When Linda Puppolo started her position as executive director of the Pacific Cancer Foundation in June, it took a few months for her and her staff to notice a trend.
“There were so many we had identified immediately, about 10 patients that were homeless,” Puppolo said earlier this month. “It's not that the doctors won't treat them, it's the doctors can't treat them if they don't have running water or respite: a place to stay or lay down.”
Not having a home has become a barrier for some to receive care. So, Puppolo and a few nonprofits on Maui are banding together to establish a medical respite for those who are homeless and undergoing cancer treatment.
“The Pacific Cancer Foundation is not a clinical operation, either; we are lay navigation,” Puppolo said. “So our job is to actually help the cancer patients navigate through the health care system, help them find housing, food subsidies, we look for solutions for all their challenges.”
One of the challenges is at the intersection of cancer and homelessness: finding a safe environment for patients to undergo treatment.
In one instance, Puppolo met a former tradesman from Haiku. At 55, he fell into what’s called a gap group, which can be people who don't outright qualify for social services based on age or other determinants.
Over time, staff was able to get him medical insurance, but doctors were unable to treat him because he was living in his car. Needing a clean, safe place to begin treatment, the Pacific Cancer Foundation tapped into a small housing fund to put him in a hotel, but that cost nearly $450 a night.
“We put him in a hotel for about two weeks, so he could get pre-treatment,” Puppolo said. “But it went from October getting medical, until he finally passed away last week. He just didn't get treatment fast enough.”
Treatment, in this case and many Puppolo has experienced, relies on housing. Without a physical address, home health care cannot come to do check-ups after surgery or chemotherapy pills cannot be delivered, oncologist Dr. Cecilia Choi of Maui Memorial Health said.
“A house is not just a place that has a roof over your head,” Choi said. “A house is a place where you could feel safe, where you could recuperate.”
After a cancer diagnosis, Choi works with her patients to figure out their best route for treatment. But she also digs deeper, to understand somebody’s living situation and their support system, and that factors into the care they can be given. Treatment may be more dangerous if a patient doesn’t have access to running water or a place to safely rest, or somebody to help them take their medication.
“We call these things social determinants of health,” Choi said. “What are the factors that help patients make decisions about what kind of workup, such as imaging or blood tests they are going to have, what kind of treatment they're going to have, whether it is surgery, or whether chemotherapy, whether it's medicine. When you are unhoused or homeless, you run into so many barriers.”
A medical respite wing of a homeless shelter may be the solution, as Puppolo and Monique Ibarra, the executive director at Ka Hale A Ke Ola Homeless Resource Centers, have partnered to do.
Ka Hale A Ke Ola has beds available at its Hale Hoʻola Medical Respite Shelter on Waiʻale Road in Wailuku. In a recently remodeled wing, there are up to five private or semi-private beds.
“It’s also conducive to having home health care come in, if they need it, because we're not a medical facility. We do have the bed space, we have the units, but we're not operating as a medical facility,” Ibarra said. “So those types of services would be welcome and would be brought in for the individuals in the program.”
Ka Hale A Ke Ola already has a medical respite shelter, which opened in 2019 and has been providing homeless patients with a place to stay during outpatient medical care. The shelter has security, access to food, and a place to get home care or medicine delivery.
The Maui medical respite shelter is modeled after Tutu Bert’s on Oʻahu operated by the Institute for Human Services. There, those with terminal or chronic illnesses can find an individualized path for care.
“It’s not like a congregational shelter, but a real home that allows people to have a more peaceful kind of place to recover,” IHS Executive Director Connie Mitchell said, describing the atmosphere like grandma’s house. “When you're a child and you get sick, that's where you feel like you're going to feel better, you're comforted. That's what we're aiming for.”
But housing and care come at a cost. Puppolo estimates to do this type of cancer-specific respite care on Maui, it could cost around $200,000, and has already submitted grant applications to try and cover it all.
IHS Chief Administrative Officer Leina Ijacic said the medical respite offers a lower cost than a hospital bed, but it’s still about $150 a night, charged directly to insurance.
“It really doesn't belong there, it really should be a Medicaid-reimbursable item,” she said. “But right now, it's not, so I think there's a lot of advocacy and policy that we can be doing to move some of these items into coverage eligible.”
Ijacic said there’s a lot that can be done for reducing the cost of health care. One move has been to more out-patient services, but that’s posed issues not just for those who are homeless, but for anybody who may struggle with finding reliable transportation and those in more rural areas.
“We really need to find solutions for our rural patients, and then also for our homeless, so that they have places that are non-acute to go to while they're receiving care,” Ijacic explained.
Until then the Pacific Cancer Foundation hears back on funding, Puppolo is committed to continue piecing together hotel funding for patients, and hopes that it will help them get treatment in time.
"There were several patients that we just couldn't help them," Puppolo said. "And because their treatment was delayed, they have passed away."
