Abstract
In 2014 The Ministry of Health commissioned a demonstration project for a new model of care for patients with Long Term Conditions (LTCs). The model focuses on empowering people with a chronic disease to successfully self-manage their condition and participate in shared decision–making with their primary health care team. This is based on the premise that patients more actively engaged in their self-care are more likely to experience better health outcomes.
Hauraki PHO chose to partner with Health Care NZ to develop its LTC programme, known as Manawanui Whai Ora Kaitiaki (MWOK) - supporting a pathway to wellness. Building on HCNZ’s Te Whiringa Ora/Care Connections (TWO) model, the programme provides outreach support for patients living with LTCs and their whanau through a mobile nursing and kaiawhina team, based in the general practice environment and operating as an extension of the general practice team.
The model of care underpinning the programme transcends across traditional health and social sector boundaries and incorporates clinical, social and environmental interventions and navigation support.
At the end of the first year of implementation, an independent evaluation has highlighted the positive impact of the programme on patient activation, ability to self-manage, maintenance of wellness and participation in lifestyle interventions to improve health.