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Neighborhood Resources - PQH Ecosystem (12)
Resource Name
Download the Neighborhood Resource Sheet of all the programs and services listed below:

001 - PMAG Integrated Behavioral Health program (Adults and Pediatrics)

002 - Kapili Kokua Care Coordination Program for Pediatrics (HMSA patients with special needs – Pediatrics)

003 - Start SMART Blood Pressure Control Program (HMSA Patients – Adults)

004 - Complex Care Management Program (HMSA Patients – Adults)

005 - Condition Care Program (HMSA Patients –Adults and Pediatrics)

006 - Kokua Mau’s Advance Health Care Directive Form (All Patients – Adults and Pediatrics)

007 - Aloha Kidney 6 Sessions Kidney Education (Adults and anyone who is interested in learning about their kidney)

008 - inControl Hawaii Diabetes Learning & Resource Center (ALL Patients – Adults and Pediatrics)

009 - HMSA’s Authorized Representative Form

010 - Million Hearts: Reducing one million heart attacks by improving cardiac health
The Pediatric Care Coordination program design is founded on evidence-based models across the US. The PMAG Care Coordinators will assist patients and their families with the following and more:

- Navigating community resources
- Referrals to appropriate community programs
- Compiling necessary documentation
- Mitigating the special education eligibility process

For more information, call Integrated Health Hawaii at 808-657-6473.
PMAG Care Coordinators can help your patients achieve their optimal health outcomes by assisting them with:

- Referral process to Mental Health Specialists in PMAG’s preferred network
- Psychiatric medication adherence
- Making the connection between Psychotherapy and medication management
- Navigating a Collaborative Care Model using BH Care Coordinators
- You may refer HMSA or non-HMSA patients who can benefit from behavioral health assistance to PMAG's Integrated Health Hawaii using the care referral form or calling Integrated Health Hawaii at 808-657-6473 for more information.
Consider the Complex Care Management (CCM) program for your HMSA patients, who have complex health conditions, who are the “sickest of the sick“ which may also include:  multiple comorbidities, uncontrolled chronic conditions, socio-economic issues, DME need or assistance with placement. The HMSA CCM nurses (RNs) can conduct in home health assessments, coordinate care and provide patient POC (plan of care) updates to you on a regular basis.

You may refer patients with this form.

For more details, call 808-440-7057.
HMSA's Condition Care Programs (CCP) is designed to help your patients reach and maintain stability with their conditions. Target population includes patients with diabetes, congestive heart failure and/or chronic pulmonary disease. You may also refer patients who wish to quit smoking or lose weight.

To refer your HMSA patients, please use this form.

For more details, call PQH at 808-942-1852.
Hawaii’s resource for Advance Care Planning, Hospice and Palliative Care.

For copies of the Advance Healthcare Directive form:

For copies of the POLST form:

For more information about advance care planning, you may refer your patients to
Dr. Ramona Wong (instructor) is a retired nephrologist who provides expert, unbiased education to ALL patients and their families. There is no cost to attend. No referral is needed. Interested participants must call 808-585-8404 to register or visit for more information.
The Start SMART program is offered at no additional cost to HMSA and non-HMSA patients with a diagnosis of hypertension. A support/family member is also welcome to attend. Start SMART supports your journey to better health by focusing on blood pressure self-monitoring, medication, healthy eating, physical activity, and stress management.

Use this Referral form. Click the Download button below for the 2019 Start SMART calendar program.

For more information, contact:

Beth Davidann, MPH

Start SMART Facilitator and HMSA Health Coach

Phone: 808-425-6245


The inControl diabetes and pre-diabetes programs are designed to educate and empower people with diabetes to adopt positive behaviors towards diabetes self-management, in order to reduce the risk of unwanted serious complications. Program is led by Kevin Kam, RPH, CDE. Refer your patients with this form or call 808-450-2402 for more information.
HMSA’s Authorized Representative Form

This form is used tell HMSA which family members or friends HMSA is authorized to share your information with. The individual or organization you list in part C of the form may contact HMSA on your behalf regarding your eligibility, billing, payment status, claims, and medical information HMSA uses to make payment decisions.

Please note that once your information is disclosed to the person or organization you indicate in part C of this form, the information in their possession may no longer be protected by privacy laws. This form may only be signed by the member or a person with the legal authority to sign for the member.

Please complete the form in its entirety and print. Incomplete forms won’t be processed and will be returned.

Return the completed form to the following address:

HMSA Privacy Office
P.O. Box 860
Honolulu, HI 96808-0860

Click here to download HMSA’s Authorized Representative Form.

For CCM or CCP referrals of HMSA patients who are incapacitated, please fax the completed Authorized Representative Form with the Care Referral Form to 808-948-8242.
About Million Hearts®
Heart disease, stroke and other cardiovascular diseases kill over 800,000 Americans each year, accounting for one in every three deaths. It’s the nation’s number one killer among both men and women and the leading cause of health disparities across the population. To address this issue, the U.S. Department of Health and Human Services (HHS) established Million Hearts®, a five-year initiative (2017-2022) co-led by the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS).

Mountain-Pacific Quality Health and PMAG are aligning with the Million Hearts® initiative to prevent one million heart attacks and strokes by addressing the ABCS of cardiac risk reduction (Aspirin therapy when appropriate, Blood pressure control, Cholesterol management, Smoking cessation) with a focus on Blood pressure control.

We are targeting Blood pressure control because it is an attainable and essential component for decreasing the number of Americans who suffer or die unnecessarily due to uncontrolled hypertension.

Need: To improve the health status and overall well-being of Native Hawaiians and other medically underserved populations in rural areas of Hawaii.Intervention: A comprehensive weight management program led by an integrated team of health professionals who work with participants on making sustainable, lifelong changes.

Results: Statistically significant reductions in weight, BMI, blood pressure, and chronic disease and pain. Increased physical activity and health knowledge.

Read more about nutrition and weight management services, click here.

For more information, call at 808-525-6255. To make an appointment online, click here.