Model of Care

Long Term Conditions Programme – Model of Care Background Long Term Conditions (LTC) such as cardiovascular disease and diabetes are leading causes of mortality in New Zealand. Statistics taken from the Māori Health Profile 2015 for the BOP DHB region show that the mortality rate for Bay of Plenty Māori was 2.3 times higher than non-Māori. Leading causes of death for Māori were heart disease, respiratory disease and diabetes and more Māori males were dying of lung cancer and suicide than female Māori. There are about 3,400 avoidable hospital admissions of Māori per year which is 40% higher than for non-Māori.

The Western Bay of Plenty PHO is committed to reducing inequities for Māori as outlined in Te Toi Huarewa, our health strategy. After establishing a living plan to deliver outcomes on Te Toi Huarewa, we were hit by a global pandemic which highlighted inequities in our community and strengthened our collaboration skills within the health sector. It is now a prime opportunity for WBoP PHO, our Iwi partners and General Practice partners to work together to deliver this whanau centred programme, supporting Māori with long term conditions to become self-managing.

The Model of Care The model of care supporting the LTC programme transcends across traditional health and social sector boundaries and incorporates clinical, social and environmental interventions and navigation support.

It is a model of care that is patient/whanau centred and will: Provide care that is respectful, responsive and meaningful to the individual patient preferences, needs and values and that ensures the patient and whanau goals inform clinical decisions.

Encourage high quality and sustainable long-term condition management within the community that empowers individuals and their whanau to take control of their wellness.

Be accessible, equitable and culturally appropriate.

The Team The programme provides support for patients living with LTCs and their whanau through a mobile nursing and kaiawhina team operating as an extension of the general practice team within the community.

The team consists of registered nurses partnered with kaiawhina (health care support workers). The team work as part of an integrated model with WBOP PHO practice team partners, WBOP PHO Māori provider partners, community and hospital-based health service provider colleagues, to proactively provide wrap around support to high-needs individuals and their family/whanau (for an expected 6 month duration).

Existing whanau ora / mobile nursing and kaiawhina services are incorporated into a continuity of care model to avoid duplication of care.

Manawanui Whai Ora Kaitiaki – Hauraki PHO Example case studies March 2015 “No-body cares” Te Kohao Referral; patient with newly diagnosed cancer, depression, and poorly managed type 2 diabetes.

Non-compliant with medications and had not been attending appointments.

Patient “B” is a Māori male, 42 years, living in social housing with his cousin and her son. Receiving job seekers deferred benefit with no disability allowance supplement. He has no cell phone or landline to be contacted on. Medications being delivered weekly on Wednesday.

We decided to call on patient “B” in person due to no available contact numbers. He was hesitant on my approach, so I left a pamphlet and my contact number and gave him options of how we could sit down and have a korero, “ I can come to your house, or pick you and we can go somewhere to sit down and talk.”

A week later he rang after a GP appointment. I picked him up and we went for a walk around the gardens and sat down to have a korero. “B” was feeling overwhelmed with his diagnosis of cancer and was not engaging with his district nurses or attending his specialist appointments; “I don’t know when they are, I don’t have a phone”. He was confused about his medications and what was prescribed for what.

After a couple of weeks, we had built a strong trusting working relationship and we established a goal / task plan.

1: Attending Appointments- We sat down went through all his upcoming appointments and missed ones.

We rang and re-booked missed appointments and made a diary of all his upcoming appointments. We also organised transport to and from these appointments via the Oncology Nurse for his oncology appointments and through the health shuttle. We went with him to a couple of appointments to support and advocate for his medical needs.

2: Medications- It was valuable attending his specialist appointments where we could advocate those key questions for him to understand the importance of his medications and help him understand when, why and how to take them.

3: Financial support- “B” was unable to consider returning to work in the near future due to undergoing treatment and his medical conditions. We sat down and discussed options such as the ‘unsupported benefit and applying for the disability allowance’ With this he would not have to worry about supplying medical certificates every 3 months and this would also increase his weekly income by $64.00 at least a week. We included in his application for disability allowance a landline, gardens and lawns, medications, GP visits, and transport to and from appointments.

With all the supporting documentation we attended the Work and Income appointment where all was granted and approved.

4: Engaging with a support group- It was important that “B” had support to help him understand his condition. We discussed groups but he was not keen initially. We went to some together and I followed one up with a phone call that he was interested in with the Cancer Society. She contacted him and the next day he went in to see her “She was cool I like her” 5: Enabling contact- We were able to secure a cell phone for “B’ and what a difference that made to him to have a point of contact until his landline came on from work and income. He was able to give medical and social services his contact number.

In Conclusion.

“B” was a young man who at times became frustrated with his conditions and people trying to help him.

He was non-compliant with services, medications and treatments and was at times becoming aggressive.

As we began this journey together and built our trust, he could start to see changes and things happening.

Now he has an increase of $98.00 a week, a landline and cell phone. He puts all his appointments into his cell phone now as his reminder and organises his own transport to appointments via the health shuttle and the Cancer Society.

He is taking his medications, and just a week ago had his follow-up oncology appointment where he was told that the cancer has not progressed, and the medications are working because he is taking them as prescribed. He has engaged with the Cancer Society and is looking forward to attending an oncology weekend workshop in Huntly.

As he has been taking this journey “B’s” outlook on life has become much more positive and is growing brighter every day.

Goals in progress: Getting his driver’s licence and vehicle.

“Living Under A Bridge” Te Kohao Referral; Education and support for alcohol dependence syndrome, chronic depression, severe emphysema, dependant personality disorder and accommodation.

Patient “A” is a European/Māori Male aged 64 years, living in transit between night shelters, friends, and a Hamilton bridge. Has 9 children and 16 grandchildren. Daily delivered medications to a friend’s house due to previous suicide attempts.

When we received the referral, we had to make contact through a friend as we had no other contact number. After speaking with the friend, we arranged a time that we could meet the patient at her house, and we could talk. He was one of the humblest people I have ever met, and we continued to build our relationship over the next 2-3 weeks.

“A” had been treated for chronic mental health issues since 2005 when he was admitted to Henry Bennett on/off for the next 3 years. Since then he has been living in transit and has become alcohol dependent with several suicide attempts. At the time of referral, he was not engaging with Mental Health Services.

“A” is receiving the unsupported benefit with no disability allowance. He has not been into a Work and Income office for several years other than to drop off medical certificates. At times “A” was missing his medications due to his transit lifestyle and with the belief that if he was drinking he shouldn’t take his medication, so at times he was going up to 4-6 days with no medication and becoming severely depressed.

“A” engages well with his GP and the Te Kohao practice; he regularly pops in there to have a cup of tea and a chat.

There was no current care plan for him except that he is to contact the crisis team if he feels unsafe to himself or others.

During those initial 2-3 weeks we were able to build trust and address some urgent needs such as accessing Kai – his weight was of concern being only 46kgs when we first met.

A couple of times we had to rebook my visit due to him being intoxicated as that was an agreement that we had made for him to be sober on visits and appointments.

Having completed an initial assessment, we established a goal setting and care plan: 1: Housing- Advocated a Social Housing Whare : First initial over the phone assessment with the need of housing due to no fixed abode and at risk of mental and physical harm as there was no permanent abode for delivery of medications.

With supporting documentation, we took “A” into work and income for a full assessment.

After 1 week and a couple of follow-up phone calls “A” was offered 2 houses. He chose the house he liked and the following week we moved him into his new house. This was the first house that he had lived in permanently for 10 years.

2; Medications- Arranged daily dispensing to his new house and a GP appointment to have a medication review. The GP explained medications and when to be taken “A” now has a sound understanding of his medications.

3 Furniture: - “A” had no furniture just a bean bag and blow up bed with a few pots and pans and dishes from friends. Advocated furniture via St Vincent De Pauls. “A” attended an assessment where they itemised his needs and arranged delivery within a week. In the meantime they also gave him 3 big boxes of pantry kai to assist.

We made an appointment with Work and Income to apply for a fridge and washing machine. I couldn’t make that appointment time, but I was so proud of “A” as I had rung him that morning explaining the situation and his response was “its ok I can go myself now”. Delivery of white ware was made within 2 days.

3: Engaging with Mental Health Services- After a week in his new home we had a catch up. “A” talked to us about not wanting to ruin this chance and that he wanted to have his kids come stay with him when they can, but that they will not when he’s intoxicated. We discussed about Mental Health and Addiction services being able to support him. He agreed to make contact again and the following week we both went along to his first assessment with the Mental Health Team.

4. Work and Income Entitlement- Disability allowance application.

Applied for Medications, GP visits transport to attend appointments and telephone needs to have contact with all support agencies.

“A” and I attended appointment with all required documentations.

In Conclusion.

With just spending a few extra hours to attend appointments with ‘A” and helping to get the correct documentations it helped break down barriers and rebuild ‘A’s” confidence.

“A” continues to move forward and is maintaining his well-being. Now living independently and very proud of his new home, even putting in a garden. He is becoming more confident attending appointments such as work and income on his own. He is engaging with services and getting support for his mental health needs and addictions, whilst taking his medications daily.

Goal in progress: House keeping