Project Kealahou: Improving Hawai’i’s System of Care for At-Risk Girls and Young Women Through Gender-Responsive, Trauma-Informed Care

Suarez E, Jackson DS, Slavin LA, Michels MS, McGeehan KM
Source: Hawaii J Med Public Health
Publication Year: 2014
Patient Need Addressed: Behavioral health, Trauma
Population Focus: Vulnerable/disadvantaged
Demographic Group: Child, Women
Intervention Type: Best practices, Partnership
Study Design: Pre-post without Comparison Group
Type of Literature: White

Project Kealahou (PK) is a six-year, federally-funded program aimed at improving services and outcomes for Hawai’i’s female youth who are at risk for running away, truancy, abuse, suicide, arrest and incarceration. PK builds upon two decades of sustained cross-agency efforts among the state’s mental health, juvenile justice, education, and child welfare systems to promote system-of-care (SOC) principles of community-based, individualized, culturally and linguistically competent, family driven, youth-guided, and evidence-based services. In addition, PK emphasizes trauma-informed and gender-responsive care in serving its target population of females ages 11-18 years who have experienced psychological trauma. Results from the first four years of the implementation of PK in the Department of Health’s (DOH) Child and Adolescent Mental Health Division (CAMHD) highlight the serious familial, socioeconomic, functional, and interpersonal challenges faced by the young women who receive services in Hawai’i’s SOC. Despite the challenges faced by PK youth and their families, preliminary results of the evaluation of PK show significant improvements across multiple clinical and functional domains of service recipients. A financial analysis indicates that these outcomes were obtained with a minimal overall increase in costs when compared to standard care alone. Overall, these results suggest that PK may offer a cost effective way to improve access, care, and outcomes for at-risk youth and their families in Hawai’i.

Insights Results

Overview of article

  • Project Keelahou (PK) was a 6 year, federally funded program that was aimed at improving services and outcomes for Hawaii’s female youth at risk of running away, truancy, abuse, suicide, arrest, and incarceration. It builds upon 2 decades of system of care projects in Hawaii developed to reach the same population
  • The goal of the system of care (SOC) is to help families keep the youth at home, in school, out of trouble, and leading balanced, connected, responsible lives in the community. This requires not only extensive coordination and collaboration among disparate and often disconnected service sectors, such as mental health, education, juvenile justice, and child welfare—each a complicated system unto itself—but also requires strong trust and collaboration among youth, families, and their service providers. Continuously eliciting the trust and active participation of youth and their families in individualizing and completing mental health services is a key engagement strategy in Hawai‘i’s SOC project
  • Once engaged in services, PK girls and their families receive gender-responsive, trauma-informed, culturally-responsive, community-based services, including: intensive case management; community supports by paraprofessionals (i.e., peer support for youth and caregivers); structured group activities; and evidence-based treatments (e.g.,, Trauma-Focused Cognitive Behavioral Therapy and Girls Circle psychoeducational support groups). PK seeks to help girls who have experienced psychological trauma find “a new pathway” (kealahou) to a better future by healing past hurts and taking constructive steps toward a more hopeful future
  • The project included a total of 144 11-18 year old female youth with an Axis I Diagnostic and Statistical Manual of Mental Disorders disorder (e.g., substance use disorder, post-traumatic stress disorder) and their caregivers. Youth participants enrolled from public education, juvenile justice, and mental health systems referrals
  • Of the total enrollees, 69 youth and 31 caregivers (providing information on their youth’s behalf), for a total of 100 participants, agreed to participate in the evaluation
  • To evaluate program success, data were collected through 1-2 hour long structured interviews with youth and/or their caregivers at intake and 6-month intervals during the first 2.5 years of PK services (September 2011-April 2014)


  • Significant improvements from baseline to 6-month follow-up on measures of youth strengths (BERS-2Y), competence (CBCL 6-18), depression (RADS-2), impairment (CIS), behavioral problems (CBCL (6-18)), and emotional problems (CBCL (6-18)). PK also received high marks from youth and caregivers regarding satisfaction with key aspects of PK, with at least 70% of youth and caregivers reporting satisfaction with: access to services, participation in treatment, cultural sensitivity, satisfaction with services, outcomes, functioning, and social connectedness
  • Measure of youth anxiety (RCMAS-2) remained stable at 6-month follow up
  • PK youth and their families enrolled in the evaluation received more services during their first 6 months of enrollment in PK compared to the 6 months prior to enrollment in PK. The cost for service event was lower for PK ($201) compared to standard of care ($201)
  • There was a increase in the level of community support serves, with 68.3% of PK girls receiving community and support services during the first 6 months of enrollment compared to 2.4% receiving services before PK
  • PK completed a study comparing the types and costs of services PK girls and their families received before and during PK. The Service Use and Cost Study is designed to examine PK’s service usage pattern and its costs of services in comparison to standard care in the public mental health system. Findings show that overall, PK youth and their families enrolled in the evaluation as of September 2013 (n = 72) received more services (1,819 service events) during their first six months of enrollment in PK compared to the six months prior to enrollment in PK (1,680 service events). For those participants for whom cost data was also available both before and after the onset of PK services (n = 41), the total cost for mental health services for the cohort during the first 6 months of PK enrollment ($365,803) was, however, only slightly higher ($21,662 more) than the total cost of mental health services for PK girls in standard care for the 6 months prior to PK enrollment ($344,141). Thus, the cost per service event was lower for PK ($201) compared to standard care ($205). Furthermore, these figures do not account for expected cost savings from decreased service usage and costs for PK girls in juvenile justice, child welfare, and educational settings, which have yet to be determined
  • Limitations of evaluation: 1) Low proportion of participants (40% youth, 51% caregivers) completed both baseline and follow-up interviews; and 2) No ability to match participants to similar cases to determine direct comparison to other similarly structured programs or individuals not enrolled in OK

Key takeaways/implications

  • Recommendations for future research: 1) Dissemination of program throughout state; and 2) Leverage PK’s current funding and past successes to achieve sustainability