Closing the Gap: Culturally Responsive, Value-Based Care for Native Hawaiian & Pacific Islander (NHPI) Communities

Native Hawaiian and Pacific Islander (NHPI) communities face disproportionate burdens of chronic disease, access barriers, and socioeconomic stressors. Life expectancy for Native Hawaiians is roughly a decade below the state average; Pacific Islanders experience a 3× higher risk of diabetes-related death; NHPI youth have higher obesity and lower activity rates; and only ~20% of NHPI adults access mental health care compared with ~45% of non-Hispanic white adults. These are not isolated statistics—they reflect structural inequities that demand targeted, culturally grounded solutions.

What Works: Community-Led, Culturally Competent Care

• Community Health Access Points: Federally qualified health centers, church- and village-based clinics, and mobile units staffed by bilingual, culturally aware teams.
• Telehealth & Hybrid Models: Low-bandwidth video/phone, hub-and-spoke tele-specialty consults, and after-hours access to reduce travel/time costs.
• Prevention First: Culturally tailored diabetes, hypertension, and cancer screening campaigns; school- and canoe club–based activity and nutrition programs.
• Mental Health Integration: Warm handoffs in primary care, peer navigators, traditional healing integration, and stigma-reducing group formats.
• Language & Literacy: Plain-language materials in ʻŌlelo Hawaiʻi, Samoan, Tongan, Chuukese, Marshallese; interpreter services embedded in scheduling and visits.

A Value-Based Care Playbook for NHPI Health

1. Stratify & Find the Gap: Build NHPI registries using EHR + payer data; segment by SDOH, language, geography, and clinical risk.
2. Design Team-Based Models: PCP + community health worker + behavioral health + pharmacist; embed peer navigators and cultural liaisons.
3. Bundle Preventive Services: Same-day BP, A1c, retinal/photo screening; cancer screening with navigation and transport vouchers.
4. Contract for Outcomes: Tie incentives to BP control, A1c <8%, cancer screening completion, depression remission, avoidable ED reductions.
5. Measure Equity Explicitly: Track outcome differences by ethnicity, language, island/zip; publish dashboards with community partners.

Data & Digital Enablers (Built for Access, Not Just Analytics)

• SDOH capture in EHR (housing, food, transport) with closed-loop referral networks to local CBOs.
• Text-first outreach, offline-capable patient apps, and community Wi-Fi kiosks; consent in preferred language.
• RPM starter kits (BP cuff, glucometer) with data plans and loaner devices; bilingual tech support.
• Privacy by design: encryption, role-based access, culturally transparent data use statements.

Policy & Community Levers

• Coverage & Payment: Expand Medicaid eligibility; reimburse CHWs, interpreters, and tele-BH; support value-based primary care.
• Food & Activity: Produce Rx; healthy school meals; safe walking paths and ocean access; partnerships with canoe clubs and churches.
• Workforce: Scholarships and pipelines for NHPI clinicians; upskill CHWs; pay differentials for rural/outer island service.

NHPI Equity Implementation Checklist

1. NHPI data fields standardized in EHR (ethnicity/language) and used in dashboards
2. Community advisory board with NHPI representation meets quarterly
3. Bilingual CHWs and interpreters embedded in clinics and call centers
4. Telehealth platform supports low-bandwidth + interpreter three-way calling
5. Co-designed education materials (ʻŌlelo Hawaiʻi, Samoan, Tongan, etc.)
6. Same-day screening bundles & navigation for diabetes, HTN, cancer
7. Mental health integration with warm handoffs + peer support
8. Transportation/childcare vouchers tied to visits and procedures
9. Equity incentives in contracts; quarterly equity review with action plans
10. Public reporting of 3–5 equity KPIs with community partners

Partner with MGA on an NHPI Equity Acceleration Plan

Note: Strategies should be co-created with NHPI leaders and adapted to local languages, islands, and cultures.