Manawanui Whai Ora Kaitiaki: Empowering self-management through a partnership approach … November 2016

Background Hauraki PHO is a Kaupapa Māori Primary Health Organisation within the Waikato DHB with 131,899 funded patients supported by 35 general practice clinics. There is a high proportion of high needs patients within this population with a high proportion of Māori (34%) and quintile five people (36%). The population is older than the national average. Data from the 2011-13 NZ Health Survey found 32.7% of the Waikato DHB population experienced unmet need for primary health care in the past 12 months (higher than the national average of 27%).

The model Centred in general practice Built on the concept of nurse based outreach service to address LTC Provides intensive support for short term duration Applied Te Whiringa Ora experience to incorporate social determinants of health

The model What’s different? Kaiawhina (navigator) role working in equal partnership with Case Manager (RN) 7 FTE RN – 7FTE Kaiawhina Holistic approach to assessment and care planning Focus on patient activation/shared care planning Empowerment model – three way partnership

Three way partnership COMMUNITY

All ready to go

Why it works “With input from general practice and allied health professionals, highly skilled registered nurses and support workers unravel complex medical and psychosocial issues at the community level and help the patient to develop a self management plan. This is not something we as GPs can do in a fifteen minute consultation. The results? A high level of patient satisfaction, improved outcomes for many and for myself as a GP the confidence that the patient is provided with a highly competent continuum of care beyond the consultation room door. Dr. Sue Greig. FRNZCGP GP Whitianga

Enablers Flexible funding approach Electronic Decision Support Tools SIA Monthly practice payments for protected nurse/admin time Mobile outreach service Electronic Decision Support Tools Care Plan built into PMS Clinical Champions in place Measured on sustainable outcomes Low hanging fruit – bonus re help with target achievement

Identifying eligible patients Identifying Patients with High Needs having 2 co-morbidities and requiring higher levels of care than usual – e.g. 6 GP/nurse visits in previous 6 months; expected to be about 30% of previous Care Plus patients and inclusive of those with HUHC. Identifying Patients with Extremely High Needs Patients with (2 hospitalisations) in previous 12 months for LTC Patients with uncontrolled LTC requiring complex primary care intervention - 8+ visits in previous 6 months or conversely low engagement which helps explain non-controlled LTC.

MWOK Activity – October 2016 360 patients currently in the programme Average 15 referrals per locality each week Primary reasons for referral: Unstable clinical condition Not coping at home Social issues impacting health Individual/Family /Whanau engagement

MWOK Referrals by Age

MWOK Referrals by Ethnicity

The learnings Practice partnerships key to success GP as MDT lead – consultant role Patients lead the way – goals need to be their goals not our goals Value of the RN and Kaiawhina roles as equal partners Importance of selecting the right staff with the right experience

What the evaluation data is showing Measured improvements in individual health outcomes High levels of GP satisfaction with the service Significant improvement in patients’ ability to self-manage their LTCs (PACIC survey responses) Enhanced sense of wellness and empowerment $$ saved in avoidance of unnecessary hospital attendances and admissions

MWOK partners Sue

MWOK partners John’s visual care plan

What’s next MWOK programme for child health Childhood obesity Dental health MWOK role in facilitating (re)engagement of non-enrolled population – Dr Info Project Advance Care Planning Programme Pre-Diabetes App Diabetes Wellness Programme

What’s next

MWOK in action Waharoa Diabetes Wellness Programme 5 week Programme 20 participants per programme Marae setting, community led and locally sponsored Understanding my diabetes Interactive chef and participants self-catering Exercise woven into each session Reducing risks- Kete kits

MWOK in action Ratings This workshop: 1)Totally Agree 2) Mostly Agree   This workshop: 1)Totally Agree 2) Mostly Agree 3) Agree 4)Mostly Disagree 5) Totally Disagree Has increased my understanding and awareness around what causes Diabetes 13 3 5 Has increased my understanding of knowing my tinana 11 2 8 Has provided information for me to think about making behavioural changes 14 Do you feel you were treated respectfully and professionally Yes 21 No Did you feel that you were treated culturally appropriately 19

MWOK in action Ratings This workshop: 1)Totally Agree 2) Mostly Agree   This workshop: 1)Totally Agree 2) Mostly Agree 3) Agree 4)Mostly Disagree 5) Totally Disagree Has increased my understanding and awareness around what causes Diabetes 13 3 5 Has increased my understanding of knowing my tinana 11 2 8 Has provided information for me to think about making behavioural changes 14 Do you feel you were treated respectfully and professionally Yes 21 No Did you feel that you were treated culturally appropriately 19

MWOK in action

MWOK in action