Te Kaahui Ora Maaori Health Whaanau Ora Services

Our Services include:

Whaanau Ora Team

Service Definition (Role)
The Whaanau Ora Service will work with Maaori clients and their whaanau admitted to Middlemore Hospital to identify their needs during hospitalisation and potentially support achievement of whaanau goals post-discharge for those requiring long term case management due to a multitude of health conditions/concerns.

Whaanau Ora Services will also do their best to ensure that whaanau are linked to the appropriate primary care services (community) and secondary care services (mainstream e.g. hospital, clinics, and any affiliated allied services that will support the whaanau journey).  

Using this information, a nominated Whaanau Ora Key Worker (which may involve one or more of a Registered Nurse, Registered Social Worker, Advanced Care Co-ordinator, Pharmacist or Kaumatua) depending on criteria or need. The Whaanau Ora Key worker will provide co-ordination and/or case management services for consenting whaanau and work with primary care providers, community services and local government and NGO agencies to meet identified goals.

Interventions may include but are not limited to assisting the client and their whaanau with treatment plans, health literacy and advocacy, clearly defined cultural support, co-ordination of care and engagement with health/community providers and/or programmes.

Note: If uncertain as to what the referral criteria are, please phone our main reception on 09 276 0138 or Extension 58138 and someone will do their best to assist you.

Service Objectives
The objectives of our service are:

  • To support seamless care transitions through the health care system for Maaori whaanau with high health needs, so as to improve and support whaanau wellbeing.
  • To work with whaanau to identify goals and implement strategies or interventions to reduce avoidable hospital admissions; improve engagement with primary care, community providers and more importantly to support and improve whaanau wellbeing that is clearly identified and achievable for the whaanau.

Service Coverage
Service coverage will include:

  • Maaori patients and their whaanau admitted to CM Health secondary care and outpatients.
  • Maaori patients and their whaanau domiciled in the CMDHB area.

Service Delivery
Not all whaanau will have the same level of need. It is assumed that whaanau will have a mix of immediate, short and long term needs, therefore three levels of engagement and assessment are proposed. Service interventions will be based on the goals identified by consenting whaanau as part of the whaanau ora assessment process. Common interventions include but are not limited to: discharge planning, whaanau hui, health literacy, service navigation and/or coordination, health education, advocacy, engagement with health/community providers and/or programmes or clearly defined cultural support.

Note: Currently what we are NOT able to provide

  • Emergency accommodation (currently under review).
  • An acute on call or afterhours service (please note: hours of service are 8:00am to 4:30pm).
  • Security services for escalated situations.
  • Mental health or renal services.
  • We are currently not a ward based service; therefore any referrals will be prioritised according to the level of acuity/severity.
  • We do appreciate timely referrals as this will enable us to do our best to meet and greet the client/whaanau and those providing care as soon as possible. This is important as often staff are already off site tending to other whaanau. Therefore, the earlier the referral is received the more likely we can catch whaanau before being discharged from Counties Manukau Health.

However, in saying that we are happy to take calls to assist or advise, as often we have found it is misinformation, misunderstanding or miscommunication which can potentially lead to a self discharge, or an unsafe or escalated situation. Therefore, we encourage ALL staff to take the appropriate training to ensure whaanau and staff can have effective and positive relationships.

How to refer to our Service (via admission only)

  1. During admission patient/whaanau/staff request Maaori Cultural Support or Services.
  2. Staff member/s tending to that patient must please then fill in the standard yellow ‘Referral Form’ which can be found on all wards most likely in your Admin or Ward Clerk areas.
  3. Include as much information as you can; we do prefer more than less.  Referrals lacking the appropriate information may cause a delay in response time. As we require good clear information in order to respond effectively to that client/whaanau need. Make the referral to Whaanau Ora Services; please refrain from individual names as ALL referrals are triaged accordingly.
  4. Once completed these can be faxed internally to 58676 where referrals will be managed appropriately.
  5. We do also have an an email address, TeKaahuiOra@middlemore.co.nz (the same referral principles apply).

Note:To assist in our triage process, please give client details and essential information such as: NHI, name, D.O.B, location of client, concerns, client address and if NO fixed abode or GP please provide clear contact details of client and/or whaanau N.O.K or significant other. If you are the person referring, please print your name clearly and the best contact number we can get you on.

It is equally as important that client/whaanau are made aware of our services upon early entry into Counties Manukau Health. This is so whaanau have the option of seeking early support before any issues may arise. Whaanau can self refer by calling us direct on Extension 58138 or 09 276 0138. However, most often the whaanau are dependent upon you being the voice for them. So any assistance is greatly appreciated.

Thank you for taking the time to refer to Te Kaahui Ora, Whaanau Ora Services, we look forward to a great working relationship with you and to continue to assist and support the Whaanau we all care for.

Mauri Ora, Whaanau Ora!

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