Abstract
Background: The Eastern Bay Primary Health Alliance (EBPHA) is a Primary Health Organisation (PHO), funded by Bay of Plenty District Health Board to support the provision of essential primary health care services either directly or through General Practices.
The Eastern Bay of Plenty has twelve General Practices and serves a population of 55,950; with 73% classified as having high health needs, 56% living in deprived circumstances, and 56% identify as having Māori ethnicity.
In 2020 the NZ Government commissioned, the Health and Disabilities report, which signalled a new model of healthcare was needed to address the systemic structural inequities. Central to the recommendations was an acknowledgement that the current health service is overly complex to navigate and has inequitable outcomes for Māori.
As a region the EBOP experiences persistent health and social inequalities particularly for Māori and people living with long-term chronic conditions.
Integrated Case Management: EBPHA introduced Integrated Case Management (ICM) as a collaborative approach to healthcare and partnered with General Practice to support patients and their whānau (family) in understanding and managing their chronic conditions and / or complex needs. The aim is to ensure a seamless continuum of care with a focus to manage long-term conditions and reducing inequalities.
The development of the Kaitautoko (Advocate) role enhanced engagement with patients and their whānau, permitting a wraparound service to be provided that is patient-centred and effective.
The ICM team have adopted Mātauranga Māori (Māori knowledge) into their practice, to address cultural inequities. These include the principles created by Taina Pōhatu, which are:
•Āhurutanga - Ability to create a safe space for the patient and the team to determine the best healthcare journey.
•Kaitiakitanga - Cultural sensitivity and awareness of the community we live and work-in.
•Te Whakakoha Rangatiratanga - Successful engagement that encourages conscious application of respectful relationships with all clients. With all initial visits, the patients may determine the location and duration for the visit - their home, their marae, or any other location as agreed by all parties.
•Mauriora - Working alongside the client and their whānau we develop a care plan, specific to their needs and personal health goals.
From a practical application perspective, ICM worked with General Practice to improve the standard of referrals and introduced the Health Planning Tool (HPT). A new ‘E3’ Evaluation Tool was developed which provides wrap around feedback from patients, case workers and the referring community.
Outcome:
•Referral numbers from General Practice have increased.
•Collaborative initiatives include the pilot Cellulitis-MRSA Star Pathway programme, between EBPHA and the Whakatāne hospital. The aim is to reduce hospital admissions of Cellulitis patients by accessing free treatment at their general practice.
•Involvement in the National Bowel Screening workstream, ICMs role is to advocate equitable engagement and outcomes for Māori communities.
•A Health Planning Tool (HPT) which provides real time visibility of a patient’s care journey.
•The (E3) Evaluation Tool, proves the ICM Service improves patient outcomes, reduces hospital admissions, minimises duplication and saves money.