HOW IT WORKS
The Awhi Ora model is a social program, co-designed by the Tāmaki community and the Auckland District Health Board with primary care and nongovernment organizations (NGOs) partners. The program serves people who experience distress from underlying social and physical challenges and who find it difficult to perform daily tasks or reach their goals. The only eligibility requirement is experiencing some level of distress from these personal challenges. To focus on well-being, the program addresses what matters most to the person and tries to remove barriers to access, such as cost or language. Patients can self-introduce to the program, obviating the need to have a general practitioner (GP). The GP identifies the source of an individual’s distress and the most appropriate supports, whether clinical or social, and introduces people to Awhi Ora when the underlying cause of the distress is social. The GP keeps the clinical responsibilities for patients’ care and the NGOs support access to services. Patients transition out of the program when they meet their goals and map out their next steps but can easily return to the program as needed.
With goals guided by the Triple Aim, this program started as a prototype in 2016 at two GP practices and has since been rolled out to more than 40 practices. Data on program activities are routinely collected. The program has been evaluated by an independent agency.
Awhi Ora relies on a collaborative, shared model of support based on a partnership with the participant, a GP (when there is a need for clinical support), and a NGO support worker. Depending on the person’s needs, either the GP or the NGO will provide management leadership. GPs predominantly provide health care, while NGOs play an advocacy role and connect people with social care providers. There is a high level of collaboration between GPs and NGOs.
The program’s purpose is to support self-management, which guides how practitioners engage with patients. With an emphasis on shared decision-making, patients define their own goals and develop individualized care plans through motivational interviews with support workers. One-on-one coaching is available to help people communicate their needs. Support for physical health conditions is provided, though the program primarily focuses on supporting social needs. There is little emphasis on caregivers in this program as participants are usually the adult patients themselves.
Awhi Ora creates new governance structures and collaborative partnerships. The model is based on three key relationships: the GP practice and lead NGO, the lead NGO and other NGOs, and the participant and support worker. Awhi Ora belongs to the wider Tāmaki Mental Health and Wellbeing initiative. A steering group meets monthly with membership including the hospital, community, primary care, NGO and funding staff.
Awhi Ora involves a new way of financing patient care. Funding that would have gone into secondary care is instead channeled toward moving people faster into primary care. Funding for community-based social services is both optimized and more transparent. This model is innovative because it identifies best practices for providing a shared-care model, and funding that works on an ongoing basis.