1. Advanced Primary Health Care MN/PG.418 2009
Assignment two - Whanau Project
September 2009
by Jo Aston

2. Setting the scene

Maori Health provider 3. Enrolled population of approximately 2900 4. 90% Maori/ Pacific or high needs

Goals of Whanau project

Workwith a group ofhigh needs families 5. Extension of Medical Centre to home 6. Whanau nurse to build partnership with family 7. Bring in experts in the field where needed 8. Identify barriers to healthcare 9. Look at home situation

Current situation

Frequent presentation of high needs families with re-occuring conditions 10. Access barriers 11. Overdue immunizations 12. Recall letters not being answered 13. Maintenance of health not being met 14. Presentations to ED out of hours or once conditions deteriorate 15. Admissions to hospital

Primary Healthcare Strategy Key Directions
16. Work with local communities and enrolled populations
Organising services around the defined population
Reaching those patients who are not accessing healthcare
Offering some intense care for whanau who require management of a new condition or existing conditions with one or more family member
17. Identify and remove health inequalities
Disparities in health status between different population groups are found worldwide (Robson B. 2006)
Identifying a target group who are not having healthcare needs met by the service
Being creative about the delivery of care with the intention of removing some barriers
18. Develop the Primary Health Care workforce
Development of Mobile Primary whanau nurse
Upskilling of all Practice nurses
Integration of healthcare services within our organisation to deliver home based healthcare
19. The Team
20. Team

Clinical Nurse leader 21. Clinical Director/ Gps 22. Mobile Primary WhanauNurse/Practice nurses 23. Kaiawhina 24. Family start 25. Social worker ?

Clinical Director /GPs

Formulates criteria for referral 26. Identifies patients in need of referral to Mobile Primary whanau nurse 27. Support to Mobile Primary Nurse 28. Clinical directorwritesstanding orders 29. All referrals andnotes communicated in med tech

The Referral Criteria
Children with asthma and or eczema
Frequent Gp visits
Families with frequent hospital admissions
Ongoing skin infections
Overdue immunisations
Familiesneeding support in the home with medical conditions and education around managing family members with medical conditions
30. Mobile Primary Whanau Nurse
Building relationships with whanau
The Broker
Liasewith allied health professionals
Bring in experts where neededeg. Asthma nurse
Holistic healthcare treating the entire family and looking at the environmental factors that impact on health
31. Kaiawhina
Build relationships with families
Support for Mobile Primary WhanauNurse
Assist in making appointments with families
32. Family Start
Employed within the organisation with the role of working with families to promote:
Health
Education
Social services
Referrals may be made by this team
They may have established relationships with the identified families
33. Social Worker
34. Leadership styles
35. Clinical Nurse Leader / facilitator
Facilitation of Gps training and discussion of Mobile Primary Nurse role
Fortnightly training sessions for teaching standing orders
Policy written around the use of standing orders
36. Facilitation of Mobile Primary Whanau Nurse
Core competencies
Identified training needsforMobile Primary whanau nurse
Ensure adequate training delivered
Facilitate meeting between specialist nurses and Mobile primary whanu nurse
37. Evaluation
Limitations within a high needs population to always see the gains
Measurements within the targeted group will be monitored and documented eg:
Increases in immunisations
Number of B4 school checks
Number of education sessions
38. References
Minestry of Health - Primary Health Care Strategy 2001
Primary Health Care in capital and coast district health board June 2009
Robson B, Harris R. Hauora: Maori standards of health 1V. A study of the years 2000 2005.
Kai Tiaki nursing magazine by Ann Manchester in April 2008 Volume 14
39. References