When two of his colleagues left the Molokai Community Health Center earlier this year, Ty McComas found himself as the only full-time medical provider for the center’s patient population of more than 2,500.

He tried to keep the clinic afloat, juggling the labs and the consults he’d previously shared with his colleagues. But soon enough, the family nurse practitioner was overwhelmed and worried he could no longer provide the care that patients needed.

“A clinician with my training and experience is not expected to independently manage a 2,500-plus patient population alone,” McComas said.

He called in sick in August, and in his absence, the medical department had to shut down for four days.

“There was no backup plan. There was no contingency plan B. There was nobody waiting ‘on deck,’ ” McComas said. “It was just me.”

HELEN KEKALIA WESCOATT, No plans to resign as CEO

The health center’s handling of provider shortages and patient care is at the heart of a growing outcry that has led to emotional public testimony, calls for leadership to resign and state lawmaker support for an investigation by the federal agency that oversees the health center.

And since the resignation of McComas and a part-time doctor from Hawaii island, the health center has been missing two crucial pieces — a chief medical officer and a medical doctor.

“It has become apparent that the trust between our community and the health center has been broken,” state Rep. Lynn DeCoite said in a statement last week. “The last thing I want is to see the center shut down or closed. I believe the MCHC board and executive leadership should step down and allow the community to reorganize the health center and build back the trust.”

Chief Executive Officer Helen Kekalia Wescoatt didn’t believe resigning was the answer.

“We’re committed to listening to the community’s concerns and investigating allegations that have been brought up, which take time,” Wescoatt said Thursday. “So at this time, we don’t feel a resignation is warranted or would solve the issues at hand. Again, we believe we all have the same goal, which is to provide health care to the people of Molokai.”

The Molokai Community Health Center has come under fire for its handling of provider shortages and patient care. The health center’s medical department had to close for four days in late August after its sole full-time medical provider called in sick. -- Molokai Community Health Center photos

Internal frustrations

Inside the health center’s medical department, providers were growing frustrated over working conditions, health center leadership and timely replacement of providers.

Dr. Robert Van Gemert retired in February after providing a six-month notice.

Family nurse practitioner Dara “Kamomi” Pagaduan left in June over “senseless bullying and harassment of employees” and “the inadequacies of education and experience of those holding administrative leadership roles,” her husband Blayne Asing wrote in a letter to The Molokai Dispatch.

Dr. Michelle Mitchell, a part-time provider from Hawaii island, resigned in August over a list of concerns that ranged from an improperly functioning electronic health record system to inadequate training of medical assistant staff, who were “patient, kind and efficient” but didn’t know routine procedures like flushing ears and swabbing for influenza — skills that Mitchell said they should’ve been taught by the clinic.

The Molokai Community Health Center is a federally qualified health center meant to provide primary care to an underserved community. About 55 percent of the health center’s $4.3 million budget comes from the federal government; the rest comes from patient revenue, state funds, private grants and donations. -- Molokai Community Health Center photos

“I want to be very clear that I practice high quality, safe medicine,” Mitchell said in her Aug. 4 resignation letter. “When the tools necessary to do so are not provided, I am unable to do my job appropriately. This becomes unsafe for the patients, the clinic and me as a physician. Substandard medical care is not a substitute for good medical care, and I am unable to continue to put my license at risk in such an environment no matter how much I may want to help.”

Mitchell’s presence on Mondays and half days on Tuesdays gave McComas some time to try and catch up on his workload. The problem is that health care doesn’t slow down, and having a part-time provider for one-and-a-half days a week isn’t enough to keep operations going, McComas said.

“Appointment times were becoming more difficult to get, and patients were waiting longer to get them,” McComas explained in a letter that was read on his behalf during a Sept. 26 community meeting. “Patients were not able to be seen and treated in a timely fashion. The feeling that I was giving the ‘illusion’ of care without providing it was causing me moral distress.

“The previously shared duties of reviewing labs, specialist consults, imaging, medication refills, and the ever-growing pile of paperwork was very overwhelming as a solo clinician,” he continued. “The utmost concentration and attention to detail is constantly needed, to avoid potential errors.”

McComas said he brought his concerns to the administration several times. He was told they could possibly get some temporary providers in three weeks and that as a salaried employee, he needed to work whatever hours the clinic needed.

“I could have worked nonstop and still not met the demands of the clinic, because it was not designed to be managed by a single clinician,” McComas said. “I really felt like I was drowning under the weight of the clinic, but instead of the MCHC lifeguard lifting me out they said, ‘Hang in there, see you in three weeks.’ ”

On Aug. 22, McComas called in sick and sought medical treatment. While he was out, on Aug. 22, 23, 26 and 27, the medical department was closed. Despite telling McComas that he would have to wait weeks for help, the health center quickly located providers during that time.

“Where was that expediency when the community needed it?” McComas wondered.

McComas sought legal representation and turned in his 90-day resignation notice, saying that he could not return until “all of the deficiencies in staffing, scheduling and other breaches were fully corrected,” and the health center had notified patients of the staffing shortage.

“I feel as though I was not supported by the CEO, as the chief medical officer, but more basically as a person,” McComas said. “I feel the lack of professional respect and support is an ongoing pattern. This was just one of many times, and for that I cannot continue to work under the current board and CEO’s leadership. I felt the organization did not take the lack of providers seriously enough, and recruitment efforts were not truly prioritized until after the medical department closure.”

McComas said he recently learned through an email that he is “no longer employed” with the health center, though he hadn’t received an official statement of termination.

“If I am truly terminated, during my leave of absence on ethical and public safety grounds, I may have legal recourse as a whistleblower who has suffered retaliation,” McComas said. “It is my true desire that MCHC does not put me in that position, but rather that they do the ‘right’ thing, fix the deficiencies, and allow me to finish my 90-day resignation period.”

The closure created day-to-day uncertainty for staff.

“Patients were getting frustrated for the late calls to reschedule appointments,” said one former employee who asked to remain anonymous for fear of retaliation. “Some appointments were rescheduled for the very next day, being that we were constantly being told that we were opening the next day. Then the next day came, and we would have to reschedule them again.”

Appointments became scarce with waits ranging from three to four weeks.

“Patients were then going without medication due to no provider to fill them,” the former employee said. “Some controlled/scheduled medication require an office visit for medication to be filled — with no available appointments, no refills could be made. Paperwork that needed to be signed by a provider were left sitting, with no signature.”

The employee left due to frustrations over mismanagement and the treatment of staff.

Long waits, close calls

While tensions were boiling inside the clinic, frustrations were growing outside as well.

Tarrah Horner has four boys between the ages of 11 and 15, all with attention deficit hyperactivity disorder. Medicine’s not a crutch, but it makes a difference, Horner said. Homework time — which used to require two to three hours per kid — has improved now that the boys can focus in the classroom and work independently on their assignments.

But over the summer, the family struggled to get their refills on time. On Aug. 6, Horner tried to set up an appointment to refill the monthlong supply they’d gotten in mid-July. Nothing was available. She tried again on Aug. 18 and was told the next open slot was Sept. 13.

“We kind of went into a panic because my boys rely on their medication to focus in the classroom,” Horner said. “We don’t use it as a crutch, but it’s proven that it helps them be able to learn.”

The medicine the boys take is a narcotic, so they have to walk in, get the physical paper prescription and take it to the pharmacy. It can’t be faxed or mailed. But, after phone calls with the state Department of Health and Molokai Drugs, Horner learned that since the boys had been stable and hadn’t missed appointments, they could get their medication without going in to see the doctor. Horner didn’t understand why the health center hadn’t given her that option.

“They had no contingency plan. No solution. I was just basically going to have to wait until Sept. 13 for the appointment,” Horner said.

The prescriptions were finally refilled on Aug. 29 and 30. By then, one of her sons had gone almost two weeks without medication.

“I got a text from one of his teachers telling me how distracted he has been, how difficult he has been in the classroom, distracting other kids,” Horner said. “I felt bad for him, because I knew exactly why.”

Since then, the boys have been on their medications and haven’t had problems like before, said Horner, who’s been frustrated with the health center’s statement to the media that “all patient prescriptions have been filled in a timely manner.”

Horner said it feels like the center is washing over patient concerns.

“They’re not taking accountability for what went wrong there,” she said. “My job is to make sure this doesn’t happen again.”

Changes in providers and difficulty getting appointments also disrupted the medical routine that Aisha Senas-Childs needs for her two kids who have developmental disabilities. Her 5-year-old son, Nazareth, was diagnosed on the autism spectrum at the age of 2, and her 4-year-old daughter, Hilkiah-Joy, was diagnosed with speech delay at the age of 1.

Within a few months of both diagnoses, their doctor “was gone with no explanation.” They went through two more providers before finally settling with McComas.

“He helped us with everything in regards to our son, writing letters, keeping my son as comfortable as he could during appointments, made referrals when asked for his support,” Senas-Childs said. “We didn’t have to keep repeating over and over again to a brand new practitioner. My son has sensory issues and has a hard time being out of his routine, especially with new people he’s unfamiliar with. NP McComas was a huge support in our autism ohana.”

Over the last few months, the family would prepare for appointments only to be told an hour beforehand that they’d been canceled. During and after the closure, her daughter’s 4-year-old checkup was canceled and rescheduled, and Senas-Childs was unable to get an appointment for herself to follow up on a blood-pressure checkup.

She said the family is hopeful for their appointment with a new doctor but are questioning whether it will be canceled, too.

“As a mother, it’s my priority to take care of my children the best I can, but it’s so hard (when) medical providers keep changing,” she said. “It’s stressful and frustrating.”

The delays caused close calls for some. Solene Duvauchelle normally phones in a refill for her dad’s prescription about two weeks before he runs out. Her dad has a heart condition and previously suffered a stroke, so he takes blood thinners and other preventive medicine.

But nobody called her back. Eventually, her dad ran out of medication, and in the early morning hours of Sept. 15, he started blacking out.

“His heart rate dropped down low, he was very faint, and he had a discolored face,” Duvauchelle said. “I ended up taking him to the ER.”

The next month, the medicine ran out again after Duvauchelle couldn’t get an appointment. Her dad went without medication for two days before getting a refill on the afternoon of Oct. 16.

“As far as refills being met as the CEO stated, that’s untrue, because it happened again,” Duvauchelle said. “Thankfully, my dad didn’t have to go to the ER, and he’s fine. That’s the main thing.”

Duvauchelle was also unhappy with the treatment of staff during her time as clinical office manager at the health center. She said she was fired in January after she mistakenly failed to claim paid time off on her time sheet, which she said was a common mistake that many employees have made.

CEO: ‘Perfect storm’ caused closure

Wescoatt, who has a business degree in marketing and merchandising, joined the health center in 2012, doing program management for early intervention services for children up to 3 years old. She was the executive assistant to former CEO Desiree Puhi and was a volunteer board member before becoming the interim CEO in February 2017 and permanent CEO in August 2017.

Wescoatt said the four-day closure was the result of a “perfect storm” — the health center was down one full-time employee, staff was adjusting to a new scheduling system, and they were fielding more patients in July and August, when numbers historically run 25 to 30 percent higher.

The health center had hired a full-time resident physician who was scheduled to start in August, but he received a terminal diagnosis and couldn’t move to Molokai.

So in late August, with McComas out sick and the health center’s call-in provider out of the country for vacation, the medical department shut down.

“What we did during that time was an expedited emergency hiring process that we’d like to avoid,” Wescoatt said.

The health center was already working with a locum tenens (medical temporary substitute) agency, but Wescoatt said the temporary provider they had lined up wasn’t due to start until early September.

She said she didn’t learn until during the closure that there was a former provider working on Oahu who wanted to return to Molokai. The paperwork and approval process went quickly because he had worked for the health center before.

In the wake of the closure, patients told Hawaii News Now that there had been delays in prescriptions.

Wescoatt emailed the news station that the statements they’d received “were incorrect” and that “all patient prescriptions have been filled in a timely manner.” She adjusted her statement in later interviews with The Molokai Dispatch and The Maui News.

“When we saw the news and reviewed our records during the four-day closure, it did not indicate delays in refills,” Wescoatt said. “We have since gone back and reviewed maybe what was going on with refills prior to the clinic closing, and we did discover that there was one request made two days before the closure that was not refilled until we got the clinic back opened. So I would say that we apologize for any hardship that caused to the families. Again, I would say it was a rare occurrence that we do not believe will happen again for the foreseeable future.”

Wescoatt said that the health center is working with the Waianae Coast Comprehensive Health Center on a locum tenens contract that would allow Waianae Coast providers to fly to Molokai the same day for immediate short-term coverage. She expected to have the contract hammered out by Nov. 2.

“We also need to start moving on developing our own pipeline of other providers,” Wescoatt said. “I don’t know at this time who that would be locally. I think we would be looking at having to fly someone in.”

When asked why McComas was left to fend for himself for so long, Wescoatt said that he “was never the sole provider until Aug. 21” because he had the help of a part-time M.D.

“Productivity standards did not actually change,” Wescoatt said. “The actual flow of appointments did not actually change and those numbers were not anything different or abnormal than any previous month. So providers were seeing anywhere from 10 to 22 patients a day during that time frame, which has kind of been the norm.”

Wescoatt said she couldn’t comment on personnel matters when asked about McComas’ termination.

In his absence, there is currently no acting chief medical officer.

“We are going through that process right now,” Wescoatt said, adding that they had two candidates lined up and could fill the position within the next month.

And, there’s currently no M.D.

“I am confident that will be rectified shortly,” Wescoatt said. “I am confident in the providers that we do have, one of whom is a former director (of nursing at Molokai General Hospital), so operationally I am confident in their skill sets and expertise. And I am also confident, with the candidate pool that we are looking at right now, that it will be resolved sooner than later.”

Of the health center’s 37.5 positions, 35 are currently filled, Wescoatt said. Currently, there are two full-time medical providers, both family nurse practitioners. The medical department also consists of three medical assistants, one full-time registered nurse, one clinical office manager and two full-time navigators who assist with care coordination.

The health center has an operating budget of about $4.3 million. About 55 percent comes from the federal government and goes toward salaries; the rest comes from patient revenue, state funds, private grants and donations.

In terms of staffing and service improvements, Wescoatt said the health center contracted a pediatric neurologist to offer quarterly visits that started in June, and they’re also working to bring in a pediatric nurse practitioner two days a week. Plans also include expanding the telehealth program to allow video visits for patients who are homebound or don’t have transportation.

Wescoatt said they also aim to roll out a program in January that would allow University of Hawaii social work students to get clinic experience and mentorship at the health center.

She said being “more engaged in these tough conversations with people, with the media” will be part of the road to recovering the broken trust between community and health center.

“There is recognition that the closure has caused hardships to members of our community, but since then, we have revamped our staffing and are now operating at capacity,” Wescoatt said. “We are doing the best job we can for our community, and we feel personal responsibility to the people that we serve.”

Wescoatt said she was “confident that we will be able to rebuild the trust since our goals are the same.” She asked anyone with concerns to come to the health center directly.

“I think one of our frustrations is the lack of specificity . . . so if we can get more specific feedback, that’s what will help drive us into action to be able to fix and resolve issues,” Wescoatt said.

The health center, which postponed a community meeting Oct. 15 due to safety concerns, plans to hold a roundtable session sometime in the first week of November.

Too little, too late?

Meanwhile, lawmakers also are applying pressure. Last week, Senate Majority Leader J. Kalani English, whose district includes Molokai, called for the Human Resources and Services Administration, the federal agency that oversees the health center, to conduct an investigation of the health center.

“The August closures highlights long-standing organizational issues, and I believe residents deserve opportunities to have their voices heard,” English said. “If the community is asking for change, MCHC should consider honoring that request.”

When asked if it would be investigating, HRSA said it monitors Health Center Program grantees throughout the year through “a variety of methods” that include grantee data reports, independent annual financial audit reports, routine conference calls and site visits.

“HRSA will continue to monitor Molokai’s operations to ensure compliance with all federal requirements,” the agency said.

Wescoatt said that “we were blindsided by that statement” from DeCoite and English and said she had since reached out to them. She said that the health center already undergoes regular audits and just completed a federal on-site review in January, earning a 95 percent passing score.

“We will gladly cooperate with an HRSA investigation,” Wescoatt said. “I do stand by the standard of care that we provide to our patients.”

Whether the changes and conversations will be enough for the community remains to be seen. McComas, for one, believed Wescoatt’s statements about rebuilding trust were “extremely arrogant or prideful.”

“You can’t say someone’s forgiven you for something you’ve done and it becomes true,” he said. “Only the community can say if she can be the one to rebuild trust in MCHC or not. And right now, it appears someone else will have to do that. She has damaged the relationship too much at this point.”

Wescoatt responded that “the language he is using is a personal attack and I don’t believe I should respond to such opinions that are aimed to hurt and slander.”

* Colleen Uechi can be reached at cuechi@mauinews.com.

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