HOW IT WORKS
The MWOK program acts as an extension of primary care to people with complex and chronic health needs, providing them with outreach and support. Referrals from general practice teams to MWOK focus primarily on health, but it is recognized that social care needs must be addressed for patients’ health status to improve. General practitioner (GP) practices identify potential patients, who must have uncontrolled long-term conditions requiring complex primary care in addition to eight or more primary care visits in the previous six months or alternatively, must have high needs but low engagement with primary care providers. Eligibility is flexible and based on professional judgment. GP practices receive alerts regarding new referrals and monthly data on Medtech, a patient-management software platform. Registered nurses act as case managers and the Kaiāwhina (in Maori culture, someone who is in a support role) act as health navigators. Kaiāwhina, who have diverse backgrounds (including social work), receive supervision and formal training. The nurse and the Kaiāwhina use a comprehensive tool for the initial assessment, which becomes the care plan.
This is a pilot program that has enrolled nearly 1,000 clients since 2014. It serves a range of other high-need populations other than those with mental health and addiction issues. The program routinely collects data on program activities, and the Hauraki Primary Health Organisation has conducted a preliminary evaluation.
For providers. The GP team, which retains responsibility for the patients’ health needs and is actively involved in the care plan, works in partnership with the MWOK team, with the latter providing regular updates. The MWOK team works collaboratively with a range of social and multidisciplinary teams to meet the specific needs of each patient.
For patients/caregivers. Patient engagement is the core philosophy of MWOK. A number of metrics and measurement tools are used to assess levels of shared decision-making, patient activation, and engagement, such as the Patient Assessment of Chronic Illness Care (PACIC). Staff, patients, and caregivers are trained in self-management. Caregivers are involved in and contribute to the care plan.
The central partnership between GP practices and the MWOK team is complemented by strong connections among the MWOK team, social care teams, and nongovernmental organizations operating in the area — particularly Maori providers, some of whom operate Whanau Ora programs. Some committees bring together a range of health and social care providers as required.
Financial support for the MWOK program comes out of a pooled budget set aside for flexible-funding initiatives. Waikato District Health Board and Hauraki Primary Health Organisation (HPHO) work together to allocate funding and agree on annual budgets. The flexible-funding model allows GP teams to deploy resources to the people most in need. The MWOK teams are employed by the PHO but function as an extension of the GP team.