For Adrian Maxwell, it can be as simple as where the client is sleeping that can hint at deeper problems. Mr Maxwell is not just looking at the person’s health conditions. He and colleagues are looking for signs of financial stress, or maybe whether the house is damp.
“Sometimes, if you walk into a person’s house and their bed is in the lounge, that for me is a red flag that this person is living in a cold house,” he says.
“You pick up different indicators when you get into the house on why they are not managing.”
Mr Maxwell is the registered nurse in the integrated case management team at the Eastern Bay Primary Health Alliance based in Whakatāne. Also on the team are two full-time and two part-time case coordinators.
Clients receive help directly related to their health condition, but might also be referred to an agency that can help with home insulation, or to a whānau ora service that can get them firewood.
At this year’s New Zealand Primary Healthcare Awards | He Tohu Mauri Ora in May, the team won the Southern Cross Health Insurance Primary and Secondary Integration Award. The runner-up was the SpineCare pathway at TBI Health.
Mr Maxwell’s group serves the alliance’s 54,000 patients in eastern Bay of Plenty. Many patients have complex needs, and GPs refer to the team those with the likes of diabetes and chronic obstructive pulmonary disease (COPD). The team manages about 600 referrals a year.
Established in 2014, the team descends from Te Whiringa Ora, a scheme created in 2011 under then-health minister Tony Ryall’s Better, Sooner, More Convenient programme. Te Whiringa Ora, wrote University of Auckland senior lecturer Peter Carswell in the International Journal of Integrated Care in 2015, was an interdisciplinary chronic care programme that led to a reduction in hospital presentations.1
After three PHOs merged into the alliance, it had critical mass and resources to invest, and was able to fund the programme; the service was provided by Healthcare New Zealand, Dr Carswell wrote.
It was an alternative to the Care Plus scheme, which funded four free general practice visits a year to improve management of long-term conditions.
The awards judges said the integrated case management team serves a real need in the area and has a significant impact on its Māori population.
As well as chronic and complex case management, the team provides a navigation and coordination service.
Some clients may be referred to the Bay of Plenty disability support service for a home-help assessment, others may need help with transport in order to attend a hospital appointment, for example.
The starting point following referral is the development of an integrated care plan made with the client, their whānau and their GP.
Mr Maxwell says many referrals are made because the GP thinks more than a 15-minute consultation is needed.
“They send the referral to us to figure out what the patient needs, what’s missing. We get lots of patients coming out of hospital without a care package, without a lot of support, not coping.”
Another team member, Georgina Moke, says one of the keys to their success is attention to whakawhanaungatanga – forming good relationships.
Mr Maxwell agrees with this principle: “Most of our team are hand-picked because we are very good at relationship-building and we understand the importance of building that relationship first.”
He says many people with COPD end up in hospital if not coping at home and might be referred to the team soon after being discharged.
Part of the job is to help patients understand their medications and to check whether they have any problems getting them.
“If they do, we work with [Work and Income]...Then we educate them on how to use their inhalers if they need education on that...
“If they are still struggling, we will refer them to [Bay of Plenty service] Asthma & Respiratory Management, or a respiratory nurse at our local Ngāti Awa services if the patient would prefer a kaupapa Māori influence.”
