Fanau Ola Implementing Fanau Ola to accelerate health

Fanau Ola Implementing Fanau Ola to accelerate health gain and improve wellbeing for Pacific families

Profile of Pacific People in Counties Manukau 117, 780 => 23% CM Health population (2013) 38, 300 => 58% of Mangere population (2011) 23, 990 => 65% of Otara population (2011) 158, 300 => Projected Estimate of Pacific 2026 73% NZDep 06 decile 9 and 10 (2006 census) ………Current health outcomes

Life Expectancy Gap

HAKAMANA Pacific Fanau Ola Fanau-Centred Patient Care FANAU OLA has been developed using the HAKAMANA Integrated System of Transformative Design 4

HAKAMANA - Breathe… HAKAMANA is informed by the sounds and words of the ancient Oceanic / Polynesian / Maori language I – O – E – A – U simultaneously ‘verbs’ and ‘nouns’, processes and outcomes. These sounds communicate states: • of relationship, creativity and potentiality, • of constancy on the one hand • of dynamic change on the other • that embody transformative processes

HAKAMANA UI I IO U O OE AU E A EA 6

HAKAMANA hui nui tui UI I pio tio IO TIKI U O TUPU HONO hau kau AU rau A E HAKA RERE Fanau Ola System CMDHB - Wolfgramm - EA hea mea pea koe hoe OE moe 7

HAKAMANA – FANAU OLA THE INTENTION • To design a healthcare solution for Pacific patients (with complex health needs and who have multiple socio-economic challenges) that includes their fanau / family members as important members of their circle of care; and provide quality patient and fanau-centric care to achieve better health outcomes THE OUTCOME • The design, development and implementation of a Fanau Ola Support Service with an evaluation that shows a decline and reduction over time in secondary service utilisations (hospital admissions, emergency care presentations), and improved quality of life for Pacific patients and fanau 8

HAKAMANA VALUES & PRINCIPLES OF ENGAGEMENT Titiro UI RANGATIRATANGA Leadership Puawaitanga; Share; Open Opportunities Sustain Benefits; Enable Leadership AROHA / Care & Compassion Values; Wairua; Ethics; Concepts Share Vision; Co-create ethical space I Vision Tupu U Sustain A U IO Kotahi O Relate OE Rewa Rawa MAURI / Mana & Life force E A Reflect; Reorient; Mediate Fail in Safety; Evaluate; Learn; Activate Achieve Whole of Systems Solutions Achieve Intentional Excellence Fanau Ola System EA CMDHB - Wolfgramm - TIKANGA / Ethical Integrity Whanaungatanga Connect; Collaborate Whakapono; Respect; Genuine Partnerships Co-create / co-design / plan / strategise MANAAKITANGA / Generosity Guardianship; Activate; Support; Implement; Real Engagement; Meaningful participation Provide / Operationalise / Deliver 9

HAKAMANA encompasses … HA – the breathe of life - connects all living things KA – the fire that burns within us – energy to transform MA – the presence of all of one’s ‘light’, knowledge of self NA – our relationships - respectful kinship HAKA – the ‘dance of life and energy’ – animation / activation MANA – the power, strength and authority, leadership HAKAMANA – the creative process of realising one’s power

HAKAMANA – Co-design, Activate, Transform Journey Lead / Share UI I Vision Tupu U Sustain Achieve Outcomes Sustain Benefits Share success Realise Outcomes Titiro Vision / Values / Ethics Conceptualise / Engage A U Reflect / Learn Measure / Analyse Quality Improvement IO Design Concepts Kotahi O Relate OE Rawa A Achieve Rewa E Activate EA Evaluate / Learn Co-Design / Define Strategise / Plan Strengthen teams Connect Collaborate Activate / Implement Integrate Operations Roles / Responsibilities 11

Vision: Fanau Ola for Pacific families Fanau will be… healthy in body, mind and spirit, educated, socially strong, and content. Fanau will have… the courage and will to live, the skills and abilities to plan and pursue their own futures. Fanau Ola System CMDHB - Wolfgramm - 12

Fanau Ola Ancient Pacific words – expressing many sounds of creation; ‘ha’ the ‘breath of life’ and ‘wa’ inferring ‘time and space’ combine to form the sound • ‘fa’, a number - signifying foundations of family life § ‘na’, interweaving family relationships with each other • ‘u’, manifesting the realisation of the family’s potential • ‘o’, animating the family space of creativity • • ‘la’, embracing the warmth of the sun as families grow Fanau Ola System CMDHB - Wolfgramm - 13

Fanau Ola Ancient Pacific words – used across the Pacific Ocean FA … NA … U O … LA Fanau - Fanau Being born; bringing forth; children; grandchildren; siblings; extended family (Maori …whanau ora) Ola - Being alive; healthy; nourished with food; healed from illness; refreshed; successful …Moui lelei …Soifua Maloloina … Oraanga Meitaki …

Fanau Ola & Whānau Ora Kaupapa Whānau Te Ao Māori Tinana Hinengaro Manawa Wairua Tangata Whenua Rawa /Tiriti o Waitangi Rangatiratanga Māori Whānau Approach Current Health Profiles Pacific Heritage Culture Language Better Health Outcomes for All Families Fanau Ola Vision Fanau Pacific Cultures Body Mind Heart Spirit Context Resources Leadership Pasifika Fanau

Fanau Ola encompasses VISION Fanau Futures / Goals / Plans SOCIAL Relationships / Caring Connections CULTURE Worldview / Tradition / Language BODY Physical Health / Conditions / Risks SPIRIT Spirituality / Beliefs / Religion HEART Emotional Wellbeing / Love / Support MIND Learning / Intellect / Education / Skills RESOURCES Resources / Housing / Income / Technology CONTEXT Environment / Community / Systems LEADERSHIP Leadership & Guidance Skills / Fanau Champions

Achieving a Balance at Counties Manukau Health Pacific Health - Whole of Systems Support Best Value for Resources

Implementation The FANAU OLA System is implemented in five interlinked phases: 1. 2. 3. 4. 5. Scoping, Strategy, Design & Planning Training & Development Organisational & Service Deployment Digital Activation Developmental Evaluation & Follow-Up

Fanau Ola System Development Consolidate Fanau Ola Approach § § § § § Consultation / Presentations / Refinement Fanau Ola Training Referrals Systems Guidelines / Protocols / Quality Control Fanau Ola Toolkit • Design / Development Assessments / Reflections • link to indicators / outcomes Baselines / Targets • weekly / monthly / quarterly tracking and monitoring Monitoring and evaluation Administration / Management support Strategic linkages / relationships – internal / external

How we help Fanau move from (and through) secondary to primary and community care

Fanau Ola Toolkit Development § § § Information materials (pamphlets / presentations) Consent/Enrol forms (Inpatient = Primary Client / Fanau Champion / Adults / Parents) Primary Client - Initial Fanau Ola Assessment (as inpatient) • § Fanau Ola Assessment / Reflections • • § § Fanau Genogram / Identification of Fanau Champion • Discharge Summary Notation (PIMS – Notify Primary Care / ARI Coordinator) Demographic details GP / Hospital / Clinics Body / Physical Heart and Mind – Mental Health and Emotional Wellbeing Resources – Housing / Income / Transport Culture / Language and Spirituality / Religion / Church Fanau Vision and Leadership – Goals Fanau Ola Plans (one for Primary Client; one for Fanau; others as needed) Referrals System Ongoing learning / monitoring / evaluation Fanau Ola Sustainability Plan – Provide Fanau Mgmt Education / Health Lit Toolkit Note: Fanau have ownership of their Fanau Ola Assessments and Plans Fanau Ola Advocates support and facilitate their Fanau Ola Journey

Referrals into Fanau Ola Programme Main Points of Entry § § § Daily List (Patients admitted in previous 24 hours) Very High Intensive Users (VHIU) Team Emergency Department Internal Referrals (e. g. Hospital Wards / ED) Pacific Cardiac Programme Other

Centralised Referral System § § § All Referrals Centralised Triage process by Fanau Ola Senior Team Considerations for triage include: • • • § Number of Hospital Admissions Number of Emergency Care Presentations Number of DNA Condition (e. g. excl dialysis patients) Age (with careful consideration of newborn to 18 yrs) ‘Red Flags’ Allocate to Fanau Ola Advocates

Fanau Ola Advocacy and Integrated Support 1. IP / Fanau Engagement Consent Enrolment 2. IP / Fanau Assessment Analysis Planning 5. IP / Fanau Sustainability Strategy Fanau Ola 4. IP / Fanau Evaluation Learning Success 3. IP / Fanau Support Services Care

Fanau Ola Journey Fanau grow through … Phase One Searching Dreaming Phase Two Reflecting Planning Phase Three Activating Generating Phase Four Learning Succeeding Phase Five Thriving Sustainably Fanau Ola Journey Timeline Week 1 Fanau Ola Phases Greet / Engage / Consent / Enrol Deliverables Impact Measures / Outcomes Indicators - Focus Primary Client engaged; Consent; Initial Fanau Ola Assessment; Primary Client / Fanau Notes on Discharge Summary Champions engaged; Primary Fanau Champion identified; Fanau Client and Fanau Consents Consent Forms signed Week 2 -3 Assess / Comprehensive Assessments; Reflect / Fanau Member Plans Analyse / Plan Week 3 -4 Implement Access to and support Pacific Patient and Fanau-Centred Plan / Support received from Fanau Ola Support, Services and Care / Connect centred services Monthly / Quarterly Month 10 -11 Fanau Ola Evaluation Fanau Ola Indicators measured / Fanau Ola Plan updates Co-create Fanau Ola Sustainability Strategy Fanau plans provide vision, strategies, implementation steps, activities, measures Outcomes / Benefits Inspired - Fanau are encouraged and inspired to participate in Fanau Ola Journey Optimistic - Fanau have a clear understanding of their situation and are engaged in planning Energised - Fanau access a range of quality Fanau Ola centred culturally appropriate support /services /care Animated - Fanau experience Comprehensive range of positive health, social, Fanau Ola indicators move in economic, educational right direction outcomes. Fanau Ola Sustainability Strategy completed Uplifted - Fanau are empowered; have the skills to plan and pursue own futures.

Links to indicators 1. National / Regional / Local – Indicators / Outcomes • Heart disease / Diabetes – checks / assessments • Smoking – cessation support provided • Maternal health – LMC enrolment / antenatal care / smoking • Child health – new born enrolments / immunisations / B 4 School Checks / rheumatic fever swabs and support • Youth – mental health / support to stop smoking, suicide prevention • Cancer – screening rates (breast / cervical) • Housing – healthy housing; insulation rates • Health of older people – engagement in services • Emergency Care - EC presentations; hospital admissions 2. Fanau Ola Indicators - Cultural / Spiritual / Leadership / Vision …

The story so far… Period: 1 July 2013 – 30 June 2015 3311 Pacific Patients 13, 755 Fanau Members

Clients and Fanau Members

Evaluation of Fanau Ola Support Service • Population Health Team CMH data analysis • Compare PCST (Jul-Dec 2012) with FO (Jul-Dec 2013) • Compare FO (Jul-Dec 2013) with FO (Mar-Aug 2014) • Interviews – FO team; other CMH • • Pacific Perspectives • • • Independent research group In-depth case studies (nine) Patient experience Literature review Documentary / discharge summary analysis

Patient profile – complexity / multiple health conditions Charlson Co-Morbidity Index Score = 4 -9 [very severe > 3]

Case studies - highlights § The role of family as main carers and supporters § Understanding and navigating complex health and social systems § The impact of health beliefs and attitudes and previous experiences of health services

Public Health Evaluation: Findings Reductions in secondary service utilisation following intervention by both Pacific Cultural Support Team and Fanau Ola Support Service Reductions over time in secondary service utilisation prior to enrolment in Fanau Ola Support Service

Number of hospitalisations and bed days per patient for the PCST ≥ 5 cohort and Fanau Ola Support Service Jul-Dec 13 cohort in the six months before and after the intervention

Number of EC attendances per patient for the PCST ≥ 5 and Fanau Ola Support Service Jul-Dec 2013 cohorts in the six months before and after the intervention

Number of hospitalisations, bed days and average length of stay to CM Health facilities for the PCST ≥ 5 cohort and the Fanau Ola Support Service Jul-Dec 13 cohort six months before and six months after the intervention, all admission types

Number and Percentage of patient who died within three months and six months of been seen by the Fanau Ola Support Service or the Pacific Cultural Support Team Cohort Died at 3 Months (%) Died at 6 Number Months (%) cases FO Jul-Dec 2013 8 (2. 5%) 10 (3. 1%) 321 PCST Jul-Dec 2012 21 (9. 8%) 28 (13. 0%) 217 of

Table 25 Number of emergency care attendances, hospitalisations and bed days at CM Health facilities for the Jul-Dec 13 and Mar-Aug 14 Fanau Ola Support Service cohorts six months before the intervention Utilisation Fanau Ola Support Service Jul-Dec 2013 Total Fanau Ola Support Service Jul-Dec 2013 per patient Fanau Ola Support Service Mar-Aug 2014 Total Fanau Ola Support Service Mar-Aug 2014 per patient Percentage difference between cohorts ED attendances 723 2. 25 1205 1. 66 -36% Hospitalisati ons 582 1. 81 834 1. 15 -58% Bed days 6. 28 2, 339 3. 22 -95% 2, 017

Real life is what counts… Fanau Living and Working Hand in Hand

Strategic Alignment Healthy Pacific 2020 Achieving a Balance: Patient & Whānau Centred Care; System Integration Pacific Plan: Healthy Pacific People 2020 Goal 2: § Implement Fanau Ola Service Delivery across the whole of system • Spread and improve Fanau Ola approaches for those Pacific patients for whom family based support is critical to recovery and living well with disease

WHOLE OF SYSTEMS - FANAU OLA APPROACH contributing to achieving health equity Healthy Services § § § Services need to be patient & fanau-centric System / programmes / services needs to be dynamic and responsive to fanau – rather than have services that are difficult for patients to access / engage with / afford Need for greater integration across system (secondary / primary / community) with improved transparency (e. g. between hospital, GP, community, fanau/patient)

WHOLE OF SYSTEMS - FANAU OLA APPROACH contributing to achieving health equity Healthy Services Need to support Fanau to engage Fanau-centric services at appropriate times e. g. Primary Care Contracts: At Risk Individual (ARI) Integrated Services Agreements (ISA) Every moment with Pacific patient / fanau can be a learning interaction -> opportunities to increase health literacy §

Change the trajectory … Evidence shows that enhanced and integrated care that incorporates system-level improvements including kind and respectful engagement; informed consent; identification of ‘family health champions; and comprehensive assessment, planning, and support processes, including targeted interventions and rehabilitation has the potential to change the illhealth trajectory of VCHN patients and families.

Fanau Ola Smart Path System § Fanau Ola Systems integration with Smart Path Healthcare Technology § Patient Portal – Interactive Pathways § Staff & Carers invited & permitted § Data & Info shared through the Cloud § Insight supports decision-making

Scale Up with OLA Integrated Care PACIFIC § Auckland Region DHBs; NZ-Wide § Pacific Islands MĀORI § CMDHB, Auckland Region DHBs, NZ-Wide INDIGENOUS § USA / Canada; Small Islands Developing States; Global INTERSECTORAL

Opportunities for Collaboration If you would like develop an OLA Integrated Care Approach for your healthcare situation, contact Tania Wolfgramm to discuss your needs tania. wolfgramm@gmail. com

Contributing to achieving Fanau Ola Outcomes Pasifika fanau will be healthy in body, mind and spirit, educated, socially strong, and content. Pasifika fanau will have the courage and will to live, the skills and abilities to plan and pursue their own futures.

Fanau Ola A beautiful and powerful bird, farsighted and keen of eye, flying across the oceans in search of new vistas, as the sun rises on the horizon, bringing light, warmth and life into the world. The bird is Pasifika Fanau, their spirit, heart, mana and dignity. They weave strong relationships with each other and their communities. They are empowered to pursue their vision of a brighter future, as they seek to experience greater wellbeing, balance and harmony in their lives.

FANAU OLA – This document was prepared and presented by: Tania Wolfgramm Cultural Development Executive Fanau Ola / Whānau Ora Systems Architect Wikuki Kingi, Tohunga, QSM Pou Kapua - Creatrix Aotearoa New Zealand For further information about FANAU OLA / WHĀNAU ORA Contact Tania Wolfgramm, OLA Integrated Care Architect Tel: + 64 21 0876 1400 Email: tania. wolfgramm@gmail. com The FANAU OLA System has been designed developed, and deployed by Tania Wolfgramm, 2012. . The HAKAMANA System of Transformative Design, Development & Transformation is Copyright © Tania Wolfgramm / Pou Kapua – Creatrix 2010. LINKS www. hakamana. com; www. smartpathhealthcare. com Photos are and images are courtesy Pou Kapua Creations; IDESIGN; Google Images