1. Whanau Ora/Long-term Condition (LTC) Nursing Navigator Innovation Programme Roll-out 1 January 2014- 31 December 2014

2. AIMS Improved wellness/decreased health inequalities Appropriately managed hospitalisations/ED presentations Strengthened primary healthcare (GP/Nurse Teams) workforce Increased health target achievement

3. APROACH Providing proactive support to high-needs, hard-to-reach individuals and their Whanau with long-term conditions (LTCs) (including mental health issues) through mobile Whanau Ora Nurses within Maori, Pacific and lower income families/communities Empowering Whanau to increase wellness/independence Working collaboratively with HPHO practice teams, WDHB community and hospital services, Maori and Pacific providers, inter-governmental services and allied health professionals Supporting equitable access (equal access for equal need) to HPHO’s enrolled population from Colville to Tokoroa; Waihi to Huntly

4. METHODOLOGIES Implementing integrated care plans through mobile Whanau Ora Nurses with high needs Whanau in collaboration with HPHO practice teams Providing active “clinical navigation” in timely, appropriate and seamless integration of service delivery across primary/secondary settings to reduce appropriately avoidable use of hospital services Tailoring/delivering service packages to high-need, hard- to-access Whanau/individuals Working closely with contracted mobile/Whanau Ora providers to maximise value and minimise duplication

5. EXPECTED OUTCOMES (MEASURES) Reduced acute episodes due to education/early support/intervention in the home/community (pre-/post- programme involvement) Reduced hospitalisations/ED visits due to proactive individual/Whanau support (pre-/post-programme involvement) Increased target achievement through focus on high-need, hard- to-access Whanau/individuals (national health targets) Increased Whanau empowerment perception of wellness through education/support (Homai to Waiora ki Ahau, SF-36) Appropriate utilisation of pharmaceuticals by reducing access barriers (e.g. cost/knowledge) to decrease acute episodes (pre-/ post- programme involvement)

6. Questions & Answers What are high needs, long-term condition management? High needs are people requiring frequent medical treatment due to a condition which will not change in the long-term. What is the difference between a Whanau Ora Nurse & a regular Nurse? Whanau Ora Nurses look at the influences surrounding the patient & plan the appropriate treatment or assistance, this is called the Service Package. What is meant by “reduce appropriately avoidable uses of hospital services?” Patients with long-term conditions will be able to call their Whanau Ora Nurse to talk to about their concerns & the Nurse will either treat them or direct them to appropriate assistance, this is called Clinical Navigation, therefore reducing the number of times these patients present to the Emergency Department. It also means the patient can be treated earlier & potentially avoid hospital admittance due to putting off seeking treatment for too long.

7. Questions & Answers cont. If people aren’t using the hospital, what will it cost to go to the practice instead? E.g. Cut to hand is free at ED, is there a consultation cost at the practice? For the Long-term patient, the Whanau Ora Nurse will come to them & treat the condition appropriately. (For the average person on the street, normal practice fees would apply.) Severe respiratory infection needing antibiotics – free at ED, is there a consultation cost at the practice? HHALT is targeted toward patients with Long-Term Chronic Conditions & in this situation the Whanau Ora Nurse will visit & treat the patient or provide the appropriate assistance. (For the average person on the street, normal practice fees would apply.)

8. Questions & Answers cont. Is all the responsibility going to be placed on the Whanau? The Whanau Ora Nurse will plan & consult with Whanau to provide both Pre & Post Programme assistance, therefore empowering Whanau with education & support through the Homai to Waiora ki Ahau process to ensure the patient’s perception of wellness is met. What about the situation where the Whanau aren’t up to it – do the patients get abandoned? The Whanau Ora Nurse will ensure the patient is still cared for regardless of Whanau input. This is a good example of a surrounding influence that they will address. For any further information please feel free to call our team on 07 868 9686