WHANAU ORA – MAORI COMMUNITY HEALTH
SERVICE
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 PU 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 Ora – Maori Community Health Service Specification
MAOR0117
1.Kaupapa/Definition
(Insert name of provider) will provide a Maori community health service providing a range of general health education/and promotion, advisory, liaison and co-ordination activities. A key objective of the service is to ensure that the activities of existing health professionals are co-ordinated and effectively targeted for Maori, and that Maori are assisted to better utilise those services, however the services will be available to the whole community.
These services will be delivered through:
- the development of a whanau health plan of specific conditions and age groups, and the development of targets for improvements in health status as agreed with each whanau
- face-to-face sessions with individuals to specifically discuss and develop strategies to address their needs
- face-to-face sessions with whanau to specifically discuss and develop strategies to address their needs
- hauora wananga – health education and information from a Maori perspective promoting an of understanding the Maori view of health in terms of:
–taha tinana (physical wellbeing)
–taha wairua (spiritual wellbeing)
–taha hinengaro (mental wellbeing)
–taha whanau (family wellbeing).
2. 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.
3.Scope of Service to be Provided
3.1Client group
The service will be available to all eligible persons resident in the suburbs of (Refer No. 1) and the surrounding area, with the target group being Maori. Latest data identifies that there are (Refer No. 2) people resident who are Maori.
The numbers that are shown in brackets ( ) are the numbers referred to in the targets schedule attached at the end of this service description.
Known health status of target group
Five main causes of hospitalisation:Asthma
Heart disease
Strokes
Cancer
Injuries / Five main causes of death:
Coronary heart disease
Cancer
Strokes
CORD
Diabetes
3.2Service Components Required
Service ComponentsTargeted group / Positive outcomes sought / Action required / Performance measures
Whanau/ General / Improved health status / Development of a whanau health plan which:
- identifies agreed strategies for improved health status for all members of the whanau
- identifies positive areas of health status(eg, level of non-smokers, amount of weekly exercise)
- identifies priorities for the whanau and the service provider
- sets targets for improvement in these priority areas
- develops specific strategies to make these improvements
- develops a simple way of assessing whether these improvements have occurred.
- current health status for whanau are identified
- areas that have been agreed to be improved are identified
- priorities are identified
- targets for improvement in these priority areas are set
- specific strategies to ensure these improvements are developed
- develops a simple way of assessing whether these improvements have occurred.
Whanau / Health planning
Decision making
Providing counselling services for whanau
Increased self-esteem and confidence to self-manage health care / Assist whanau to formulate health plans.
Assist whanau on making decisions related to health issues.
Assist whanau and individuals with strengthening whanau, hapu and Iwi links. / Number of health plans written and agreed to (3).
Number of health plans reviewed within six months (target 90%).
How whanau rate this programme and specific aspects of it (positive and negative).
The number of whanau/individuals assisted with identifying whakapapa.
Specific strategies / Management of asthma / Provide specialist support for whanau with asthma.
Assist in identifying asthma for at risk or potential whanau members. / Whanau with asthma who have had specialised advice given to them (4).
The number of asthma health education and promotional activities that have been held.
Improved nutrition / Provide specialised nutritional advice consistent with modern knowledge and Maori tradition.
Promoting advice to reduce fat intake.
Promoting weight loss. / The number of whanau provided with nutritional advice (5).
Whanau / Management of diabetes / Assist in the management plans for people with diabetes.
Giving advice on the ways to prevent diabetes or reduce its impact among Maori.
Assist in identifying diabetes for at risk or potential whanau members (testing and screening). / The development of a plan to improve the care of people with diabetes including foot problems.
The number of people assisted with problems caused by diabetes (6).
The number of diabetes health education and promotional activities that have been held.
Key Health Factors for Tamariki
Immunisation
Asthma
SIDS
Injuries
Hearing loss
Targeted Group: Tamariki (0–14)(Approximate total in target population (7))
Positive outcomes sought / Action required / Performance measures
Management of asthma / Giving advice to reduce factors leading to asthma in households and community settings (eg, smokefree environments, maternal non smoking).
Encourage use of medical services when necessary.
Encourage use of asthma action plans when these are developed with whanau. / The development of a plan to help prevent the impact of asthma on tamariki.
Health promotion and education on reducing the risk factors for asthma in children.
Achieving/maintaining good hearing / Providing advice to prevent glue ear, and promoting early treatment of children with infections and repeated ear troubles. / The number of whanau given advice to help prevent glue ear (8).
Healthy eating for tamariki / Providing good dietary advice to whanau.
Following up children referred by the general practise to provide good nutritional advice and support. / Number of whanau provided with nutritional advice and support (9).
Improving immunisation coverage (preventing disease) / Provide information to whanau to enable informed choices about immunisation.
Facilitate immunisation of tamariki.
Referral to immunisation provider as appropriate. / The number of promotional activities addressed to provide information about immunisations (10).
The number of immunisations given to tamariki on referral by (11) (target 100% of those children whose parents choose to immunise their children).
Promoting safety and preventing injury of tamariki / Following up children treated for injury to help whanau prevent future accidents.
Give specific advice at promotional activities about keeping kids children from harm.
Encourage a “keep children safe” environment.
Assessment of suspected neglect/abuse/behavioural problems referral to appropriate agencies such as CYPFS services. / The development of a health education and promotion plan to prevent childhood accidents.
The number of children and whanau followed up after referral by hospital service providers.
The number of promotional activities addressed to help prevent childhood accidents (12).
The number of children referred to appropriate agencies such as CYPFS.
Key Health Factors for Rangatahi
Sexual health promotion and education
Alcohol and drug information and education
Smoking
Mental health
Targeted Group: Rangatahi (15–24)(Approximate total in target population (13))
Positive outcomes sought / Action required / Performance measures
Promoting mental health through promoting confidence and self-esteem / Assist rangatahi and whanau to recognise early signs of stress. / Referral to counsellors and support networks.
Provision of information to promote mental well being and stress management.
The number of rangatahi and their whanau who have been assisted in these cases.
Whakapapa linkages (see whanau section).
Preventing self-harm (suicide) / Use the best available knowledge and resources to prevent self-harm of rangatahi.
Provide information about support networks available. / The number of rangatahi and whanau who have been assisted after suicide threats and/or attempts.
Preventing rangatahi uptake of smoking
Encouraging smoking cessation in rangatahi / To provide information and activities about effects of smoking to enable rangatahi to make positive choices about uptake of smoking and smoking cessation. / The development of a strategy to reduce the number of tangatahi who take up smoking.
The number of promotional activities addressed to provide information about problems caused by smoking and ways to stop it (14).
A survey is done within 12 months to assess change in smoking rates by rangatahi registered with the provider (rates per whanau health plan).
Sexual health and promoting well being / Promotion of safe-sex messages in promotional activities to ensure good access to rangatahi for support service. / The development a plan to assist rangatahi taking responsibility for their sexual health.
The number of promotional activities addressed positive sexual health responsibility by rangatahi (15).
Use the number of rangatahi assisted in this way.
Promotion of safe use of alcohol and drug use / Providing information on the effects of alcohol and drug use to enable rangatahi to make positive choices and decisions about their use. / The provision of information to assist rangatahi taking responsibility in alcohol and drug use.
The number of promotional activities addressed about the need for responsibility in alcohol and drug use by rangatahi (16).
Key Health Factors for Pakeke
Heart disease
Cancer
Respiratory diseases (including asthma)
Diabetes
Drug and alcohol abuse
Mental health
Targeted Group: Pakeke (25–45)(Approximate total in target population (17))
Positive outcomes sought / Action required / Performance measures
Promoting fitness and mobility of pakeke
Prevention of coronary heart disease (including stroke) / Give advice to pakeke about improving their mobility and fitness.
Advice about the need for regular blood pressure checks, fitness and good diet. / The development of a plan to improve the fitness and mobility of pakeke.
The number of pakeke and their whanau who have been assisted to improve mobility and fitness (18).
Feedback from whanau/individuals that the support and advice has helped.
Management and prevention of respiratory illness, including asthma and CORD (chronic obstructive respiratory disease, eg, emphysema) / Advise pakeke and their whanau in ways to prevent and better manage asthma and CORD, and attacks of these for sufferers. / Advise pakeke and their whanau in ways to prevent and better manage asthma and CORD, and attacks of these for sufferers.
The number of pakeke and whanau assisted in this way (19).
Identifying, managing and preventing diabetes / Assist in the management plans for people with diabetes.
Give advice on the ways to prevent diabetes or reduce its impact among Maori.
Help identify and confirm diabetes for at risk or potential whanau members (testing/ screening). / The development of a plan to improve the care of people with diabetes including foot problems.
The number of people assisted with problems caused by diabetes including foot problems (20).
Key Health Factors for Wahine
Breast cancer screening
Maternity services
Cervical screening
Sexual health services
Mental health services
Targeted Group: Wahine (15 years plus)(Approximate total in target population (21))
Positive outcomes sought / Action required / Performance measures
Promoting appropriate and relevant use of contraception (for
15–35 year olds) / Give information at promotional activities and to whanau and wahine about family planning.
Provide contraception information to wahine and refer for medical advise where necessary. / The number of promotional activities at which information is given about family planning (22).
Feedback from wahine is that information and education was appropriate and sensitive.
Promoting healthy pregnancies and positive birth outcomes (for 15–45 year olds) / Give advice to promotional activities/wahine about the importance of good maternity care.
Provide information about choices of LMC.
Encourage wahine to have regular check-ups for maternity care. / The number of promotional activities at which advice is given to promotional activities/wahine about the importance of good maternity care (23).
Number of referrals to LMCs.
Feedback from women and providers that attendance rates at maternity care have improved.
Prevention of and screening for breast cancer / Give information at promotional activities and to whanau and women about breast cancer.
Promote the breast cancer screening programme (50–64 years). / The number of promotional activities at which information is given about breast cancer (24).
The specific ways in which the breast cancer screening programme has been promoted.
Feedback from wahine that the promotion has helped in their knowledge about the importance of this service.
Promotion of cervical screening (for 20–70 years) / Give information at promotional activities and to whanau and wahine about cervical screening.
Promote the national cervical cancer screening programme. / The number of promotional activities at which information is given about cervical cancer (25).
The specific ways in which the importance of cervical cancer screening has been promoted.
Key Health Factors for Koroua and Kuia
Hospitalisation
Causes of death
Life expectancy
Injury
Home support services
Targeted Group: Koroua and Kuia (60+)(Approximate total in target population (26))
Positive outcomes sought / Action required / Performance measures
Promoting and maintaining fitness and mobility of Koroua and kuia / Give advice and support to Koroua and kuia about improving their mobility and fitness.
Make referrals for assistance where needs are identified for help with supporting disability and decreasing mobility. / The development of plan to improve the fitness and mobility of Koroua and kuia.
The number of Koroua and kuia and their whanau who have been assisted to improve mobility and fitness (27)
Management of asthma and CORD / Advise Koroua, kuia and their whanau in ways to prevent and better manage asthma and CORD, and attacks of these for sufferers. / The development of a plan to reduce the impact of smoking and respiratory disease.
The number of Koroua and kuia and their whanau referred assistance for asthma and CORD (28).
Management of diabetes / Assist in the management plans for people with diabetes.
Give advice on the ways to prevent diabetes or reduce its impact among Koroua and kuia. / The development of a plan to improve the care of people with diabetes including foot problems.
The number of people assisted with problems caused by diabetes including foot problems (29).
3.3Key Components
Key components of the service include:
- assessment of self referred conditions, advice and minor treatment with referral as necessary to appropriate health providers
- support and assistance to clients referred by other health providers including general practitioners
- health advice, follow-up, treatment and monitoring of acute and ongoing health care conditions as referred by other health providers
- coordination with other health care providers
- coordination of health related activities, eg, health education sessions.
3.4Provision and Level of Service
Services will be available between the hours of 8.30 am and 5.00 pm. Services will be provided in a range of settings including, marae, schools, Te Kohango Reo and in private homes where appropriate.
3.5Service Coverage Area
Services will be provided in the following areas (insert coverage area).
3.6.Key Linkages
- 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 Kohan Reo
- hospital service providers in respect to community health and public health programmes and hospital services.
You will have written protocols and systems in place to facilitate these linkages.
3.7Outputs
Refer to the Annual Targets Schedule page.
3.7.1Reporting Requirements
Provide a brief quarterly narrative report on your performance against the quality standards listed in the service specification and the Maori Standard Terms and Conditions.
Provide a brief quarterly narrative report on the service, including the following:
•number of full time equivalent staff
•staff training undertaken
•highlights, issues of concerns and any trends within the quarter