Manawanui Whai Ora Kaitiaki
“Pathway to Wellness Support Team”
The purpose of the Manawanui Whai Ora Kaitiaki(MWOK) programme is to walk alongside and empower individuals, and their whanau, who have Long term Health conditions (LTC) to successfully self-manage their conditions.
We provide a mobile nurse and kaiawhina partnership working together with Hauraki PHO practice teams, community agencies and hospital-based health service provider colleagues.
Having a nurse and kaiawhina partnership gives the individual/whanau support with clinical aspects and social issues that may be effecting their health.
Some of the services that are provided are as follows:
- Mobile/home based service
- Support, advice and education around health conditions
- Development of a personalised care plan
- Advocacy/navagational support to clinical (eg.hospital, GP, community) and social (eg. WINZ, budget, housing, transport) appointments
- Connecting you with other services that are available
- Encouraging Whanau involvement and support
- Lifestyle advice
The MWOK model of care is patient/whānau centred and provides care that is respectful, responsive and meaningful to the individual patient preferences, needs and values. We encourage high quality and sustainable long-term condition management within the community that empowers individuals and their whānau to take control of their wellbeing.
The MWOK team understand the importance of whanaungatanga and getting to know individuals and their whanau. Our team will discuss with the individuals/whanau what is important to them and strive to support them in anyway they can.
This service is free for patients enrolled with a Hauraki PHO practice and has an expected enrolment period for each individual of up to 6 months to assist them to move to self-management. GPs refer patients who they believe will benefit from more intensive assessment and intervention.
The main criteria for entry to the programme is as follows:
- Two of eight identified long term conditions including - diabetes, heart disease, asthma, COPD, ischaemic heart disease, renal impairment, depression and anxiety
- More than two hospital visits concerning your long term condition in the last year
- More than 8 GP visits concerning your long term condition over the last year
- Frequent or non attendence at a medical practice/doctors surgery
Patients are referred by utilising the Medtech/Evolution Outbox document called MWOK Referral