Hawaii is known for its beautiful beaches and lush fauna. But its geographical isolation and limited resources can result in poor communication among health care providers, leading to gaps in care and poor care coordination.

Mountain-Pacific Quality Health—the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Montana, Wyoming, Hawaii, Alaska, the U.S. Pacific Islands of Guam and American Samoa, and the Commonwealth of the Northern Mariana Islands—is embracing “laulima,” the Hawaiian word meaning “hands working together,”—and a core principle of Hawaiian culture—to improve care coordination and health outcomes for Medicare beneficiaries in the state.

An integral part of all hands working together is ensuring all hands are included and involved. Mountain-Pacific has recruited partners and stakeholders from across the care spectrum, including hospitals and health systems, skilled nursing facilities, pharmacies and community-based organizations, to form community coalitions across the state.

“There are many lessons learned from community-building activities, but most important is always keeping patients first.”

The coalitions develop interventions that improve provider communication about a beneficiary’s transfer to another health care facility after being discharged from the hospital, or about available health care services and resources in the community. These interventions often target providers who care for Medicare beneficiaries with multiple chronic conditions such as heart failure, heart disease, chronic obstructive pulmonary disease (COPD) and diabetes, as these beneficiaries are more likely to be readmitted to the hospital within 30 days of discharge.

“The coalitions are a cohesive community of cross-setting providers that come together to improve care coordination, the discharge process during transitions of care, and provider communications,” said a Mountain-Pacific Hawaii team member. “There are many lessons learned from community-building activities, but most important is always keeping patients first.”

Mountain-Pacific supports coalition work by fostering relationships with key partners in each community and by developing tools and resources to improve communication and coordination among providers. For example, Mountain-Pacific created a minimum discharge requirement checklist for the Honolulu Community Coalition to show providers what services a beneficiary will need after hospital discharge and who in the community can provide that service.

The ease of accessing resources is another important component of all hands working together. In Honolulu, the coalition recently developed the 808 Community Partner website, hosted by Mountain-Pacific. The site organizes community resources in one place to help providers and coalition members meet the needs of beneficiaries and their caregivers during transitions of care. The website is currently in beta testing and will launch in February 2019.

Mountain-Pacific tracks the success of coalitions in several communities using an assessment that generates a performance score based on the coalition’s progression toward the goal of implementing effective interventions to prevent avoidable inpatient hospitalizations. The data from the assessments is used to monitor trends in the community and is shared with the coalition, whose members share it with senior leadership.

Mountain-Pacific Quality Health’s efforts have brought a new level of awareness to the need to improve care coordination, which has become an ongoing quality initiative in many communities throughout Hawaii. Many of the interventions that have been implemented in these communities are now standard policy and process, and coalitions continue to meet regularly to share barriers, resources and best practices to support sustainability.