Approaches to integration

He Ara Oranga: Report of the Inquiry into Mental Health and Addiction (2019) included 40 recommendations intended to transform the approach to mental health and addiction in Aotearoa New Zealand. As part of this, He Ara Oranga identified the urgent need to design and implement a broad spectrum of people-centred and integrated services that would increase people’s access to and choice of services across primary health, community-based non-government organisations (NGOs) and district health boards (DHBs). In this context the term ‘primary health’ is inclusive of Māori health and iwi providers, Pacific providers, NGOs and general practice.

An increase of access to and choice of integrated services necessitates associated development in the capacity and capability of the workforce. This guidance is a first step towards supporting this. It aims to address the initial priorities of the primary and community workforce to support delivery of integrated care for people experiencing mental health and addiction needs.

Skills for integration in primary and community health settings offers information, guidance and resources applicable across models of integration and across the range of professional disciplines and roles involved. While acknowledging the breadth of focus that integration implies, in line with the recommendations of He Ara Oranga, there is a particular focus on addressing mental health and addiction needs.

Regardless of the specific model of care employed, an integrated approach is about bringing together people from across services and sectors to support people and their whānau in a way that is effective, seamless and easy to navigate. Optimally, all integrated approaches create “connectivity, alignment and collaboration” across teams and between different parts of the health and other sectors to address health and a range of other needs for example, housing, employment, financial resources, education, and community participation.

Working within an integrated approach means working in teams (including virtual teams) that are comprised of a variety of roles, sometimes from different services and sectors and often from different professional disciplines. In an integrated approach tasks and services are coordinated across traditional professional boundaries.

At the organisational level an integrated approach is likely to require, for example, leading a diverse team (sometimes virtually), building and maintaining a collaborative culture, developing and managing systems and structures to support integration and fostering inter-agency and inter-sectoral collaboration.

While models of integration vary, an integrated approach generally includes the following key features:

• A holistic approach to wellbeing and recovery; person/whānau centred; culturally capable and responsive; strengths based; responsive to the spectrum of needs that people bring.
• Easy/actively facilitated access to a wide range of support (across a range of services and sectors).
• A proactive approach.
• Coordination across the intervention continuum and across sectors; redefining of traditional professional boundaries.
• Shared understanding of roles, systems and processes; everyone working to top-of-scope.
• Close collaboration and team work within and across services and sectors; high levels of communication; shared culture.

A new model of integrated primary mental health and addiction services (IPMHA) is being implemented across New Zealand by the Ministry of Health. This model of care is a part of suite of services being developed to expand access to, and choice of, Primary Mental Health and Addiction support.

The aim of these new services is to:

• Increase access and equity of access
• Increase choice in addressing people’s holistic concerns
• Reduce wait times for mental health and addictions support
• Improve population health and equity outcomes

This service is for anyone who is enrolled in the practice whose thoughts, feelings or actions are impacting on their health and wellbeing. There are no barriers to accessing this support, no referral criteria, no wait time, no cost to the patient and services are designed to ‘flex’ to meet the identified population health needs.

There are ‘key components’ of the service which will look similar across New Zealand. All services will be accessed via the general practice with priority given to Maori and Pacific peoples, youth and those people living in rural and remote locations. Some services may choose to use a locally relevant name for their service, however in all cases new staff will join the practice team and become integrated within the practice. The key components of the service include:

• Health Improvement Practitioner (HIP) - an experienced and registered mental health clinician who will provide assessment and brief intervention therapy as needed
• Health Coach (HC) – a trained support, peer or cultural worker who will support the individual to manage their health through a range of personalised interventions
• Support Worker (SW) who will provide access to cultural and social supports within the local community
• A confident and competent general practice team
• Effective links and coordination between primary and secondary services
  

The IPMHA model includes an evidenced based approach to providing behavioural health support within general practice. The IPMHA model has been adapted, piloted and provided in various regions in New Zealand since 2017. The HIP and HC work as a part of the practice team to provide brief intervention focused on strengthening self-management strategies. Their notes are written directly into the practice-based PMS and ‘warm handovers’ ensure that the practice team members can make an introduction when the need arises and are kept updated with patient information. Additionally, the HIP also supports the practice team through psycho-education, consultation and identifying patient pathways to increase access to behavioural support.

Te Tumu Waiora is just one of the iterations of the programme that is being rolled out across New Zealand. Te Tumu Waiora is a holistic model, supporting and addressing the physical, emotional, and social needs of the person. The model is based on a pilot initially conducted by urban Auckland DHBs and expanded to 5 additional DHBs across the country. Elements of the model include new roles in enhanced GP teams (such as, health improvement practitioners, health coaches, and mental health credentialed primary care nurses); increased access to NGO community-based support services and enhanced interface between primary care and DHB services.

Further information on Te Tumu Waiora is available at: Te Tumu Waiora. https://www.tetumuwaiora.co.nz/

The Health Care Home

The Health Care Home is a patient-centred model which maximises the role of general practice and its integration with other services enabling primary health to deliver a better patient and staff experience, improved quality of care, and greater efficiency. The model provides convenient and flexible appointments; access to a wider range of services; a team approach to patients’ care and improved business efficiencies. The model is operating in approximately 150 practices in New Zealand. It is continuously reviewed and updated to improve care and health outcomes. The current outline of the Health Care Home Model of Care Requirements includes an explicit focus on equity and meaningful consumer involvement. An underpinning assumption is that a Model of Care that delivers improved outcomes for Māori will also deliver improved outcomes for other priority populations and for all New Zealanders.

Further information on the Health Care Home model is available at: Health Care Home Collaborative. https://www.healthcarehome.org.nz/download/enhanced-hch-moc-october-2020-web-final.pdf?inline

Whānau Ora

Whānau Ora is a culturally based, whānau-centred approach aimed at supporting whānau wellbeing. It is designed to be comprehensive and integrated, addressing “multiple needs with minimal overlap, little inconvenience and no confusion” (Whānau Ora: Report of the Taskforce on Whānau-Centred Initiatives.) Whānau Ora acknowledges the cultural significance of wellbeing. While the approach is specifically designed to support Māori and Pasifika wellbeing, it is inclusive and available to all New Zealanders. Whānau Ora has a holistic focus, building on the strengths of whānau and bringing together services and support in areas such as primary health, housing, education, employment, finances and cultural identity. Kaiārahi (navigators) work with whānau to identify their needs and aspirations, then they work together to identify relevant services and opportunities for support and growth. Three not-for-profit commissioning agencies administer Whānau Ora, including one for Pasifika peoples.

Further information on Whānau Ora is available at: https://whanauora.nz/

Mahi a Atua

Mahi a Atua (tracing the ancestral footsteps of the Gods) is a kaupapa Māori approach to primary mental health care which is provided in the Tairāwhiti / Gisborne area. Mahi a Atua incorporates holistic, whānau-centred engagement, assessment and intervention based on pūrākau (Maori creation and custom narratives). Whaiora who are experiencing mental distress and their whānau work together with a therapeutic team of professionals from primary health, mental health, social services, education and the arts who are trained in the approach. Mahi a Atua has grown into a community-driven and district-wide initiative which is available to and accessed by Māori and non-Māori.

Further information on Mahi a Atua is available at: https://www.mahiaatua.com/