Operating Model within the new Health System

To give effect to the design principles of a national model of care, four hubs are expected, based on the provider network model in Te Whatu Ora - Health New Zealand. The shape of these networks will be designed through a process led by Te Whatu Ora and Te Aka Whai Ora - the Māori Health Authority in collaboration with locality stakeholders. It is expected there will be a focus on integration across services so that people with more complex care needs have a better experience when accessing different parts of the health system.

It is expected that any chronic pain services need to align with other tertiary pain services and consider capacity to service inpatient workload, including acute, cancer and palliative care patients.

In addition to providing specialist chronic pain services, the hubs aim to contribute: • to promoting chronic pain self-management and promote peer-support • to appropriate utilisation of healthcare services related to pain • to addressing unmet need and inequity in chronic pain service access across groups, especially for Māori and Pacific whānau • to seamless transitions of care for paediatric, adolescent, and adult patients and their whānau • to enable primary and community care to provide care including research, education, mentoring (peer review, clinical supervision, professional development), and support from specialist hubs • to enable whānau in pain to be seen virtually, and reduce unnecessary travel Locality-based care & provider networks

Well resourced, coordinated, and integrated networks of providers will support the delivery of care to a locality.

Provider networks will also work to establish and support community-based providers including Māori and Pacific providers, GPs, and other community care providers, to work together in comprehensive primary and community care teams – making more

services available locally.

Figure 2: Interim Health NZ Locality & Provider Networks https://www.futureofhealth.govt.nz/assets/Uploads/Documents/Localities-update-for-the-HealthSector-April-2022.pdf

It is proposed that high complexity pain interventions or the most intensive transdisciplinary programmes are provided at one for the four regional hubs, while medium pain complexity and some ongoing case management services should be available through each locality, with support from the hub as required.

As supported by the literature, this may mean that most paediatric and adolescent services are provided through provider networks, given the intensive pain management approach and specialist workforce required.

A chronic pain self-management programme offered in a community setting is a considered a recommended precursor to multi-disciplinary chronic pain services.

Partnering with Māori whānau to address inequities to pain management – A qualitative case study

Research Aim/Objective

The main aims are to (1) co-design and pilot-test an initial version of the whānaufocused (family and significant others) pain management programme in Māori with persistent pain; (2) evaluate the clinical and process outcomes of the whānaufocused pain management programme.

Research Methods

This is community-based participatory action research (PAR) guided by a Māori centred research approach, both of which uphold community engagement and empowerment. In this study, the Tū Kotahi Māori Asthma & Research trust (Tū Kotahi) identified the research aim and I’m working with our Māori community partner – Cheryl Davies from Tū Kotahi supported by Kaumātua from Kokiri Marae, throughout the research process. Our previous co-design study with Tū Kotahi whānau living with persistent pain identified the need for a Marae-based pain clinic and whānau-focused pain management programme. Based on these inputs and in

consultation with Wellington Pain Service clinicians, a 6-week whānau-focused pain management programme (July - August 2021) and the Marae-based pain clinic was implemented in Kokiri Marae (ongoing). Whānau interviews were analysed using the General Inductive Approach.

Preliminary results from the whānau pain programme

Eight whānau living with persistent pain participated in the 6-week programme and the month Kokiri pain clinic is ongoing. For the whānau-focused pain management programme, Te Whare Tapa Whā (the four cornerstones of Māori wellbeing) was used as a holistic framework focusing on the whānau wellbeing as a collective instead of the individual living with pain. The sessions were led by our Māori community partner (CD) and a pain management physiotherapist (HD). A dedicated session on Māori traditional treatment (Rongoā Māori) for pain management was led by a Rongoā practitioner. Supporting resources for the programme was codeveloped in collaboration with our Māori community partner, Wellington Regional Pain Service clinicians (DH), a Health literacy expert (SR), and a Māori illustrator. Preliminary analysis from whānau interviews suggests an enhanced understanding of persistent pain mechanisms (e.g. pain as an overprotective sensory system response) and provided whānau with "more tools to manage" their pain including Rongoā. A short video https://youtu.be/x1bewks-Zhw capturing whānau experiences from the programme.

Discussion

Persistent pain disproportionately affects Māori and their whānau. Māori face significant inequities in accessing specialist pain services and experience stigma and stoicism in expressing and managing pain. In line with the proposed Aotearoa New Zealand health system reform, this community-based pain programme is a commitment to Te Tiriti obligations to address health inequities for Māori and a result of an ongoing meaningful partnership between Tū Kotahi, University of Otago, and Wellington Regional Pain Service.

Telehealth and virtual care

Telehealth and virtual care options are expected to be a key strategy for improving access for people to ensure care is delivered close to home. For example, telehealth facilities in a community setting alongside resident expert team members within a locality could provide appropriate support for people to access specialist-level chronic pain services.

These services will use common clinical standards and guidance, using an integrated continuum of care approach.

One-team culture with equitable and timely pathways to care

To support patients with chronic pain with an appropriate level of accessible specialist care across their journey with chronic pain and supported to self-manage their condition, the locality and the provider networks need to function as one service with consistent and coherent ways of working.

• For this to be operationalised effectively, appropriate pathways for referral and/or consultation need to be well established, with shared clinical guidance, shared care approaches between primary care and specialist teams. • To ensure there is equitable access to care, consistent triage and wait times should be established, as well as the use of telehealth to improve equitable access to rural communities. • As the service is integrated, professional development and capability building in chronic pain management across the service, including timely access to specialists for advice for patients being managed locally is supported with regular meetings and strong relationships despite working in distinct settings. • A workforce team consistent with the range of holistic services offered should be available at all hubs and will operate using a transdisciplinary team approach. This includes Rongoa practitioners, Kaiāwhina and Pacific navigators to build culturally safe services.

These teams will apply their collective specialist expertise to deliver a range of persistent pain services that will be integrated with, as well as support and enhance, those services provided by Māori, Pacific, and broader primary health care providers. Education and research into persistent pain

Provider networks will be expected to be resourced to collaborate with local tertiary educators, with the opportunity to develop clinician researchers within the hub team. Having specialised clinician-researcher roles in hubs could make collaborative research feasible, which in turn helps to inform key clinical questions in terms of access, experience, and effectiveness.