As a Community, We CAN: How Collaboration in East Hawai'i Led to Community-Wide Initiatives Focused on Reducing Avoidable Emergency Department Visits and Inpatient Admissions.

East Hawai'i and its local hospital face unsustainable cost and health care utilization trends. The medical and social service organizations in this region, which includes the city of Hilo and its surrounding area on Hawai'i Island, previously worked in silos regarding coordination of patient care. To mitigate these factors, community initiatives have been implemented to address the needs of high-cost, high-need (HCHN) patients. Can community initiatives that better coordinate medical and social services to directly address social determinants of health improve quality of care and reduce utilization of emergency department (ED) and inpatient (IP) resources? Respected community leaders and diverse stakeholders in East Hawai'i have organized a community to improve health while lowering costs, influence legislative policy, and work collaboratively with the largest health plan in Hawai'i and the local hospital to change health care delivery. A population of patients with high cost, utilization, and disease burden was identified. A model of care was developed with 2 centers of excellence, providing care coordination across medical and social services. Community health workers (CHWs) were added to help patients navigate the system, comply with treatment plans, and request exception funding. A community forum for medical and social services has been established and an online referral system improves efficiency and accountability. Finally, a community quality assurance (QA) committee is being put into place to drive systemic improvements. The community approach adopted in East Hawai'i holds great promise to realize structural changes to healthcare. While not yet fully implemented, anecdotal data suggest that this program is reducing ED and IP utilization and effectively addressing social determinants of health.

Newborn with desquamating rash.

A 9-day-old boy was brought to the emergency department by his mother. The infant had been doing well until his most recent diaper change when his mother noticed a rash around the umbilicus, genitalia, and anus. The infant was born at term via spontaneous vaginal delivery. The pregnancy was uncomplicated; the infant's mother was group B strep negative. Following a routine postpartum course, the infant underwent an elective circumcision before hospital discharge on his second day of life. There were no interval reports of irritability, poor feeding, fevers, vomiting, or changes in urine or stool output.

Establishing a Joint Theater Trauma System During Phase Zero Operations.

OBJECTIVES: Military personnel risk injury due to accidents, disasters, and military threats during Phase Zero "shaping" operations. Medical facilities must be poised to respond. METHODS: The U.S. Pacific Command (PACOM) Area of Responsibility (AOR) covers more than 50% of the earth's surface; relevant Clinical Practice Guidelines must include the maritime setting and extended evacuation periods. Military hospitals in the region are not connected by a defined Trauma System. There is variable adherence to trauma training requirements before assignment in this AOR. Demand for trauma care at any 1 location is low and trauma teams have little opportunity to maintain competency for high-risk/low-volume interventions. There is no documentation of total demand for trauma care in the AOR. Trauma care in PACOM is often deferred to civilian facilities. RESULTS: Core elements of a Joint Theater Trauma System (JTTS) as established during combat operations in U.S. Central Command are applicable during Phase Zero. A PACOM JTTS was established to address the region's readiness to respond to Phase Zero trauma as well as escalation of regional threats. Information technology coordination was a critical hurdle to overcome. CONCLUSION: PACOM lessons learned are applicable to other Geographic Combatant Commands developing a JTTS during Phase Zero operations.

Attention deficit hyperactivity disorder subtypes and their relation to cognitive functioning, mood states, and combat stress symptomatology in deploying U.S. soldiers.

OBJECTIVES: To explore the relationship between adult attention deficit hyperactivity disorder (ADHD) subtypes and neuropsychological functioning among U.S. soldiers. METHODS: Deploying soldiers (N = 260) completed the World Health Organization Adult ADHD Self-Report Scale (ASRS) Screener. Cognitive tests, a deployment health-history questionnaire, and the post-traumatic stress disorder (PTSD) Checklist-Military Version were completed by subsamples of available participants. RESULTS: The prevalence of positive ASRS screens was 10.4%. ASRS scores were correlated with PTSD avoidance (n = 63, p = 0.37, p = 0.003), hyperarousal (n = 63, p = 0.25, p = 0.047), and total PTSD scores (n = 62, p = 0.33, p = 0.009); and all six moods (e.g., anger, anxiety) scale scores (n = 110; p = -0.37 to 0.43). ASRS was also correlated with scores on the match-to-sample (n = 110, p = -0.23, p = 0.014) and emotional Stroop (n = 108, p = -0.23, p = 0.016) tasks. In addition, a differential pattern between subtypes of ADHD was noted with regard to cognitive functioning, mood, and combat stress symptomatology. CONCLUSIONS: Although the results are preliminary given the sample size, the prevalence and comorbidities of ADHD appear to be similar among military and nonmilitary populations.