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WHANAU BASED HOLISTIC COMMUNITY HEALTH WORKER

SERVICE SPECIFICATION
STATUS:These service specifications may be amended to meet local agreement needs. / NON-MANDATORY 
Review History / Date
Published on NSFL / July 2002
Amendments
changed to non-mandatory status by agreement with DHB GMs Planning and Funding.Added MAOR0117 / July 2012

Note: Contact the Service Specification Programme Manager, National Health Board Business Unit, Ministry of Health to discuss the process and guidance available in developing new or updating and revising existing service specifications.

Web site address of the Nationwide Service Framework Library:

Whanau Based Holistic Community Health Worker

MAOR0117

A.Services to be Provided

A1. The provider will provide the services described in accordance with the Ministry of health’s purchasing framework

A2The purchasing framework is attached to this Agreement and forms part of this Schedule A.

1.Maori Health

The service is expected to contribute to the reduction in health inequalities, the 13 priority Population Health Objectives, as well as the Maori health gain objectives, in particular, targeting services to impact on asthma, diabetes, injury prevention, smoking, hearing, mental health, oral health and immunisation, including violence prevention.

The Maori Health Strategy: He Korowai Oranga is referred to and Maori Health requirements are outlined in the General Terms and Conditions and Provider Quality Specifications. In addition the provider arm of the DHB is to develop and implement a Maori Health Plan that outlines how it will contribute to improving outcomes for Maori for the services contained in this service specification.

The Plan should include the following objectives as a minimum:

  • How you will ensure that Maori utilisation is at least equal to the Maori population in the provider's catchment.
  • How you will ensure your effectiveness and the acceptability and accessibility of services to Maori
  • How links with primary care - general practice, community providers and Maori providers will be effective for improved outcomes in Maori health;
  • How discharge planning and rehabilitation processes will meet the needs of Maori;
  • Links with the DHB provider arm's Maori Health Plan and other contractual quality specifications, especially consultation with Maori.
  • How these objectives will be monitored and measured for Maori health outcomes.

2.The Contract Objectives

2.1To provide Whanau based holistic health education and promotion services.

2.2To encourage health awareness and wider health service utilisation by members of the community.

2.3To provide a community based health service which co-ordinates the assessment and referral requirements of clients.

3.The Services to be Provided

3.1(insert name of provider) will provide a community based health service using suitably qualified community health workers, which incorporates the following:

  • improve community access to primary medical and community health facilities through effective education and promotion activities and by providing transport assistance where necessary.
  • Whanau support and advocacy services through the provision of a community based assessment coordination and referral service.
  • Health education to individuals as appropriate to the needs of that individual
  • develop and record linkages with other health providers and to ensure that where necessary, a client is properly referred to the appropriate health professional.

3.2(insert name of provider) will increase community awareness of personal health and wellbeing through an organised programme of health education to targeted groups within the community. Programme delivery will first require the development of a series of Health Education and Promotion Modules covering each of the targeted health topics.

These modules should outline the content, focus, and methodology under-pinning delivery for each of the contracted topics, and should provide the basis for ongoing consistency and quality in service delivery. A copy of each module should be supplied to the Ministry of Health with the quality improvement plan.

The programme should be delivered in the community setting that is most appropriate and such settings could include, Kohango Reo, and marae. The programme will specialise but will not be limited to the following topics:

  • Oral Health
  • Diabetes
  • Nutrition
  • Hearing
  • Tobacco Control
  • Immunisation
  • Injury Prevention

4.Indicators of Successful Use of the Resources Supplied by the Ministry of Health

  • the provider is able to meet the agreed monitoring targets for the contract
  • the provider is able to fulfil its objectives, as outlined in the contract
  • the provider develops and implements agreed quality improvement plans
  • the provider is able to demonstrate health gain (as defined below) for those individuals who have utilised the service.
  • the provider is able to demonstrate client satisfaction for those individuals that have utilised the service.

5.Persons who will Benefit

This agreement provides for service delivery to Maori who reside in the (insert area). The services provided by you are primarily for Maori but do not exclude people of other cultures. However, and as a priority, the services delivered will focus specifically on the needs of Maori in the service boundaries.

6.Health Gain

The Ministry of Health defines health gain as;

  • improvement in health status for people with known poor health
  • maintenance/restoration to acceptable levels of health for people who are generally healthy
  • maintenance/improvement of independence/quality of life for people with long term illness or disability.

7.Community Health Worker – Key Functions

The community health worker can be the first point of call for whanau when accessing the health system and as such, form an important link with health professionals. Their main objective is to improve health outcomes for their clients by working in the following manner:

  • Advocating for whanau when the need arises in the area of health services
  • Educating and informing Maori about health services, health issues and general health matters concerning Maori
  • Facilitating the smooth transition for whanau through the health system
  • Providing links and consultation between whanau, community and service agencies
  • Developing demographic profiles of whanau and the community they live in
  • Developing a profile of the key health services, community groups and organisations in the area
  • Strategically plan and implement programs for target groups in the area which assess disease prevention, health education, independence, and healthy lifestyles.

8.Service Linkages and Accountability

The service is required to demonstrate good linkages with:

  • Maori providers and Maori organisations such as MWWL, Runanga a Iwi, local general practitioners, practice nurses and their staff.
  • Other local health care providers including ambulance services, community nurses such as Plunket, Public Health and district nurses and midwives.
  • Local providers of social and community services, eg schools, kura kaupapa Maori and Te Kohango Reo.

9.Staff Training – Disability, Violence and Abuse

Staff training must be given specifically in:

Disability

  1. disability awareness to ensure disabled children/adults and disabled carers are given appropriate access and support
  2. specific issues in the patterns and identification of abuse and interpersonal violence for these groups.

Violence/Abuse

Staff must have training in how to identify, support and refer victims of child/adult abuse and interpersonal violence. The agency must have protocols in place to support staff in this intervention.

10.Performance Targets

Specific performance targets relating to each of the service centres are detailed in the attached purchasing frameworks. The targets that relate to the agreements as opposed to individual services are set out below:

·A Quality Improvement Plan is to be developed, implemented and monitored in accordance with Schedule D of this contract. Copies of this plan are to be made available to the (insert relevant DHB) by (insert date)

·As part of the quality improvement plan, to develop a series of Health Education Modules covering each of the targeted health topics. These modules should outline the content, focus and methodology under-pinning delivery for each of the contracted topics, and should provide the basis of ongoing consistency and quality in service delivery. A copy of each module should be supplied to the (insert relevant DHB) by (insert date)

·Linkages and referral to other agencies and health professionals recorded.

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Schedule A.1

PURCHASING FRAMEWORK

2 FTE - Community Health Workers

COMMUNITY HEALTH WORKERS - TE KOHAO HEALTH LIMITED
Service Type / Activity / Care Setting / Location / TLA ./ G10 / Service Level / Target Group
Health Promotion / Local campaigns covering:
Oral health
Diabetes
Nutrition
Hearing
Immunisation
Injury Prevention
Other issues / Community / (insert name) City / 2 Campaign per month / Maori residing in Hamilton particularly:
Financially disadvantaged Maori
Lower socio-economic areas
High Maori populations
High health needs
- Tamariki
- Rangatahi
Health
Education / Whanau based health education:
Topics to be covered as identified above / Individual / Whanau
Community / (insert name) / 12 per month / As previous
Community based health service which coordinates the assessment and referral requirements of clients / clinic services
service coordination
advocacy services / Whare Haora
Community / (insert name) / 200 Contacts per month:
The number of requests for advocacy support must be separately identified. / As previous
Referrals to other health providers / Immediate referral where appropriate
Follow up assistance as required. / Clinic / Community / (insert name) / All referrals are to be recorded and reported by type

Schedule A.2

PURCHASING FRAMEWORK

1 FTE - Community Health Worker

TOBACCO CONTROL - TE KOHAO HEALTH LIMITED
Service Type / Activity / Care Setting / Location / TLA ./ G10 / Service Level / Target Group
Health
Promotion / Provide the number of health promotion programmes provided for the following groups of Mäori women / Community / (insert name) / 1 campaign per month / Financially disadvantaged
Maori women
Maori smokers
Rangatahi
Maori parents
Kuia / Koroua
Maori role models
Pregnant women
25+ year

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Health
Education / Provide the proposed number of specific group education programmes to be provided as specified below:
Services available and how to access them, support groups available
Smoke cessation options - what are they, how they work, who facilitates
Information to Maori women (whanau) so an informed decision can be made regarding smoke cessation
He Maori, He Taonga” / Community / (insert city) / 6 per month / As previous
Individual
Information
Advocacy / Provide the number of eligible Maori identified.
Provide the number of clients referred to independent advocacy services / Community / (insert city) / 100 per month / As previous
Service
Co-ordination / Liaise with the Te Hotu Manawa, Apatahi Tautoko Auahi Kore to facilitate acceptable information use for planning purposes.
Liaise with the Maori providers, tobacco control organisations as appropriate.
Liase and market concept of Auahi Kore with health providers in Hamilton
Liase with Maori providers throughout the Tainui waka providing information and support as requested / (insert city) / 5 per month

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Activity /
Intervention / Provide the number of smoke cessation programmes undertaken:
Well Women centres
Kohango Reo
Marae
Private residence
Noho marae
Acupuncture / Acupuncture
and where in the Waikato:
Private residence
Marae
Health Clinic
Other / Community / (insert city) / minimum of 6 group/ whanau programmes per annum / As previous

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11.Reporting Requirements

PUID / PU Short Name / PU Measure / Reporting Requirements
Frequency / Information
M-174 / Community Health Workers / Programme / Quarterly
Annually /
  1. Total number of clients by ethnicity* (NZ Maori, Pacific Island, Other)
  2. Number of clients by gender
  3. Number of clients exiting the service for quarter
  4. Number of new clients for quarter
  5. Number of contacts
  6. Number of follow-up face-to-face contacts with individual/family
  7. Total number of clients supported by services during each month
  8. Number of clients receiving minimal interventions
  9. Total number of clients attending smoking cessation programmes
  10. Number of health education sessions
  11. Number of referrals to other health providers (GP, Maori providers, HHS, Other)
  12. Number of contacts with other health provides (in > (insert area) and outside < > (insert area)
  13. Number of individuals/whanau requiring more than one Health and Disability Support service
  14. Financial report
  15. Narrative report including the following:
  • Group sessions (topics delivered, venue and audience)
  • Health promotion campaigns and topics
  • General description of activities, issues encountered and methods of resolution, achievements
  • Name of staff, qualifications and roles
  • Any changes to the organisation
  • Grievances/complaints and how they were dealt with, customer satisfaction feedback including examples of consumer involvement in service development.
  • Outline of quality assurance plan development – milestones achieved etc.
  1. Narrative outlining performance against the objectives and targets specified in this schedule, also including:
  • Discussion of any particular circumstances which favourably or unfavourably influenced the ability of the organisation to meet the agreed targets.
  1. Number of people supported by services over the 12 month period
  2. A set of audited accounts
  3. An itemised list of assets purchased under the contract with final report

*Ethnicity is recorded as perceived by the family/whanau. People may therefore perceive themselves as belonging to more than one ethnic group. Ethnicity is to be reported according to the following priority system: if perceived ethnicity includes:

  • Maori, report as Maori
  • Pacific, report as Pacific
  • otherwise, report as Other

12.Quality Requirements for the Service

The provider shall submit to the MOH a quality improvement plan within six months of this agreement commencement date.

The Quality Characteristics for these services are as described in the Services to be provided in Schedule A

13.Submission of Reports

For this agreement you will report at 3 monthly intervals on the reporting requirements detailed in tables in the service specifications.

14.Financial and Services Reporting

The provider will report on service delivery and programme development progress using the performance indicators specified in the Schedules

Service Reports

Service reports for each quarter / Report due by
1st quarter ended 30 September / 20 October
2nd quarter ended 31 December / 20 January
3rd quarter ended 31 March / 20 April
4th quarter ended 30 June / 20 July
5th quarter ended 30 September / 20 October

Financial Reports

The provider will supply the following financial reports to Ministry of Health.

Financial reports for each quarter / Report due by
1st quarter ended 30 September / 20 October
2nd quarter ended 31 December / 20 January
3rd quarter ended 31 March / 20 April
4th quarter ended 30 June / 20 July
5th quarter ended 30 September / 20 October

Monthly payments will be suspended if reports are not received by the due date.

The reports are to consist of an Income and Expenditure Account (accrued) Balance Sheet and a Cashflow Statement (not accrued).

Draft end of year reports (Income and Expenditure Account and Balance Sheet) are to be supplied to the Ministry of Health within one month of the end of the financial year, ie. 30 June 2000. The provider will use its best endeavours to have audited end of year financial reports (Income and Expenditure Account and Balance Sheet) supplied to the Ministry of Health within three months of the end of the financial year ie. 30 September 2000

Annual Report

These reports should briefly outline performance against the objectives and targets specified in this schedule.

The report will also include the following:

  • Number of people supported by services over the twelve month period;
  • Discussion of any particular circumstances which (favourably or unfavourably) influenced the ability of the organisation to meet the agreed targets.
  • A set of audited accounts
  • An itemised list of assets purchased under the contract should also be included with the final report.

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