The "non--nursing" whānau ora model: Te Puna Hauora

1 July 2012

Lyvia Marsden brings 50 years of nursing to the ‘non-nursing’ whānau ora model she developed for North Shore’s Te Puna Hauora. FIONA CASSIE talks to the president of the National Council of Māori Nurses and other Te Puna nurses about their approach to chronic conditions and whānau ora. And how nurses can't be all things to all people.

Lyvia Marsden’s whānau ora model grew out of frustration.With 50 years nursing now under her belt, she’s long seen the toll of chronic disease on her people and known something’s amiss.

When she became the founding nurse coordinator for North Shore’s Te Puna Hauora in 1995, and soon after, the leader of the Māori health provider, she began seeking some solutions.

Along the way, she decided that clinical excellence alone wasn’t enough to resolve the significant social and health issues faced by many Māori and a ‘whānau ora’ approach was needed to help families help themselves.

Marsden – a founding member of the National Council of Māori Nurses (Te Kaunihera) and currently its president – also decided nurses should not and could not be expected to be all things to all people. Their clinical role was demanding enough without taking on a social services or whānau ora role.

“I’ve been a nurse for many a year, and I’ve seen many a burnt-out nurse,” says Marsden.

The result is that, unlike at Te Kohao Health, whānau ora practitioners or “navigators” in Te Puna’s model are never nurses.

“Because of the heavy burden of chronic disease, their (nurses’) pathway is set to deal with that,” says Marsden. “The nurses’ workload is so heavy, it’s so specific clinically, and people are so sick that you need your energy to concentrate on it.”

She believes its nurses should work holistically and culturally appropriately with the many cultures it works with and in tune with the whānau ora approach.

“They are not expected to do all that (whānau ora) work themselves They stick to nursing management because it’s huge,” says Marsden. “Our population is too big for us to manage now.”

For the past 15 years, Marsden has evolved a model of parallel services for Te Puna Hauora – clinical services delivered by GPs, nurses, and other health professionals working in tandem with whānau ora (social) services to help whānau turn their lives around.

Te Puna Hauora has grown to accommodate ‘wraparound services’ at three clinics across the North Shore, employing 63 staff (including 14 nurses and five full-time equivalent GPs) and serving 10,500 enrolled clients (about 60 per cent of the North Shore’s low socio-economic population), of which about 45 per cent are Māori. Te Puna’s home base is its main clinic at Northcote, which also has a pharmacy on site and regular physiotherapy, podiatry, midwifery, and healthy lifestyle clinics along with mental health services and social services.

A key element of Te Puna’s whānau ora model is its IMAP (I-Management Action Plan), which Marsden developed in response to an “epiphany” at a 1997 seminar by priest Pa Henare Tate on his Dynamics of Whānaungatanga model.

The whānau-driven IMAP model was entered by Te Puna in the Ministry of Health’s inaugural Whānau Ora Awards in 2004 and took out the supreme award.

IMAP is described as an intensive home and centre-based case management service involving a multidisciplinary team to “support, motivate, and mentor whānau to achieve self-determined goals”, including getting up-to-date with health screenings and assessments.

The original paper tool is being launched as an online tool that can be viewed on the new website for the whānau ora subsidiary of Te Puna – known as Te Puna Whānau Ora Network Alliance (TWONA) – which Marsden now heads (see www.twona.org.nz which includes moving video testaments from clients about the difference that Te Puna’s whānau ora practitioners have made to their families).

The separation of the parallel clinical and social services has also been taken a step further with an alliance agreement with Auckland’s ProCare (see PHO politics and whānau ora sidebar).

After many years of frustration and work, Marsden thinks she has a model that can make a difference: social services getting families back on their feet so their health needs don’t always come off second best.

Marsden says its whānau ora programme is in the spirit of Whānau Ora Minister Tariana Turia’s vision, but for now, Te Puna’s service is funded from the profits from its general practice clinics.

“We’re just ahead of the eight ball, as we’ve been doing it for so long.”

It is exciting times for a concept she has believed in for so long. She also has some Ministry of Health funding to support other providers getting ready to deliver whānau ora, plus there is her work trying to rekindle Te Kaunihera.

“As you can see, I can’t die. I’ve got to keep breathing,” she laughs.

So what keeps her going after 50 plus years of nursing? “Passion,” is her first answer., but also duty.

“I believe that we older nurses are like an encyclopaedia. We almost have a responsibility to lay some sort of foundation and share our knowledge.”

PHO politics and whānau ora

Te Puna Hauora was one of the initial PHOs signed up with the National Hauora Coalition as it pursued its whānau ora approach.

However, it pulled out in late 2010 after Te Puna head Lyvia Marsden decided that the coalition’s emphasis at the time was too focused on health minister Tony Ryall’s Better, Sooner, More Convenient (BSMC) health policy.

“I wanted the emphasis to be on (Te Puni Kōkiri) whānau ora because we already know how to do BSMC – we’re already doing that,” says Marsden.

At the time, its home DHB, Waitemata District Health Board, was cutting down the number of PHOs it was contracting with, so Te Puna negotiated an alliance and joined the country’s largest PHO, Auckland’s ProCare.

Brian O’Shea, ProCare’s regional manager for Counties Manukau, says in a nutshell, the alliance means it receives and manages the primary health funding for Te Puna.

In return, when the TPK whānau ora funding starts flowing, Te Puna, as a Māori provider, will manage that funding source for ProCare’s practices south of the harbour bridge. There has been some cynicism expressed about ProCare’s commitment to a whānau ora service.

O’Shea, a born and bred West Aucklander of Ngati Awa, Nga Puhi, and Irish descent, has a running brief over Māori health for ProCare and says ProCare is committed and is investing a large bulk of its SIA (services to improve access) funding in whānau ora – but will be starting out slowly by implementing the service in its major Otara practice this winter.

It will be using its existing community health coordinators, currently working with hard-to-reach and high needs patients, and it is just about to employ a social worker bringing the team up to ten. The social worker will carry out the home-based assessment of whānau referred to the service, using Te Puna’s IMAP tool, and the community coordinators will then work with up to 17 families each to develop their whānau ora plan.

Nursing, chronic conditions and the spirit of whānau ora

Te Puna Hauora’s philosophy is its nurses’ energy is best expended using their much-needed clinical expertise.

Nurse Joel Razon, clinical coordinator for Te Puna’s three clinics, supports the focus on nurses doing their clinical best, albeit with a holistic and whānau ora approach for its high needs, multicultural population.

Mobile long-term conditions nurse, Bernie Burkett, agrees that the clinical workload is huge enough, particularly with 200 of its 700 diabetes clients having high-risk blood levels (Hb1AC of 8 per cent or more).

Having a wraparound service means if she discovers a patient’s diabetes management has gone off track because they can’t afford to pay for prescriptions, or they are neglecting themselves while prioritising a sick child at Starship, she can refer them to the budgeting, mental health team, or social services team for support.

Rather than pry or lose the trust of a patient not ready to confide family problems to her, she can call on its community support workers or its Asian community support worker to get to the bottom of the problem.

Razon, originally from the Philippines, enjoys being part of a multicultural team and is accustomed to working with a kaupapa Māori approach while respecting whatever culture the patient is drawn from.

Te Puna’s clinical services model to assess and manage chronic conditions includes a comprehensive nursing assessment tool, developed by Razon and the clinical partner to IMAP, the self-management My Health Plan. In addition, it has mobile disease state management nurses (Buckett and her colleague) working with the high risk and hard-to-reach clients (with the close support of Waitemata District Health Board’s diabetes service).

Razon is proud of the wide-ranging assessment form that ensures any new patient gets a full nurse assessment and blood test to filter out those with undetected diabetes, at risk of heart disease, or with social issues they can refer to the social services team.

To overcome previous problems with patients failing to follow through on diagnostic blood tests, the clinic nurses are all trained to takes bloods there-and-then at the clinic. This can also capture existing patients with gaps in their patient record.

Patients detected with long-term conditions are signed up to My Health Plan – a patient self-management plan that includes nurse education about their condition, lifestyle changes, and a ‘passport’-style book in which the nurse records their diagnosis, latest results, the patient’s current medication, and their health goals.

Every three months when the patients have their medication reviewed by the GP, they also meet with the nurse to review their goals. As an incentive to keep up with their programme, the fee is halved to $8 if they remember to bring their ‘passport’ and attend regularly on time.

All clinics are involved in the long-term conditions My Health Plan as part of Te Puna’s policy of rotating its practice nurse staff weekly through the clinic’s three nursing roles. One week, they are the phone nurse taking patient calls and offering advice, the next week, they are on the clinic floor triaging patients and supporting the GP’s work, and the third week, they work as long-term condition nurses with booked appointments, carrying out nurse assessments and My Health Plan reviews.

Razon says it can be sometimes challenging work with its high needs clientele but “slowly and surely, we are achieving some good outcomes with blood sugar levels and blood pressure”.

He says Te Puna is also seeing the number of people on the sickness benefit dropping.

“When we refer them to the proper channels, it makes a huge change to their lives as well. That’s what whānau ora is all about, I guess. Not working on just one side of the issue.”