Tui Ora Ltd Presentation for MIDLANDS REGION PRIMARY HEALTH CARE NURSE LEADERS FORUM Date 30TH May 2014 Tui Ora Ltd Tui Ora • Background • Vision • Mission • Funding Geographical Area Services offered Child & Adolescent Mental Health Service General Mental Alcohol and Drugs, Health Wellness Team TPC Taranaki Primary Connections Supported Accommodation Long Term Conditions Youth Services Alt Ed Tui Ora Family Health Cultural Advisor, Kaiawhina. Koroua Kuia Services Homebased Support Public Health POPULATION – TUI ORA FAMILY HEALTH MHN Locality: North Taranaki Proportion of MHN: 4% iii TUI ORA FAMILY HEALTH – POPULATION AGE Population Age 0-4 313 5-14 593 15-24 481 25-44 911 45-64 701 65-74 138 75+ 72 TUI ORA FAMILY HEALTH – POPULATION ETHNICITY Population Ethnicity Asian European 197 1,015 Maori 1,796 Pacific Island 130 Other 71 TUI ORA FAMILY HEALTH – POPULATION QUINTILE Population Quintile Q1 169 Q2 364 Q3 601 Q4 912 Q5 995 Not recorded 168 TUI ORA FAMILY HEALTH – POPULATION GENDER Population Gender Female 1660 Male 1549 POPULATION – TUI ORA FAMILY HEALTH MHN Locality: North Taranaki - Proportion of MHN: 4% POPULATION – TUI ORA FAMILY HEALTH MHN Locality: North Taranaki - Proportion of MHN: 4% POPULATION – TUI ORA FAMILY HEALTH MHN Locality: North Taranaki - Proportion of MHN: 4% Role of the Nurse in Whanau ora Clinical Practice Holistic Approach Culturally aware NAVIGATOR/KAIAWHINA In a GP environment the clinical team has limited time and resources to attend to patient’s holistic wellbeing with most engagements are the standard 15 minute appointment. The most important phase of engagement is ‘Whakawhanaungatanga’. Listening and capturing their story at its rawest must be given respect. NAVIGATOR/KAIAWHINA There are whanau who identify their needs as ‘small’ or ‘one-off’ - but we have learnt that the smallest of need can have a huge impact on whanau. My child has no shoes to wear to school My child is always sick, always in hospital. I have been kicked out of home. I am sleeping in my car I have no money I have no food I DNA my appointments because I have no transport or I have a car but I can not afford the registration / w.o.f / petrol. I have come to see my doctor today because I have a sore knee but what actually pains me is I was raped as a child and now my 7yr old moko tells me she is being touched by a known person. Pathway Phone calls (network) – i.e. Salvation Army, Winz, Budget advice, CYF Phone calls to TDHB – OPD, Radiology Outcome Follow up – on-going aspirations WHANAU ORA PLAN Patient 1 Lives alone – ex wife and their 17yr old daughter live in NP Friends picked up his medication from the pharmacy – they are all users Friends took his eftpos card and emptied his account weekly Friend was his signatory at the bank He has short term memory loss Cannot walk 2 flights of stairs – awaiting surgery for hip replacement Has Multi outstanding bills Has seizures – ambulance callouts numerous times, has an outstanding account Unopened mail WHANAU ORA PLAN Patient 1 Pathway • • • • • • Kaiawhina – support and advocate to Winz, set up redirection of the benefit to support his outstanding accounts Access Ability – home support – PC, house cleaning, shopping Navigator – transport and support to medical appointments Conversation with pharmacy – weekly courier pick up & selected people to pick up Continence nurse support Medlab home visits Outcome • • • • • • • • Medication oversight Joined St John Ambulance membership group Bills / mortgage / insurance are being paid Cupboards are stocked weekly & meals are prepared Daily care support Transported to medical appointments Incontinent products available Communication with ex wife now active WHANAU ORA PLAN Patient 2 • Moved home with whanau to Taranaki from Australia after 10yrs, staying with uncle • Has Klippel-Feil Syndrome – can not lie in an ordinary bed • Constant seizures • Menorrhagia • Profoundly deaf • Signs • Mother transports patient to a friend’s house 1.5 km away daily for a shower – hygiene, therapeutic • Bathroom tiny, separate toilet. WHANAU ORA PLAN Patient 2 Pathway • Access Ability – to support with PC & outings • Deaf foundation – interpreter • TDHB OT – assess bathroom Outcome • Care support for outings in the event of seizures. • Medical alarm • Interpreter available when necessary • Given a hospital bed • Has a new wet-floor bathroom thanks to local tradesmen and businesses that provided free materials and time – now showers whenever she feels the need • Volunteers for 2 hrs a week at the SPCA – she never ever thought in her wildest dream that this would be possible.