title: Kokua Mau: a statewide effort to improve end-of-life care.
abstract: BACKGROUND
  Many Americans die in pain, without hospice, and without regard to advance directives, suggesting a need to improve end-of-life (EOL) awareness and services.
  
  
  OBJECTIVE
  This paper describes Kokua Mau, a community-state partnership to improve EOL in Hawaii funded by The Robert Wood Johnson Foundation (RWJF). Coalition activities were guided by innovation-diffusion theory, targeting "innovators" and "change agents" within communities and organizations willing to learn about and facilitate improvements to EOL care.
  
  
  METHODS
  Evaluation of a community-wide intervention to improve EOL care.
  
  
  METHODS
  Honolulu, Hawaii.
  
  
  METHODS
  We tracked dissemination of campaign messages by counting numbers of coalition members (including innovators and change agents to carry on the work), individuals reached through awareness and educational offerings, and new EOL projects initiated during and after the initial 3-year RWJF funding. To measure change, we counted the number of legislative policies that were modified by the coalition as well as indicators of hospice utilization, advance directive (AD) completion, support for physician-assisted death, and place of death.
  
  
  RESULTS
  In the first 3 years of the project: coalition membership grew to 350 members; EOL care curricula were developed and offered to various target audiences; 17,000 individuals attended educational events; policy changes were facilitated; decreases were seen in proportions of residents supporting physician-assisted suicide; and increases were seen in advance directive completion rates and hospice utilization. Most importantly, after the grant period, coalition members went on to develop and implement new programs to improve care to the dying.
  
  
  CONCLUSIONS
  Although it will take several years to effect comprehensive and sustained changes in the way death is perceived and the dying process is facilitated, findings suggest that programs based on innovation-diffusion theory can increase EOL awareness and help develop the change agents and role models needed to affect community-wide change over the long term.
authors.affiliation: Center on Aging, University of Hawaii, 1960 East-West Road, Biomed C-106, Honolulu, HI 96922, USA. kbraun@hawaii.edu
authors.forename: Kathryn L
authors.initials: KL
authors.lastname: Braun
authors.forename: Ana
authors.initials: A
authors.lastname: Zir
authors.forename: Joanna
authors.initials: J
authors.lastname: Crocker
authors.forename: Marilyn R
authors.initials: MR
authors.lastname: Seely
mesh_terms: D000293:Adolescent; D000328:Adult; D016223:Advance Directives / Q000706:statistics & numerical data; D026683:Advisory Committees / Q000458:organization & administration*; D000368:Aged; D016009:Chi-Square Distribution; D004059:Diffusion of Innovation; D005260:Female; D006254:Hawaii; D006291:Health Policy / Q000331:legislation & jurisprudence; D017051:Hospice Care / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D010166:Palliative Care / Q000592:standards*; D013727:Terminal Care / Q000592:standards*