The whānau ora approach to nursing chronic conditions

1 July 2012

If your car is your home, it’s tough getting diabetes under control. FIONA CASSIE looks at a whānau ora approach to chronic conditions at one of the country’s first whānau ora centres.

The patient’s blood sugar is going haywire – sky-high one day and plummeting the next. Visiting disease state management nurse, Sharon Matangi-Nixon, is puzzled and asks what’s up?

It turns out his family has moved back home.

“They aren’t working, so the food isn’t stretching far enough, and he isn’t eating properly,” recalls Matangi-Nixon. “He’s also busy occupied with the children, so he’s got out of his routine and is not taking his medication.”

All nurses know that health suffers if a person’s basic needs aren’t met first. But not all nurses work for a health provider who has decided that the “buck stops here” when it comes to acting on meeting those needs and more.

Matangi-Nixon works for Te Kohao Health in Hamilton, which in late 2010 became one of the country’s first whānau ora centres and a demonstration site for the National Hauora Coalition’s evolving whānau ora system (see coalition sidebar). Becoming a demonstration site meant no more money and a lot more work but Matangi-Nixon says whānau ora has its rewards.

“Whānau ora is a fabulous process that enables us to pull everything together for the family on their issues as they see them,” says Matangi-Nixon, who prefers to call herself a wellness nurse.

Te Kohao was founded on Kirikiriroa Marae in the late 1990s to provide low or no cost health and social services to high needs whānau – about 85 per cent of its 5500 plus clients are Māori. It currently employs 45 people at its marae base to deliver its health and social services, including ten nurses, five doctors (two of them part-time), a social worker, a psychologist, community health workers, and others working in the areas of exercise and nutrition.

While the National Hauora Coalition is awaiting approval to roll out its whānau ora system – including its long term conditions programme, Oranga Ki Tua – Te Kohao has been trialling some likely components of the system.

In particular, Te Kohao has been trialling the whānau ora assessment tool the provider developed to help its highest needs families identify and meet their immediate and long-term goals from financial to cultural. A case manager or ‘navigator’ is assigned to carry out the assessment and help the whānau navigate services to meet their goals. It is a voluntary and totally whānau driven process.

Te Kohao Health managing director, Tureiti Moxon, is clear that a whānau ora approach means the first step to managing long-term conditions is ensuring a whānau’s bread and butter needs are met.

“Sometimes, we have people who come to us who are living in cars. What are you supposed to do? Turn a blind eye? But the buck stops with us,” says Moxon.

“Unless you get rid of all the other issues, the chances of them being able to manage and control their own chronic disease is minimal.

“They may come to the doctor and get a pill but that doesn’t get rid of the money issues or them cutting down the power bill by having one heater in one room. So of course everybody stays in that one room, which exacerbates respiratory conditions and is stressful, so it exacerbates their heart disease. The last thing they are thinking of is how to manage their own diabetes.”

Nurses are expected to take a whānau ora approach to all clients, not just the highest needs families referred to the formal whānau ora assessment process.

“It’s no good going in (to a client’s home) and finding no food and not doing anything about it,” says Moxon.

However, she acknowledges trying to provide a more comprehensive wraparound service without extra funding is tough and has increased “everybody’s workload a hundredfold”.

Matangi-Nixon is well aware that DHB district health nurses earn “quite a few more thousand” than herself and that she and other Māori provider nurses do over and above what the funding provides in a “very draining” job.

She says it’s also a very rewarding job and she chose to become a whānau ora ‘navigator’ on top of a demanding nursing caseload of 140 clients with diabetes, lung disease, heart disease, and renal failure.

The six whānau she is currently working with are all at different levels of need. One she began working with about eight months ago are now really good ‘navigators’.

“We’re just going through tidying up some things. Their children’s schooling is now sorted, their counselling is in place, their housing sorted, budgeting done, and the schools and church are on board, too.”

The initial whānau ora assessment can take anywhere between 90 minutes to two hours and all adult members of the family or household (she’s had up to five in one assessment) have to agree to be part of the process.

The tool assesses wide-ranging areas of their lives including the family’s social connectedness, their cultural needs, their financial and housing situation, their social needs and their clinical health needs. The philosophy behind the tool is Mason Durie’s Te Pae Mahutonga health promotion model with the four key principles being: mauriora (cultural identity), waiora (physical environment), toiora (healthy lifestyles), and te oranga (participation in society).

At the end of the assessment, the family sets goals to meet its needs – be it financial, literacy, entering job training, or ensuring the whānau are up to date with health priorities like childhood immunisations and diabetes annual reviews. Matangi-Nixon helps them navigate the services that Te Kohao can provide, along with wider social agencies like Work and Income, Housing New Zealand, and Child, Youth and Family to work through those goals.

Individual clients living on their own aren’t eligible for whānau ora assessment and case management – like her diabetes client with the rollercoaster blood sugar levels used to be until his family unexpectedly returned.

But Matangi-Nixon still takes a whānau ora approach to such clients. Like the client who can turn her hot water back on after Matangi-Nixon discovered one of the reasons she was trying to slash her power bill was to pay for expensive funeral insurance, when as a beneficiary, she was eligible for iwi grants.

There is some debate over whether nurses are the right people to take on ‘navigator’ roles. Matangi-Nixon believes it comes down to the individual nurse. Not all have the life experience, skills, or desire to work outside of a clinical role.

“I think nurses can work effectively as navigators … but it’s a real juggling act,” she says with a short laugh.

Moxon says the difference between before whānau ora and now is that Te Kohao is focusing on the wider needs of whānau rather than simply focusing on the individual targets of its various funding contracts. She says providers like Te Kohao can’t afford not take a whānau ora approach, as continuing to do the same old thing just keeps getting the same old results.

Matangi-Nixon is also an optimist that the whānau ora approach can break the cycle.

She points to an iwi health worker who takes a hands-on approach to teaching her clients with diabetes about healthy kai and exercise.

“She’s in their backyards teaching them to dig the soil and put a garden in. It’s amazing.”

When weighed down by family issues, it was often easiest to pop down to the shop and buy processed food. Now families are learning to grow their own food and get exercise at the same time.

”In a couple of generations, we are going to see a totally different family dynamic.”

 

SO WHAT EXACTLY IS WHĀNAU ORA AGAIN?

Whānau ora has been used for some time in its literal meaning of whānau wellbeing or healthy whānau, and taking a whānau ora approach to health and social services is not new.

In the Ministry of Health’s 2002 Māori Health Strategy He Korowai Oranga, the whānau ora concept was defined as “Māori families are supported to achieve the fullness of health and wellbeing within te ao Māori and New Zealand society as a whole”.

Tariana Turia’s Taskforce for Whānau-Centred initiatives, which quickly became known as the ‘Whānau Ora Taskforce’, decided the key characteristics of whānau ora as being about whānau wellbeing, self-determination, possessing a strong cultural dimension, and applying across a wide range of social, health, and economic sectors.

The taskforce culminated in the whānau ora policy announced in 2010, under the leadership of Whānau Ora Minster Tariana Turia and government agency Te Puni Kōkiri, which defined whānau ora as “an inclusive interagency approach to providing health and social services to build the capacity of all New Zealand families in need”.

Since then, $164 million over four years has been budgeted for the still-evolving policy, and more than 25 whānau ora collectives representing 183 social service and health providers have been selected and funded to develop whānau-centred services. Amongst those collectives is the Pacific-led Alliance Health+ primary health organisation, which has 13 general practices across Auckland.

Also in 2010, the National Hauora Coalition was successful in winning one-off funding from the Ministry of Health to develop its outcomes-based whānau ora approach as a Better, Sooner, More Convenient model for primary health care under Health Minister Tony Ryall.

A former member of the Coalition, North Shore’s Te Puna Hauora health provider, has also developed a whānau ora vision and model, to be rolled out by Auckland’s ProCare PHO.

All the whānau ora approaches share a commonality of being predominantly but not exclusively for Māori (or Pacific) whānau, of being whānau driven, aiming to improve whānau overall wellbeing, and the option of case management to better co-ordinate support services and avoid the “five cars up the driveway” syndrome.

Pay equity for Māori and iwi provider nurses

  • The longstanding Te Rau Kōkiri campaign by the New Zealand Nurses Organisation and Māori and iwi providers to achieve pay parity for their nurses and health workers is still ongoing.
  • Back in 2008, an 11,000-signature petition was presented to parliament to try to win extra Government funding to close the gap that sees Māori and iwi provider health workers earning up to 25 per cent less than colleagues in the public hospital sector.
  • The Te Rau Kōkiri project team met with the Race Relations Commission late last year to brief him on the campaign. There has also been six days of facilitated negotiations between NZNO and employers this year as NZNO tries to achieve great collective agreement coverage for its iwi and Māori provider members.