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

2. 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 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%).

3. 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

4. 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

5. Three way partnership
COMMUNITY

6. All ready to go

7. 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

8. 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

9. 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.

10. 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

11. MWOK Referrals by Age

12. MWOK Referrals by Ethnicity

13. 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

14. 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

15. MWOK partners
Sue

16. MWOK partners
John’s visual care plan

17. 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

18. What’s next

19. 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

20. 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

21. 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

22. MWOK in action

23. MWOK in action