Transcript Example Title - National Hauora Coalition

Oranga Ki Tua
Programme Development &
Service Delivery Model
National Hauora Coalition
© National Hauora Coalition
Whānau Ora System
© National Hauora Coalition
18/07/2015
National
Hauora Hauora
Coalition
© National
Coalition
Impact on Whānau Ora Outcomes
NHC Outcomes Framework
Health Determinants
Risk & Protective Factors
Social Determinants
Population Accountability - Indicators (How NHC measure these conditions)
Education
·
Participation in
ECE
·
School leavers
with higher
education
·
Adult upskilling
·
Adult literacy
Housing
·
Household
Crowding
·
Warm houses
·
Housing Related
Potentially
Avoidable
Admissions
·
Affordable
Homes
Income
·
Household
Income Status
·
Financial stress
Cultural & Social
Connectedness
·
Support Network
·
Cultural
engagement
·
Te Ao Maori
Alcohol & Drug Use
Gambling
Nutrition
Physical Activity
Body Mass index
Tobacco use
Sexual Health
Whanau Safety – Family Violence, Elder abuse, Child abuse, Neglect and Sexual Abuse
Unintentional injuries
Rates of Crime
Whole of life
·
Ambulatory
Sensitive
Hospitalisations
·
Mental health
·
Obesity
·
Skin Infection
·
Oral Health
·
Infectious
Disease
0 -14 years
·
Baby Blues and
Post natal
depression
·
Postnatal
·
Antenatal
·
Breast feeding
·
Sudden infant
Death Syndrome
·
Hearing
·
Child Oral health
·
Reumatic Fever
·
Low Birth weight
·
Vision
© National Hauora Coalition
15 – 25 years
·
Suicide &
Intentional self
harm
Performance Accountability --
25+ years
·
Self management
·
Cancer
·
Respiratory
disease
·
Suicide &
intentional self
harm
Service Utilisation
General
Practitioners
·
Emergenncy
Care
·
Specialist
Services
·
Prescription
·
Social providers
·
Health Providers
·
Strategies & Actions
(What works to
improve these
conditions?)
·
Specificity –
practical
implementation
·
Leverage –
impact on
indicator
·
Values – aligned
to Whanau ora
ethos
·
Research –
feasibility and
affordability
Performance
Measures
(How NHC know how
WO Network is
working)
·
How much did
the WO Network
do? (outputs)
·
How well did the
WO Network do
it? (quality of
services)
·
Is whanau better
off? (Skills,
Knowledge,
Attitude, Opinion,
Behaviour &
Circumstance
Impact on Whānau Ora Outcomes
• Improve
health
outcomes
• Impact on
whole of
life
outcomes
© National Hauora Coalition
PPP Targets, National
Health Targets, Service
Utilisation, Child
Health, Risk &
Protective Factors
Participation in ECE,
Adult Literacy, cultural
engagement, Te Ao
Maori, overcrowding,
warm homes, rates of
abuse, unintentional
injuries, financial stress
ASH rates, mental
health, obesity, skin
infections, oral health
infectious disease,
respiratory disease,
disability – function
limitation
Incidence of type 2
diabetes; complication
rates, heart disease;
medication adherence;
self management; care
plans.
• Improve
social, and
cultural
outcomes
• Impact on
those with
long term
conditions
Whaanau Ora case management
Te Ao Maori
Basic Needs
(implement)
Tinana
Manawa
Hinengaro
Pito
Housing
Healthy
Lifestyles
(implement)
Connected
to Whaanau
(how)
Health Literacy
Rangatirata
nga /
Collective
Self
determinati
on
Smoking
Cessation
Immunisation
Money
Manage
ment
Wairua
Mauri
Entitlem
ents
© National Hauora Coalition
Screening
Medicine
Adherence
Health Risk
Connecting
to
community,
marae,
whaanau
Economically
Independent
(strong links)
Employmen
t
Accessing
education
Child Safety
Nutrition
Exercise
Safe Homes
(Assess)
Family
Violence
Engaging
children in
education
Literacy,
Primary Care Relationship
Primary Care
Medical Home
Referral
MDTs
Triage
identifies need
for Whaanau
Ora
assessment
Specialist or
Community
Referral
Maatua, Pepi
& Tamariki
Programmes
Whaanau Ora Practitioners
•
•
•
•
•
•
Feedback loop to
the medical home
(strengthening households)
Basic Needs
Healthy Lifestyles
Connected to whaanau
Safe homes
Economic Independence
Te Ao Maori
Whanau Ora Environment
•
•
•
•
(health & social services integration)
Self Management
Minor Intervention
Whaanau Ora programmes
Whaanau Ora Case Management
© National Hauora Coalition
Services delivered in
homes, IFHC, marae &
communities
Rangatahi
Programmes
Oranga Ki
Tua
Programmes
OKT Programme Design
• Living actively and independently is a human right; when that is
compromised
–
–
–
–
Disability & Rehabilitation
Cancer
Medical Long Term Conditions
Mental Health
• The OKT programmes can:
– Guide FFP allocation
• Medical
• Mental Health
– Guide Service Integration projects
• Counties Manukau – Mental Health & Medical LTC Funding
• Taranaki – Mental Health & Older People
– Locality Projects
• Taumarunui – partnership with the hospital
• Taranaki – Te Kawau Maro – Mental Health/Older People
• CMDHB – Otara - Medical
© National Hauora Coalition
OKT Program Design Principles
Services funded through the MPT Services Program will:
1. Focus on early intervention and prevention of avoidable long term
conditions
2. Provide proactive support of pēpi / tamariki through strengths based and
solution focused interventions
3. Work in partnership with whānau, their communities and other key
stakeholders, through tamariki-centred, kaupapa whānau focused practice
4. Work across agency and organisational boundaries to promote
collaboration, coordination and integration of quality services
5. Build services that are evidenced based, accountable and responsive to
emerging needs and trends
6. Support the concept of ‘any door is the right door’ which is central to
connecting people with the services they require as soon as possible
© National Hauora Coalition
Summary points for OKT design
Connection, Communication, Coordination, Caring;
• Building engagement with whānau;
1. Focus on early intervention
2. Provide proactive support of inidividuals and whanau moving from
dependency to responsibility
3. Work in partnership with whānau & their communities by building
engagement with whanau
4. Work across agency and organisational boundaries to promote
collaboration, coordination and integration of quality services
5. Build services that are evidenced based, accountable and
responsive to emerging needs and trends
6. Support the concept of ‘any door is the right door’ which is central
to connecting people with the services they require as soon as
possible
© National Hauora Coalition
Engaging with Whānau
• Competencies for all Health Professionals &
Whānau Ora Practitioners
–
–
–
–
–
Build Trust & Confidence
Build Health Literacy
Self responsibility
Supported Responsibility
Quality systems, standards and review
• Whanau
• Hierarchy of needs prioritised by the client & their
family/whānau
• Personal & whānau goal setting
© National Hauora Coalition
Model of Care to Guide Service Delivery
Highly complex set of needs requiring
intensive specialised care with an
acute response, better managed in
secondary or tertiary health settings,
or led in other sectors
Intensive Primary & Community Care
modules of services as evidenced by
medium to high needs across clinical,
social or in self identified assessment
Health promotion, prevention, and
early detection interventions in
primary and community settings to
meet the basic needs of tamariki in
high needs communities
© National Hauora Coalition
Supporting People to Live Well
Proactive,
coordinated
care
Supported
Self
Management
Active
engagement
in being
healthy
© National Hauora Coalition
•A 68 year old woman with type 1 diabetes, a heart condition and in
the early stages of kidney failure had at least ten clinic appointments
each month on different days and each time she was admitted to
hospital her medications changed, then her GP changed them back.
Following a consultation by the “shared care team” she saw her GP
once a month who shared her results with her specialists. The team
pharmacist monitored her medications. Her kidney function is stable,
and her heart medications have been reduced. She now has one plan
of care and feels that her care is being managed safely and she is not
on everyone’s waiting list for appointments.
•A 20 year old man was in denial about his diabetes. He hadn’t told
anyone about his condition, rarely measured his blood sugars and had
not seen his GP in 18 months. After being acutely admitted with
hypoglycaemia for the third time he was referred to a “LTC case
manager”, he now regularly monitors his blood glucose, is in regular
contact with his primary care team, has moderated his alcohol intake
and has explained his condition to family and friends. He hasn’t been in
hospital since.
•A smoking 32 year old mother of four was overweight, and found herself
regularly short of breath. She was struggling to get to work everyday and
to keep her house warm and feed her children as she missed days at work
and lost pay. Taking her daughter to the doctor for a chest infection, they
gave her a cardiovascular/diabetes screen and appointed a “whānau ora
case manager“ who helped her join a community wellness programme,
and assessed her social circumstances. She lost weight, started exercising
every day with her kids and gave up smoking. She gets to work, her blood
pressure and blood sugars are normal and her kids are eating well. Her
case manager identified that her house qualified for a “healthy homes”
initiative. Her daughter hasn’t been to the GP for a chest infection since.
Whanau Ora Practitioner
Oranga Ki Tua
- Nutrition &
Exercise
- Smoking
Cessation
- Housing
-A&D
- Cultural
Connection
Literacy
Advocacy
Translation
Rongoa etc
Glucose
Smoking CVDRA
Cx Cancer
Prostate Cancer
Bowel Cancer
GPs
Nurse
© National Hauora Coalition
DARs
CVDM
Care Plus
Specialist
Communications
GPs
Nurse
Pharmacist
Specialist
Complications
Palliative
Navigators
Specialists
Psychologist
GPs
Nurse
The System
Whanau Ora
Practitioners
Self Management
Support
?Professionals
The
Multidisciplinary
Medical Home
© National Hauora Coalition
OKT Medical Packages of Care
Self Management
Packages of Care
(e.g. Diabetes,
Gout, CVD, COPD)
Intensive
Integrated
Primary Care
© National Hauora Coalition
•Strong health literacy centred self management programmes
•Self management services - Telecare
•Led by what professions / coaching role / Group and/or individual
•Person who touches the person/whanau most / the coaching role / not
disease specific / coaching the whanau
•Person/professional/community
•Risk Assessments
•Annual reviews
•Active MDT Management of Care Plans – Nurse Led Service
•Reduced Cost Barriers to Clinical Interventions – insulin start up, podiatry,
•Generic LTC good practise
•Disease specific rehab groups (stratified)
• Care Plans
• Supported by MDT
• Pharmacist & medicine review
• Specialist Care
• Preventing avoidable hospital or specialist teams
Common Requirements of OKT Services
Services funded through the OKT Services Program are:
•
•
•
•
•
•
•
•
•
•
•
•
Whanau focused and recognises the importance of family connections and relationships in
achieving optimal life outcomes
Inter-sectoral approach to achieving Whānau Ora outcomes
Able to articulate the planned outcomes of interventions and whanau achievement against
these outcomes
Evidenced based and able to identify the evidence base for achieving the best outcomes for
their target population
Continually reviewed in line with a quality improvement framework
Culturally competent
Able to demonstrate an ability and willingness to work collaboratively with other service
providers
Provided by trained professionals with the attributes, knowledge and experience to provide
the funded service
Committed to professional development of staff including professional supervision in
accordance with best practice
Actively involved in the collection of data and measurement of mama, pepi, tamariki /
whanau progress against key performance indicators
Committed to research and evaluation and improved service provision to reflect the
changing evidence base and population needs
Persona/professional/community
© National Hauora Coalition
Enablers for OKT clinical integration
Locality Approach
• Serve geographic rather than enrolled populations
• Promote better whole of service approaches
• Greater self management & whānau engagement
Funding Models
• fund integrated service delivery including MDTs and delivery in IFHCs
• Funding to support identification & assessment of “at risk” patients
• accountability frameworks for specific whanau ora outcomes for patients from LTC clinical integration,
Organisation structure
• locality clinical partnerships to develop integrated service delivery in localities including case management
• quality & outcomes frameworks reward organisation performance across GPs & whanau ora provider
• Location of service delivery (IFHC/ Hub & Spoke)
Workforce
• Multidisciplinary teams available within General Practise;
• Professional Whanau Ora workforce
Technology
• Electronic shared care plans are supported by IT platforms
• Implementation of community e-prescribing and e-referrals
• Development and implementation of self management tools
• Use of clinical pathways supported by an electronictool
© National Hauora Coalition
Agree next steps
© National Hauora Coalition
© National Hauora Coalition