1. © HHL Group March 2013 Ray Wihapi 14 November 2013 Te Whiringa Ora

2. © HHL Group March 2013 Te Whiringa Ora/Care Connections 1 1.Background 2.The model 3.The results

3. © HHL Group March 2013 Why we developed Te Whiringa Ora 2

4. © HHL Group March 2013 Why (continued...) 3 Te Whiringa Ora Chronic health conditions are increasing globally. New Zealand has followed this trend, with an estimated 80% of all deaths resulting from a chronic condition (National Advisory Committee on Health and Disability, 2007). Need for a more proactive and responsive approach. Current reactive models of health care are failing to meet the needs of some individuals

5. © HHL Group March 2013 Our people 4 Te Whiringa Ora Eastern Bay of Plenty Population of 50,000 48% identifying as Māori (national average is 14%). The area has high levels of long-term conditions which are higher than the national average Clients are those who have been admitted to hospital two or more times over the past 12 months and/or have had six primary care visits in the past 12 months (including ED visits)

6. © HHL Group March 2013 Te Whiringa Ora approach 5 Te Whiringa Ora Underpinned by the principles of Whānau Ora Innovative and evidenced-based approach to addressing long term conditions The client and their whānau in the driver’s seat Facilitating interdisciplinary care Complex health needs and high users of hospital services Provide a ‘web of care’ to connect what exists already Time-limited support phase of three to six months

7. © HHL Group March 2013 What we do 6 Te Whiringa Ora Home visits – CM and KTT Engage, relate and build trust Holistic assessment at intake and discharge

8. © HHL Group March 2013 What we do (continued) 7 Te Whiringa Ora Shared support plan Client prioritised goals Interventions associated with goals Linking to the right service at the right time Enabling people to better understand and manage their condition - health literacy Provide information and support Tele-monitoring

9. © HHL Group March 2013 Linking people to the right service at the right time 8 Te Whiringa Ora

10. © HHL Group March 2013 Key objectives 9 Te Whiringa Ora Improve access to primary, secondary and community health care to achieve better health outcomes for clients and whānau Provide seamless access to quality health services that meet clinical, social and cultural needs Reduce disparities in health outcomes Contribute to improving primary care management of chronic and long-term conditions Improve client self-management of long-term conditions Support the health outcome priorities for Eastern Bay of Plenty

11. © HHL Group March 2013 Key objectives (continued) 10 Te Whiringa Ora Reduce preventable hospital admissions and hospital length of stay Increase proactive intervention to prevent or delay deterioration which results in increasing levels of care and acute admissions Provide a holistic client-centred and whānau ora approach to care Educate service users and their whānau in self- management of chronic care and lifestyle changes Increase sustainability of future health services by increased use of the unregulated workforce

12. © HHL Group March 2013 Results - Synergia evaluation 11 Te Whiringa Ora SF12 scores - quality of life Analysis of baseline and follow-up SF-12 data Physical composite score: bodily pain, physical functioning, role-limitation physical and general health Mental composite score: mental health, energy/vitality, role limitation - emotional and social functioning

13. © HHL Group March 2013 Results - Synergia evaluation 12 Te Whiringa Ora Whose health improved?  Māori and non-Māori (approach applies cross culturally)  Males and females  All age groups All showed a clinically significant increase in their SF-12 scores

14. © HHL Group March 2013 So what does this mean? 13 Te Whiringa Ora TWO assists in the improvement of clients’ quality of life Deterioration is typical for clients with multiple long-term conditions SF-12 struggles to monitor change in smaller samples Many evaluations of other models have found no change in these outcomes

15. © HHL Group March 2013 Use of inpatient services 14 Te Whiringa Ora Time in hospital: A 10% reduction in bed days for TWO clients A 47% increase in bed days for the control group Hospital admissions: A reduction in the use of inpatient services for TWO clients. No change for the control group TWO clients were spending more time at home and using inpatient services less frequently

16. © HHL Group March 2013 Use of outpatient services 15 Te Whiringa Ora TWO clients usage of outpatient services decreased in frequency or stabilised: Decreased for COPD Stabilised for diabetes Decreased for heart disease Control groups’ use of outpatient services: Increased for COPD Increased for diabetes Remained the same for heart disease patients

17. © HHL Group March 2013 Emergency Department presentations 16 Te Whiringa Ora ED presentations occurred less frequently for most TWO clients - especially COPD and diabetes clients.

18. © HHL Group March 2013 TWO potential savings (per client) 17 Te Whiringa Ora

19. © HHL Group March 2013 Evaluation summary 18 Te Whiringa Ora TWO evaluation findings are very positive Evidence provides support for TWO and the model underpinning it TWO supports: Improvements in service coordination and access Improvements in self-management Improvements in clients’ quality of life Reductions in clients’ use of hospital services

20. © HHL Group March 2013 19 Te Whiringa Ora “ People don’t care how much you know until they know how much you care”