI 96748 1520 EAST MAIN STREET WAILUKU HI Home Health Agency HOME HEALTH AGENCY HALE MAKUA HOME HEALTH SERVICE 96793 360 PAPA PLACE SUITE 205 KAHULUI Home Health Agency HOME HEALTH AGENCY INTERIM HEALTHCARE KAHULUI HI 96732 40 ALA MALAMA STREET Home Health Agency HOME HEALTH AGENCY INTERIM HEALTHCARE MOLOKAI KAUNAKAKAI HI 96748 KAISER PERMANENTE HOME HEALTH 55 MAUI LANI PARKWAY WAILUKU HI Home Health Agency HOME HEALTH AGENCY AGENCY MAUI 96793 Home Health Agency HOME HEALTH AGENCY LANAI HOME HEALTH AGENCY P O BOX 763 LANAI CITY HI 96763 65 MAKAENA STREET KAUNAKAKAI Home Health Agency HOME HEALTH AGENCY MOLOKAI HOME HEALTH AGENCY HI 96748

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Facility Type Facility Sub‐Type Facility Name Address 400 MAHALANI STREET WAILUKU HI Hospice HOSPICE HOSPICE MAUI 96793 Hospital Critical Access Hospitals KULA HOSPITAL 100 KOKEA PLACE KULA HI 96790 280 HOME OLU PLACE KAUNAKAKAI Hospital Critical Access Hospitals MOLOKAI GENERAL HOSPITAL HI 96748 Hospital Short Term KULA HOSPITAL 100 KEOKEA PLACE KULA HI 96790 Hospital Short Term LANAI COMMUNITY HOSPITAL 628 7TH STREET LANAI CITY HI 96763 221 MAHALANI STREET WAILUKU HI Hospital Short Term MAUI MEMORIAL MEDICAL CENTER 96793 280 PUALI STREET KAUNAKAKAI HI Hospital Short Term MOLOKAI GENERAL HOSPITAL 96748 Intermediate Care Facility‐Mentally 95 MAHALANI STREET WAILUKU HI TITLE 19 ONLY HALE KIHEI HOUSING INC Retarded 96793 Intermediate Care Facility‐Mentally TITLE 19 ONLY KULA HOSPITAL 100 KEOKEA PLACE KULA HI 96790 Retarded Intermediate Care Facility‐Mentally 450‐B KANALOA AVENUE KAHULUI HI TITLE 19 ONLY THE ARC OF MAUI ‐ HALE KANALOA Retarded 96732 Intermediate Care Facility‐Mentally TITLE 19 ONLY THE ARC OF MAUI ‐ HALE KIHEI 179 HALE KAI STREET KIHEI HI 96753 Retarded Intermediate Care Facility‐Mentally 450 KANALOA AVENUE KAHULUI HI TITLE 19 ONLY THE ARC OF MAUI ‐ MANA OLA Retarded 96732 1540 LOWER MAIN STREET WAILUKU Nursing Facility TITLE 19 ONLY HALE MAKUA ‐ WAILUKU HI 96793 Nursing Facility TITLE 19 ONLY KULA HOSP ICF KULA HI 96790 Nursing Facility TITLE 19 ONLY LANI COMMUNITY HOSP ‐ SNF/ICF 729 7TH ST LANAI CITY HI 96763 Nursing Facility TITLE 19 ONLY MOLOKAI GENERAL HOSPITAL ICF/DP P O BOX 408 KAUNAKAKAI HI 96748 Outpatient Physical Therapy/Speech HEALTHSOUTH REHABILITATION 450 HOOKAHI STREET WAILUKU HI OPT OR SPEECH PATHOLOGY Pathology CENTER OF HAWAII 96793 Outpatient Physical Therapy/Speech 221 PIIKEA AVENUE, SUITE D KIHEI HI OPT OR SPEECH PATHOLOGY REHAB AT MAUI‐KIHEI Pathology 96753 Outpatient Physical Therapy/Speech 180 DICKENSON ST, STE 210 LAHAINA OPT OR SPEECH PATHOLOGY REHAB AT MAUI‐LAHAINA Pathology HI 96761 280 HOME OLU PLACE KAUNAKAKAI Rural Health Clinic RURAL HEALTH CLINICS MOLOKAI GENERAL HOSPITAL HI 96748

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Facility Type Facility Sub‐Type Facility Name Address Rural Health Clinic RURAL HEALTH CLINICS MOLOKAI RURAL HEALTH CLINIC PO BOX 408 KAUNAKAKAI HI 96748 Skilled Nursing Facility/Nursing 1540 EAST MAIN STREET WAILUKU HI TITLE 18/19 HALE MAKUA Facility (Dually Certified) 96793 Skilled Nursing Facility/Nursing 472 KAULANA STREET KAHULUI HI TITLE 18/19 HALE MAKUA ‐ KAHULUI Facility (Dually Certified) 96732 Skilled Nursing Facility/Nursing 1540 LOWER MAIN STREET WAILUKU TITLE 18/19 HALE MAKUA ‐ WAILUKU Facility (Dually Certified) HI 96793 Skilled Nursing Facility/Nursing TITLE 18/19 KULA HOSPITAL 100 KEOKEA PLACE KULA HI 96790 Facility (Dually Certified) Skilled Nursing Facility/Nursing TITLE 18/19 LANAI COMMUNITY HOSPITAL 628 7TH STREET LANAI CITY HI 96763 Facility (Dually Certified) Skilled Nursing Facility/Nursing 221 MAHALANI STREET WAILUKU HI TITLE 18/19 MAUI MEMORIAL MEDICAL CENTER Facility (Dually Certified) 96793 Skilled Nursing Facility/Nursing 280 HOME OLU PLACE KAUNAKAKAI TITLE 18/19 MOLOKAI GENERAL HOSPITAL Facility (Dually Certified) HI 96748

Licensed Facilities Reported by CMS: Honolulu County

Facility Type Facility Sub‐Type Facility Name Address CATARACT & VISION CENTER OF 1712 LILIHA STREET, SUITE 400 Ambulatory Surgical Center AMBULATORY SURGICAL CENTER HAWAII HONOLULU HI 96817 2226 LILIHA STREET #307 HONOLULU Ambulatory Surgical Center AMBULATORY SURGICAL CENTER HAWAII ENDOSCOPY CENTERS LLC HI 96817 606 KILANI AVENUE WAHIAWA HI Ambulatory Surgical Center AMBULATORY SURGICAL CENTER HAWAIIAN EYE CENTER 96786 550 S BERETANIA ST HONOLULU HI Ambulatory Surgical Center AMBULATORY SURGICAL CENTER HONOLULU MEDICAL GROUP,THE 96813 500 ALA MOANA BOULEVARD, Ambulatory Surgical Center AMBULATORY SURGICAL CENTER HONOLULU SPINE CENTER BUILDING 1, SUITE 301 HONOLULU HI 96813 KAISER PERMANENTE HONOLULU 1010 PENSACOLA STREET HONOLULU Ambulatory Surgical Center AMBULATORY SURGICAL CENTER CLINIC ‐ ASC HI 96814

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Facility Type Facility Sub‐Type Facility Name Address PACIFIC ASC LLC DBA EYE SURGERY 650 IWILEI RD, SUITE 225 HON HI Ambulatory Surgical Center AMBULATORY SURGICAL CENTER CTR OF HAWAII 96817 1520 LILIHA STREET SUITE 302 Ambulatory Surgical Center AMBULATORY SURGICAL CENTER PROFESSIONAL PLAZA ASC HONOLULU HI 96817 500 ALA MOANA BOULEVARD, Ambulatory Surgical Center AMBULATORY SURGICAL CENTER SURGICARE OF HAWAII TOWER 1 SUITE 1B HONOLULU HI 96813 1100 WARD AVENUE, SUITE 1001 Ambulatory Surgical Center AMBULATORY SURGICAL CENTER THE SURGICAL SUITES, LLC HONOLULU HI 96814 Comprehensive Outpatient Rehab 226 N KUAKINI STREET HONOLULU HI COMPREHENSIVE OUTPATIENT CORF OF HAWAII INC Facility 96817 Comprehensive Outpatient Rehab 550 S BERETANIA ST HONOLULU HI COMPREHENSIVE OUTPATIENT HONOLULU MEDICAL GROUP CORF Facility 96813 1520 LILIHA STREET HONOLULU HI End Stage Renal Disease Facility END STAGE RENAL DISEASE ALOHA DIALYSIS CENTER 96817 555 FARRINGTON HIGHWAY KAPOLEI End Stage Renal Disease Facility END STAGE RENAL DISEASE FMC DIALYSIS SERVICES OF KAPOL HI 96707 FMC‐DIALYSIS SERVICES OF 98‐1005 MOANALUA ROAD SUITE End Stage Renal Disease Facility END STAGE RENAL DISEASE PEARLRIDGE 420 AIEA HI 96701 45‐480 KANEOHE BAY DRIVE End Stage Renal Disease Facility END STAGE RENAL DISEASE FMC‐WINDWARD DIALYSIS CENTER KANEOHE HI 96744 FRESENIUS MEDICAL CARE ‐ 750 PALANI AVENUE HONOLULU HI End Stage Renal Disease Facility END STAGE RENAL DISEASE KAPAHULU 96816 47‐388 HUI IWA STREET KANEOHE HI End Stage Renal Disease Facility END STAGE RENAL DISEASE FRESENIUS MEDICAL CARE KO'OLAU 96744 226 NORTH KUAKINI STREET End Stage Renal Disease Facility END STAGE RENAL DISEASE HONOLULU DIALYSIS CENTER HONOLULU HI 96817 3625 HARDING AVENUE HONOLULU End Stage Renal Disease Facility END STAGE RENAL DISEASE KAIMUKI DIALYSIS FACILITY HI 96816 347 N KUAKINI STREET HONOLULU HI End Stage Renal Disease Facility END STAGE RENAL DISEASE KUAKINI DIDNEY DISEASE CENTER 96817 91‐2137 FORT WEAVER ROAD EWA End Stage Renal Disease Facility END STAGE RENAL DISEASE LEEWARD DIALYSIS FACILITY BEACH HI 96706

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Facility Type Facility Sub‐Type Facility Name Address LIBERTY DIALYSIS HAWAII LLC‐ 2230 LILIHA STREET HONOLULU HI End Stage Renal Disease Facility END STAGE RENAL DISEASE SIEMSEN DIALYSIS 96817 LIBERTY DIALYSIS HAWAII LLC‐ 86‐080 FARRINGTON HIGHWAY End Stage Renal Disease Facility END STAGE RENAL DISEASE WAIANAE DIALYSIS WAIANAE HI 96792 LIBERTY DIALYSIS‐HAWAII ‐ KAILUA 25 KANEOHE BAY DRIVE, SUITE 230 End Stage Renal Disease Facility END STAGE RENAL DISEASE DIALYSIS FACILITY KAILUA HI 96734 LIBERTY DIALYSIS‐HAWAII LLC‐ 91‐2137 FORT WEAVER ROAD EWA End Stage Renal Disease Facility END STAGE RENAL DISEASE LEEWARD DIALYSIS BEACH HI 96706 LIBERTY DIALYSIS‐HAWAII, WAIPAHU 94‐450 MOKUOLA STREET, SUITE 109 End Stage Renal Disease Facility END STAGE RENAL DISEASE DIALYSIS FACILITY WAIPAHU HI 96797 2230 LILIHA STREET HONOLULU HI End Stage Renal Disease Facility END STAGE RENAL DISEASE SIEMSEN DIALYSIS CENTER 96817 850 KILANI AVENUE WAHIAWA HI End Stage Renal Disease Facility END STAGE RENAL DISEASE WAHIAWA DIALYSIS CENTER 96786 86‐080 FARRINGTON HIGHWAY End Stage Renal Disease Facility END STAGE RENAL DISEASE WAIANAE DIALYSIS SATELLITE FAC WAIANAE HI 96792 HEALTHSOUTH REHABILITATION 1221 KAPIOLANI BOULEVARD, SUITE Extension or Branch OPT EXTENSION CENTER OF HAWAII 730 HONOLULU HI 96814 FEDERALLY QUALIFIED HEALTH 607 N KING STREET HONOLULU HI Federally Qualified Health Center ISLAND WEST CLINIC CENTER 96817 FEDERALLY QUALIFIED HEALTH 89 SOUTH KING STREET HONOLULU Federally Qualified Health Center KALIHI PALAMA HEALTH CENTER CENTER HI 96813 FEDERALLY QUALIFIED HEALTH Federally Qualified Health Center KALIHI‐PALAMA HEALTH CENTER 766 N KING ST HONOLULU HI 96817 CENTER FEDERALLY QUALIFIED HEALTH 525 FARRINGTON HIGHWAY, SUITE Federally Qualified Health Center KAPOLEI HEALTH CARE CENTER CENTER 102 KAPOLEI HI 96707 FEDERALLY QUALIFIED HEALTH KO'OLAULOA COMMUNITY HEALTH & 54‐316 KAMEHAMEHA HIGHWAY, Federally Qualified Health Center CENTER WELLNESS CENTER, INC SUITE 6 & 7 HAUULA HI 96717 FEDERALLY QUALIFIED HEALTH KO'OLAULOA COMMUNITY HEALTH & 56‐119 PUALALEA STREET KAHUKU HI Federally Qualified Health Center CENTER WELLNESS CENTER, INC 96731 FEDERALLY QUALIFIED HEALTH KO'OLAULOA COMMUNITY HEALTH & 56‐565 KAMEHAMEHA HIGHWAY Federally Qualified Health Center CENTER WELLNESS CENTERS KAHUKU HI 96731 FEDERALLY QUALIFIED HEALTH Federally Qualified Health Center KOKUA KALIHI VALLEY 1846 GULICK AVE HON HI 96819 CENTER

82

Facility Type Facility Sub‐Type Facility Name Address FEDERALLY QUALIFIED HEALTH KOKUA KALIHI VALLEY 1475 LINAPUNI STREET, BLDG A, #105 Federally Qualified Health Center CENTER COMPREHENSIVE FAMILY SERVICES HONOLULU HI 96819 FEDERALLY QUALIFIED HEALTH KOKUA KALIHI VALLEY 1846 GULICK AVENUE HONOLULU HI Federally Qualified Health Center CENTER COMPREHENSIVE FAMILY SERVICES 96819 FEDERALLY QUALIFIED HEALTH 952 NORTH KING STREET HONOLULU Federally Qualified Health Center KPHC BEHAVORAL HEALTH DEPT CENTER HI 96817 FEDERALLY QUALIFIED HEALTH 904 KOHOU STREET SUITES 306 & Federally Qualified Health Center KPHC ICM KOHOU CLINIC CENTER 307 HONOLULU HI 96819 FEDERALLY QUALIFIED HEALTH KPHC WOMEN & FAMILY SHELTER 546 KAAAHI STREET HONOLULU HI Federally Qualified Health Center CENTER KAAAHI ST CLINIC 96817 FEDERALLY QUALIFIED HEALTH 87‐2070 FARRINGTON HIGHWAY Federally Qualified Health Center LEEWARD PEDIATRICS CENTER WAIANAE HI 96792 FEDERALLY QUALIFIED HEALTH 101 NORTH PAUAHI STREET Federally Qualified Health Center RIVER OF LIFE MISSION SITE CENTER HONOLULU HI 96817 FEDERALLY QUALIFIED HEALTH 41 SOUTH BERENTANIA STREET Federally Qualified Health Center SAFE HAVEN SITE CENTER HONOLULU HI 96813 FEDERALLY QUALIFIED HEALTH 350 SUMNER STREET HONOLULU HI Federally Qualified Health Center SUMNER STREET CLINIC CENTER 96817 FEDERALLY QUALIFIED HEALTH WAIANAE COAST COMPREHENSIVE 86‐260 FARRINGTON HIGHWAY Federally Qualified Health Center CENTER HLTH CTR WAIANAE HI 96792 FEDERALLY QUALIFIED HEALTH 277 OHUA AVENUE HONOLULU HI Federally Qualified Health Center WAIKIKI HEALTH CENTER CENTER 96815 FEDERALLY QUALIFIED HEALTH 415 KEONIANA STREET HONOLULU HI Federally Qualified Health Center WAIKIKI HEALTH CENTER CENTER 96815 FEDERALLY QUALIFIED HEALTH 407 KAIOLU STREET HONOLULU HI Federally Qualified Health Center WAIKIKI HEALTH CENTER CENTER 96815 FEDERALLY QUALIFIED HEALTH WAIKIKI HEALTH CENTER ‐ HO'OLA KEY PROJECT, 47‐200 WAIHE ROAD Federally Qualified Health Center CENTER LIKE PROJECT KANEOHE HI 96744 FEDERALLY QUALIFIED HEALTH 41‐1347 KALANIANAOLE HIGHWAY Federally Qualified Health Center WAIMANALO HEALTH CENTER CENTER WAIMANALO HI 96795 FEDERALLY QUALIFIED HEALTH 86‐120 FARRINGTON HIGHWAY, Federally Qualified Health Center WAIOLA CLINIC CENTER SUITE 350‐B WAIANAE HI 96792 FEDERALLY QUALIFIED HEALTH 94‐428 MOKUOLA STREET, SUITE Federally Qualified Health Center WAIPAHU FAMILY HEALTH CENTER CENTER 108‐B WAIPAHU HI 96797

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Facility Type Facility Sub‐Type Facility Name Address 680 IWILEI ROAD, SUITE 660 Home Health Agency HOME HEALTH AGENCY CARERESOURCE HAWAII HONOLULU HI 96817 702 SOUTH BERETANIA ST, SUITE 3‐A Home Health Agency HOME HEALTH AGENCY CARERESOURCE HAWAII HONOLULU HI 96813 46 001 KAMEHAMEHA HIGHWAY, Home Health Agency HOME HEALTH AGENCY CASTLE HOME CARE SUITE 212 KANEOHE HI 96744 860 IWILEI ROAD HONOLULU HI Home Health Agency HOME HEALTH AGENCY HOSPICE HAWAII INC 96817 1441 KAPIOLANI BLVD SUITE 1320 Home Health Agency HOME HEALTH AGENCY INTERIM HEALTHCARE HONOLULU HONOLULU HI 96814 56‐117 PUALALEA STREET KAHUKU HI Home Health Agency HOME HEALTH AGENCY KAHUKU HOSPITAL HHA 96731 KAISER HOME HEALTH AGENCY ‐ 2828 PA'A STREET #2048 HONOLULU Home Health Agency HOME HEALTH AGENCY OAHU HI 96819 94‐479 UKE'E STREET, SUITE 201 Home Health Agency HOME HEALTH AGENCY KAPIOLANI HOME HEALTH SERVICES WAIPAHU HI 96797 1210 ARTESIAN STREET, SUITE 201 Home Health Agency HOME HEALTH AGENCY KOKUA NURSES INC HONOLULU HI 96826 1027 HALA DRIVE HONOLULU HI Home Health Agency HOME HEALTH AGENCY MALUHIA HOME HEALTH CARE 96817 3375 KOAPAKA STREET, SUITE I‐570 Home Health Agency HOME HEALTH AGENCY PRIME CARE SERVICES HAWAII INC HONOLULU HI 96819 2226 LILIHA STREET, SUITE 505 Home Health Agency HOME HEALTH AGENCY ST FRANCIS HOME CARE SERVICES HONOLULU HI 96817 Home Health Agency HOME HEALTH AGENCY STRAUB HOME HEALTH AGENCY 641 KAILUA ROAD KAILUA HI 96734 Home Health Agency HOME HEALTH AGENCY UPJOHN HOME HEALTH AGENCY 210 WARD AVE HONOLULU HI 96814 Home Health Agency HOME HEALTH AGENCY WAHIAWA GENERAL HOSP HHA 128 LEHUA ST WAHIAWA HI 96786 1008 CALIFORNIA AVENUE, UNIT Home Health Agency HOME HEALTH AGENCY WAHIAWA GENERAL HOSPITAL HHA A101 WAHIAWA HI 96786 WAIANAE COAST COMPREHENSIVE 86‐260 FARRINGTON HIGHWAY Home Health Agency HOME HEALTH AGENCY HEALTH CTR WAIANAE HI 96792 500 ALA MOANA BOULEVARD, SUITE Hospice HOSPICE BRISTOL HOSPICE ‐ HAWAII, LLC 4‐545 AND 547 HONOLULU HI 96813 Hospice HOSPICE HOSPICE HAWAII 860 IWILEI RD HONOLULU HI 96817

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Facility Type Facility Sub‐Type Facility Name Address 560 NORTH NIMITZ HIGHWAY, SUITE Hospice HOSPICE ISLANDS HOSPICE 204 HONOLULU HI 96817 24 PUIWA ROAD HONOLULU HI Hospice HOSPICE ST FRANCIS HOSPICE 96817 Hospital HALE MOHALU HOSP PEARL CITY HI 96782 1310 PUNAHOU STREET HONOLULU Hospital SHRINERS HOSPITALS FOR CHILDREN HI 96826 459 PATTERSON ROAD HONOLULU HI Hospital VA PACIFIC ISLANDS HCS 96819 WAIMANO TRAINING SCHOOL & Hospital PEARL CITY HI 96782 HOSP KAPIOLANI MEDICAL CENTER FOR 1319 PUNAHOU STREET HONOLULU Hospital CHILDRENS WOMEN & CHILDREN HI 96826 1310 PUNAHOU STREET HONOLULU Hospital CHILDRENS SHRINERS HOSPITAL FOR CHILDREN HI 96826 56‐117 PUALALEA STREET KAHUKU HI Hospital CRITICAL ACCESS HOSPITALS KAHUKU MEDICAL CENTER 96731 3675 KILAUEA AVENUE HONOLULU Hospital LONG TERM LEAHI HOSPITAL HI 96816 47‐710 KEAAHALA ROAD KANEOHE HI Hospital PSYCHIATRIC HAWAII STATE HOSP 96744 91‐2301 FORT WEAVER ROAD EWA Hospital PSYCHIATRIC KAHI MOHALA BEACH HI 96706 REHABILITATION HOSPITAL OF THE 226 N KUAKINI STREET HONOLULU HI Hospital REHABILITATION PACIFIC 96817 Hospital SHORT TERM CASTLE MEDICAL CENTER 640 ULUKAHIKI ST KAILUA HI 96734 2230 LILIHA STREET HONOLULU HI Hospital SHORT TERM HAWAII MEDICAL CENTER EAST 96817 91‐2141 FORT WEAVER ROAD EWA Hospital SHORT TERM HAWAII MEDICAL CENTER WEST BEACH HI 96706 56‐117 PUALALEA STREET KAHUKU HI Hospital SHORT TERM KAHUKU HOSPITAL 96731 3288 MOANALUA RD HONOLULU HI Hospital SHORT TERM KAISER FOUNDATION HOSPITAL 96819

85

Facility Type Facility Sub‐Type Facility Name Address 347 NORTH KUAKINI STREET Hospital SHORT TERM KUAKINI MEDICAL CENTER HONOLULU HI 96817 98‐1079 MOANALUA ROAD AIEA HI Hospital SHORT TERM PALI MOMI MEDICAL CENTER 96701 1301 PUNCHBOWL ST, Hospital SHORT TERM SELECT SPECIALTY HOSPITAL KAMAHEMAHA, 3RD FLOOR HONOLULU HI 96813 888 SO KING STREET HONOLULU HI Hospital SHORT TERM STRAUB CLINIC AND HOSPITAL 96813 1301 PUNCHBOWL ST HONOLULU HI Hospital SHORT TERM THE QUEENS MEDICAL CENTER 96813 128 LEHUA STREET WAHIAWA HI Hospital SHORT TERM WAHIAWA GENERAL HOSPITAL 96786 2230 LILIHA STREET, HONOLULU HI Hospital TRANSPLANT HOSPITALS HAWAII MEDICAL CENTER EAST 96817 1301 PUNCHBOWL STREET HON HI Hospital TRANSPLANT HOSPITALS THE QUEEN'S MEDICAL CENTER 96813 Intermediate Care Facility‐Mentally 1316 DOMINIS ST HONOLULU HI TITLE 19 ONLY ARC IN HAWAII ‐ DOMINIS Retarded 96822 Intermediate Care Facility‐Mentally 91‐824 A HANAKAHI ST EWA BEACH TITLE 19 ONLY ARC IN HAWAII ‐ EWA A Retarded HI 96706 Intermediate Care Facility‐Mentally 99‐545 HALAWA HEIGHTS RD AIEA HI TITLE 19 ONLY ARC IN HAWAII ‐ HALAWA Retarded 96701 Intermediate Care Facility‐Mentally OPPORTUNITIES AND RESOURCES, 64‐1510 KAMEHAMEHA HIGHWAY TITLE 19 ONLY Retarded INC (HOUSE 1‐A) WAHIAWA HI 96786 Intermediate Care Facility‐Mentally OPPORTUNITIES AND RESOURCES, 64‐1510 KAMEHAMEHA HIGHWAY TITLE 19 ONLY Retarded INC (HOUSE 1‐B) WAHIAWA HI 96786 Intermediate Care Facility‐Mentally OPPORTUNITIES AND RESOURCES, 64‐1510 KAMEHAMEHA HIGHWAY TITLE 19 ONLY Retarded INC (HOUSE 1‐C) WAHIAWA HI 96786 Intermediate Care Facility‐Mentally OPPORTUNITIES AND RESOURCES, 64‐1510 KAMEHAMEHA HIGHWAY TITLE 19 ONLY Retarded INC (HOUSE 2‐A) WAHIAWA HI 96786 Intermediate Care Facility‐Mentally OPPORTUNITIES AND RESOURCES, 64‐1510 KAMEHAMEHA HIGHWAY TITLE 19 ONLY Retarded INC (HOUSE 3‐A) WAHIAWA HI 96786

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Facility Type Facility Sub‐Type Facility Name Address Intermediate Care Facility‐Mentally OPPORTUNITIES AND RESOURCES, 64‐1510 KAMEHAMEHA HIGHWAY TITLE 19 ONLY Retarded INC (HOUSE 3‐B) WAHIAWA HI 96786 Intermediate Care Facility‐Mentally OPPORTUNITIES AND RESOURCES, 64‐1510 KAMEHAMEHA HIGHWAY TITLE 19 ONLY Retarded INC (HOUSE 3‐C) WAHIAWA HI 96786 Intermediate Care Facility‐Mentally 2240 WILSON ST HONOLULU HI TITLE 19 ONLY RESEARCH CENTER OF HAWAII Retarded 96819 Intermediate Care Facility‐Mentally 911 LALASWAI ST WAHIAWA HI TITLE 19 ONLY RESEARCH CENTER OF HAWAII Retarded 96786 Intermediate Care Facility‐Mentally TITLE 19 ONLY RESEARCH CENTER OF HAWAII 268 KILEA ST WAHIAWA HI 96786 Retarded Intermediate Care Facility‐Mentally 91‐1020 KEKAIHILI PLACE EWA TITLE 19 ONLY RESEARCH CENTER OF HAWAII Retarded BEACH HI 96706 Intermediate Care Facility‐Mentally 94‐547 ANA AINA PLACE WAIPAHU HI TITLE 19 ONLY RESEARCH CENTER OF HAWAII Retarded 96797 Intermediate Care Facility‐Mentally 91‐838 KEHUE ST EWA BEACH HI TITLE 19 ONLY RESEARCH CENTER OF HAWAII Retarded 96706 Intermediate Care Facility‐Mentally 94‐1032 LUMIKULA ST WAIPAHU HI TITLE 19 ONLY RESEARCH CENTER OF HAWAII Retarded 96797 Intermediate Care Facility‐Mentally 2467 N. SCHOOL ST HONOLULU HI TITLE 19 ONLY RESEARCH CENTER OF HAWAII Retarded 96819 Intermediate Care Facility‐Mentally 94‐1149 HOOMAKOA ST WAIPAHU HI TITLE 19 ONLY RESEARCH CENTER OF HAWAII Retarded 96797 Intermediate Care Facility‐Mentally TITLE 19 ONLY RESEARCH CENTER OF HAWAII 94‐943 HIAPO ST WAIPAHU HI 96797 Retarded Intermediate Care Facility‐Mentally 94‐511 APII STREET WAIPAHU HI TITLE 19 ONLY RESEARCH CENTER OF HAWAII Retarded 96797 Intermediate Care Facility‐Mentally 1018 MCCANDLESS LANE HONOLULU TITLE 19 ONLY RESEARCH CENTER OF HAWAII Retarded HI 96817 Intermediate Care Facility‐Mentally 94‐912 KUMUAO ST WAIPAHU HI TITLE 19 ONLY RESEARCH CTR OF HI ‐ WAIPAHU III Retarded 96797 Intermediate Care Facility‐Mentally 911‐A LALAWAI ST WAHIAWA HI TITLE 19 ONLY RESEARCH CTR OF HI ‐ WHITMORE Retarded 96786 Intermediate Care Facility‐Mentally 99‐112 PUAKALA STREET AIEA HI TITLE 19 ONLY RESPONSIVE CAREGIVERS OF HAWAII Retarded 96701

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Facility Type Facility Sub‐Type Facility Name Address Intermediate Care Facility‐Mentally 94‐1054 LUMIKULA STREET WAIPAHU TITLE 19 ONLY RESPONSIVE CAREGIVERS OF HAWAII Retarded HI 96797 Intermediate Care Facility‐Mentally 99‐226 OHENANA PLACE AIEA HI TITLE 19 ONLY RESPONSIVE CAREGIVERS OF HAWAII Retarded 96701 Intermediate Care Facility‐Mentally 852 PAAHANA STREET HONOLULU HI TITLE 19 ONLY THE ARC IN HAWAII ‐ 6 A Retarded 96816 Intermediate Care Facility‐Mentally 852‐A PAAHANA STREET HONOLULU TITLE 19 ONLY THE ARC IN HAWAII ‐ 6 B Retarded HI 96816 Intermediate Care Facility‐Mentally 91‐824 B HANAKAHI STREET EWA TITLE 19 ONLY THE ARC IN HAWAII ‐ EWA B Retarded BEACH HI 96706 Intermediate Care Facility‐Mentally 91‐824 C HANAKAHI STREET EWA TITLE 19 ONLY THE ARC IN HAWAII ‐ EWA C Retarded BEACH HI 96706 Intermediate Care Facility‐Mentally 3705 MAHINA AVENUE HONOLULU TITLE 19 ONLY THE ARC IN HAWAII ‐ KAIMUKI A Retarded HI 96816 Intermediate Care Facility‐Mentally 811 19TH AVENUE HONOLULU HI TITLE 19 ONLY THE ARC IN HAWAII ‐ KAIMUKI B Retarded 96816 Intermediate Care Facility‐Mentally 140‐A KUAHIWI AVENUE WAHIAWA TITLE 19 ONLY THE ARC IN HAWAII ‐ WAHIAWA A Retarded HI 96786 Intermediate Care Facility‐Mentally WAIMANO TRAINING SCHOOL AND 2201 WAIMANO HOME ROAD PEARL TITLE 19 ONLY Retarded HOSPITAL CITY HI 96782 45‐545 KAMEHAMEHA HWY Nursing Facility TITLE 19 ONLY ALOHA HEALTH CARE CENTER KANEOHE HI 96744 ANN PEARL INTERMEDIATE CARE 45‐181 WAIKALUA RD KANEOHE HI Nursing Facility TITLE 19 ONLY FACILITY 96744 1930 KAM IV ROAD HONOLULU HI Nursing Facility TITLE 19 ONLY BEVERLY MANOR CONV CTR 96819 58‐130 KAMEHAMEHA HIGHWAY Nursing Facility TITLE 19 ONLY CRAWFORD`S CONVALESCENT HOME HALEIWA HI 96712 6163 SUMMER ST HONOLULU HI Nursing Facility TITLE 19 ONLY HALE MALAMALAMA 96821 1677 PENSACOLA ST HONOLULU HI Nursing Facility TITLE 19 ONLY HALE NANI HEALTH CENTER 96822 45‐090 NAMOKU ST KANEOHE HI Nursing Facility TITLE 19 ONLY KAHANAOLA CONV HOSP 96744

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Facility Type Facility Sub‐Type Facility Name Address 347 N KUAKINI ST HONOLULU HI Nursing Facility TITLE 19 ONLY KUAKINI MEDICAL CTR ICF 96817 3675 KILAUEA AVE HONOLULU HI Nursing Facility TITLE 19 ONLY LEAHI HOSPITAL ICF/DP 96816 Nursing Facility TITLE 19 ONLY LEEWARD NURSING HOME 84‐390 JADE ST WAIANAE HI 96792 Nursing Facility TITLE 19 ONLY LILIHA HEALTHCARE CENTER 1814 LILIHA ST HONOLULU HI 96817 Nursing Facility TITLE 19 ONLY OAHU CARE FACILITY 1808 S BERETANIA ST HON HI 96822 Nursing Facility TITLE 19 ONLY WAHIAWA GEN HOSP ICF 128 LEHUA ST WHIAWA HI 96786 WAIMANO TRAINING SCHOOL & 2201 WAIMANO HOME ROAD PEARL Nursing Facility TITLE 19 ONLY HOSPITAL CITY HI 96782 WAIMANO TRAINING SCHOOL AND WAIMANO HOME RD PEARL CITY HI Nursing Facility TITLE 19 ONLY HOSPITAL 96782 405 NORTH KUAKINI STREET, SUIT Organ Procurement Organization ORGAN PROCUREMENT LEGACY OF LIFE HAWAII 810 HONOLULU HI 96817 Outpatient Physical Therapy/Speech 863 HALEKAUWILA STREET, SUITE A OPT OR SPEECH PATHOLOGY ACTION REHAB Pathology HONOLULU HI 96813 Outpatient Physical Therapy/Speech HALE NANI REHABILITATION & 1677 PENSACOLA STREET HONOLULU OPT OR SPEECH PATHOLOGY Pathology NURSING CTR HI 96822 Outpatient Physical Therapy/Speech HEALTHSOUTH REHABILITATION 3221 WAIALAE AVENUE, SUITE 360 OPT OR SPEECH PATHOLOGY Pathology CENTER OF KAIMUKI HONOLULU HI 96816 Outpatient Physical Therapy/Speech HEALTHSOUTH REHABILITATION CTR 94 307 FARRINGTON HWY A 11 OPT OR SPEECH PATHOLOGY Pathology WAIPAHU WAIPAHU HI 96797 Outpatient Physical Therapy/Speech 98‐1005 MOANALUA ROAD, STE 425 OPT OR SPEECH PATHOLOGY REHAB AT AIEA Pathology AIEA HI 96701 Outpatient Physical Therapy/Speech SUNDANCE REHABILITATION OPT OR SPEECH PATHOLOGY 406 ULUNIU STREET KAILUA HI 96734 Pathology THERAPY 1502 PENSACOLA STREET, SUITE B‐1 Portable X‐Ray Supplier X‐RAY ALOHA MOBILE IMAGING HONOLULU HI 96822 1010 S KING STREET, SUITE B6 Portable X‐Ray Supplier X‐RAY PACIFIC MOBILE IMAGING, LLC HONOLULU HI 96814 1380 LUSITANA ST, #215 HONOLULU Portable X‐Ray Supplier X‐RAY PORTA‐MED OF HAWAII HI 96813 1434 PUNAHOU STREET HONOLULU Skilled Nursing Facility TITLE 18 ONLY ARCADIA RETIREMENT RESIDENCE HI 96822

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Facility Type Facility Sub‐Type Facility Name Address REHABILITATION HOSPITAL OF THE 226 NORTH KUAKINI STREET Skilled Nursing Facility TITLE 18 ONLY PACIFIC HONOLULU HI 96817 Skilled Nursing Facility/Nursing 1314 KALAKAUA AVENUE, 2ND TITLE 18/19 HALE OLA KINO Facility (Distinct Part) FLOOR HONOLULU HI 96826 Skilled Nursing Facility/Nursing HI'OLANI CARE CENTER AT KAHALA 4389 MALIA STREET HONOLULU HI TITLE 18/19 Facility (Distinct Part) NUI 96821 Skilled Nursing Facility/Nursing MAUNALANI NURSING AND 5113 MAUNALANI CIRCLE HONOLULU TITLE 18/19 Facility (Distinct Part) REHABILITATION CENTER HI 96816 Skilled Nursing Facility/Nursing 15 CRAIGSIDE PLACE HONOLULU HI TITLE 18/19 15 CRAIGSIDE Facility (Dually Certified) 96817 Skilled Nursing Facility/Nursing 45‐545 KAMEHAMEHA HIGHWAY TITLE 18/19 ALOHA NURSING & REHAB CENTRE Facility (Dually Certified) KANEOHE HI 96744 Skilled Nursing Facility/Nursing 45‐181 WAIKALUA ROAD KANEOHE TITLE 18/19 ANN PEARL NURSING FACILITY Facility (Dually Certified) HI 96744 Skilled Nursing Facility/Nursing AVALON CARE CENTER ‐ HONOLULU, 1930 KAMEHAMEHA IV RD TITLE 18/19 Facility (Dually Certified) LLC HONOLULU HI 96819 Skilled Nursing Facility/Nursing 640 ULUKAHIKI STREET KAILUA HI TITLE 18/19 CASTLE MEDICAL CENTER Facility (Dually Certified) 96734 Skilled Nursing Facility/Nursing CONVALESCENT CENTER OF 1900 BACHELOT STREET HONOLULU TITLE 18/19 Facility (Dually Certified) HONOLULU HI 96817 Skilled Nursing Facility/Nursing 6163 SUMMER STREET HONOLULU HI TITLE 18/19 HALE MALAMALAMA Facility (Dually Certified) 96821 Skilled Nursing Facility/Nursing HALE NANI REHABILITATION AND 1677 PENSACOLA STREET HONOLULU TITLE 18/19 Facility (Dually Certified) NURSING CENTER HI 96822 Skilled Nursing Facility/Nursing HARRY AND JEANETTE WEINBERG 45‐090 NAMOKU ST KANEOHE HI TITLE 18/19 Facility (Dually Certified) CARE CENTER 96744 Skilled Nursing Facility/Nursing 2230 LILIHA STREET HONOLULU HI TITLE 18/19 HAWAII MEDICAL CENTER EAST Facility (Dually Certified) 96817 Skilled Nursing Facility/Nursing 1205 ALEXANDER STREET HONOLULU TITLE 18/19 ISLAND NURSING HOME Facility (Dually Certified) HI 96826 Skilled Nursing Facility/Nursing 91‐575 FARRINGTON HIGHWAY TITLE 18/19 KA PUNAWAI OLA Facility (Dually Certified) KAPOLEI HI 96707 Skilled Nursing Facility/Nursing 56‐117 PUALALEA STREET KAHUKU HI TITLE 18/19 KAHUKU MEDICAL CENTER Facility (Dually Certified) 96731

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Facility Type Facility Sub‐Type Facility Name Address Skilled Nursing Facility/Nursing KFH ‐ MALAMA 'OHANA NURSING 3288 MOANALUA ROAD HONOLULU TITLE 18/19 Facility (Dually Certified) AND REHAB CENTER HI 96819 Skilled Nursing Facility/Nursing 347 NORTH KUAKINI STREET TITLE 18/19 KUAKINI GERIATRIC CARE Facility (Dually Certified) HONOLULU HI 96817 Skilled Nursing Facility/Nursing 91‐1360 KARAYAN STREET EWA TITLE 18/19 KULANA MALAMA Facility (Dually Certified) BEACH HI 96706 Skilled Nursing Facility/Nursing 3675 KILAUEA AVENUE HONOLULU TITLE 18/19 LEAHI HOSPITAL Facility (Dually Certified) HI 96816 Skilled Nursing Facility/Nursing LEEWARD INTEGRATED HEALTH 84‐390 JADE STREET WAIANAE HI TITLE 18/19 Facility (Dually Certified) SERVICES 96792 Skilled Nursing Facility/Nursing 1814 LILIHA STREET HONOLULU HI TITLE 18/19 LILIHA HEALTHCARE CENTER Facility (Dually Certified) 96817 Skilled Nursing Facility/Nursing 3288 MOANALUA ROAD HONOLULU TITLE 18/19 MALAMA OHANA SCF Facility (Dually Certified) HI 96819 Skilled Nursing Facility/Nursing 1027 HALA DRIVE HONOLULU HI TITLE 18/19 MALUHIA Facility (Dually Certified) 96817 Skilled Nursing Facility/Nursing 2900 PALI HIGHWAY HONOLULU HI TITLE 18/19 NUUANU HALE Facility (Dually Certified) 96817 Skilled Nursing Facility/Nursing 1808 SOUTH BERETANIA STREET TITLE 18/19 OAHU CARE FACILITY Facility (Dually Certified) HONOLULU HI 96826 Skilled Nursing Facility/Nursing 2459 10TH AVENUE HONOLULU HI TITLE 18/19 PALOLO CHINESE HOME Facility (Dually Certified) 96816 Skilled Nursing Facility/Nursing 919 LEHUA AVENUE PEARL CITY HI TITLE 18/19 PEARL CITY NURSING HOME Facility (Dually Certified) 96782 Skilled Nursing Facility/Nursing 1301 PUNCHBOWL STREET TITLE 18/19 THE QUEEN`S MEDICAL CENTER Facility (Dually Certified) HONOLULU HI 96813 Skilled Nursing Facility/Nursing 128 LEHUA STREET WAHIAWA HI TITLE 18/19 WAHIAWA GENERAL HOSPITAL Facility (Dually Certified) 96786 1 JARRETT WHITE ROAD HONOLULU Hospital US ARMY TRIPLER GEN HOSP HI 96859

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Appendix E: Referenced Reports

While only some of the following reports are referenced throughout the report, the list below includes all previously published reports that contributed to the authors’ understanding of the health needs of Molokai. These reports may be useful for further assessment and planning.

Chronic Disease Disparities Report 2011: Social Determinants Chronic Disease Management and Control Branch, Hawaii State Department of Health http://hawaii.gov/health/family‐child‐health/chronic‐disease/reports/CD_BurdenReport_FINAL.pdf

The Burden of Cardiovascular Disease in Hawaii 2007 Hawaii State Department of Health, Community Health Division http://hawaii.gov/health/family‐child‐health/chronic‐disease/cvd/CVD2007.pdf

State of Hawaii Maternal & Child Health Needs Assessment Summary 2010 Family Health Services Division, Department of Health, State of Hawaii http://hawaii.gov/health/doc/MCH‐NASummary2010

State of Hawaii Primary Care Needs Assessment Data Book 2012 Family Health Services Division, Hawaii Department of Health http://hawaii.gov/health/doc/pcna2012databook.pdf

Hawaii Community Health Needs Assessment Kaiser Foundation Health Plan of Hawaii https://healthy.kaiserpermanente.org/static/health/pdfs/how_to_get_care/hi_community_voices_on_health.pdf

Special Action Team Report to the Governor on Revitalization of the Adult Mental Health System and Effective Management of the Hawaii State Hospital Census October 2012 Hawaii Department of Health http://www.amhd.org/SAT%20Report.pdf

A Costly Dental Destination The Pew Center on the States, Pew Research Center http://www.pewstates.org/uploadedFiles/PCS_Assets/2012/A%20Costly%20Dental%20Destination(1).pdf

Falling Short: Most States Lag on Dental Sealants The Pew Center on the States, Pew Research Center http://www.pewstates.org/uploadedFiles/PCS_Assets/2013/Pew_dental_sealants_report.pdf

The State of Children's Dental Health: Making Coverage Matter The Pew Center on the States, Pew Research Center http://www.pewtrusts.org/uploadedFiles/wwwpewtrustsorg/Reports/State_policy/Childrens_Dental_50_State_Re port_2011.pdf

Molokai: Future of a Hawaiian Island Prepared by members of the Molokai community http://molokai.org/fileadmin/user/pdf/molokai.pdf

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Appendix F: Road map to IRS Requirements in Schedule H Form

All IRS 990 requirements are met by this CHNA in the referenced sections: Community Health Needs Assessment Requirements ‐ SCHEDULE H Reference (Form 990) http://www.irs.gov/pub/irs‐pdf/f990sh.pdf The definition of the community served by the hospital facility Section 1.2 Demographics of the community Section 3.1 Existing health care facilities and resources within the community Appendix D that are available to respond to the health needs of the community How data was obtained Section 2.1 ‐ 2.4 The health needs of the community, including the primary and Section 3.2 chronic disease needs and other health issues of uninsured persons, low‐income persons, and minority groups The process for identifying and prioritizing community health needs Section 5 and services to meet the community health needs The process for consulting with persons representing the Section 2.3 community's interests Information gaps that limit the hospital facility's ability to assess all Section 4.1.2 of the community's health needs Make CHNA widely available to the public www.molokaigeneralhospital.org

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Appendix G: Authors

Jenny Belforte, MPH HCI Account Manager Project Manager

Jennifer Carter, MPH HCI Researcher Lead Project Researcher

Florence Reinisch, MPH HCI Senior Vice President of Strategic Planning Senior Project Advisor

Diana Zheng HCI Researcher Project Researcher

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