Primary ry mental health support for people wit ith dia iabetes - - PowerPoint PPT Presentation

Primary ry mental health support for people wit ith dia iabetes

Today’s presentation

• Background to the project
• Profile Northland and Tairāwhiti’s approaches
• Hear from participants in Northland’s Rangatahi project
• Early feedback on what is working and what challenges have been

encountered

Background

• Improving mental health and wellbeing has the potential to improve

both quality of life and glycaemic control

• The MOH funded projects aim to improve access to primary mental

health services for people with poorly controlled diabetes

• The project includes Northland and Tairāwhiti DHBs – rapid

implementation within existing resources (over 200 contracts across community providers)

• Opportunity to be innovative, supported by Ministry flexibility
• The Ministry funded an evaluation to learn from the project

The evaluation

• The projects are pilots – the evaluation is focussed on learning from

the pilots

Formative evaluation contributes to local planning

Data collection (2017) Interviews/ workshop (key stakeholders) Site visits

Process evaluation provides feedback on progress

Quarterly interviews key stakeholders Quarterly evaluation reports

Outcomes evaluation

Final provider interviews and survey Final interviews with key stakeholders Interviews Final evaluation workshop and synthesis report Site visits September- October 2017 Set up admin data templates/ client recruitment Progressive data collection from clients (Hua Oranga, survey) February to October 2017 Final extract of admin data, financial data - 30 September Quarterly admin data reporting Develop evaluation approaches for specific initiatives Workshop to discuss first quarter evaluation findings Plan timelines and finalise approach Co-design evaluation with sites Complete ethics review process – agree site requirements Logic model and evaluation questions Practical approaches to data collection Timelines Agree evaluation approach

Hua Oranga

• Tool developed based on Te Whare Tapa Whā
• Developed by Mason Durie and Te Kani Kingi and adapted by Dr

Simon Bennett

• Four domains with four (5-point scale) questions in each domain
• Taha whānau
• Taha wairua - Spiritual
• Taha tinana - Physical health
• Taha hinengaro - Mental health

Tairāwhiti approach

Tairāwhiti approach – about Tairāwhiti

• Population around 48,000 people.
• Over half of population Māori
• Average deprivation score of 7 with 67% of

Māori and 30% of non-Māori considered to live in the most deprived areas

• Rurality – with around 30% of residents

living in rural districts and facing additional challenges in accessing services

• Around 2,000 people identified with

diabetes and approximately 700 with an HbA1c over 64

• Three PHOs (12 practices): Ngati Porou

Hauora, National Hauora Coalition, Midlands/Pinnacle Health and further iwi- led NGOs.

Tairāwhiti approach - consultation

• Child & youth diabetes service doing well – focus on adults
• Appropriate messaging and communication “Is diabetes

a disease? My doc doesn’t tell me nothing about it. It only seems to affect me when I’m hurt – takes ages to recover”

• Whanau approach “I come home to a greasy meal and cakes”
• Flexible approach “no use coming to see just me when you

turn up during the day, wait until everyone is home”

• Finding the right triggers “it’s only me and my sister left. My

mum and dad and siblings died because of diabetes and I still lived the way I did until recently”

• Mana-enhancing, aspirational and empowering service

Tairāwhiti approach – targeted

Māori or Pacific person with poorly controlled Diabetes (HbA1c level of 64mmol/mol or more) and an indication of potential mild to moderate mental health issues:

• poorly controlled diabetes
• low/non-attendance
• low/non-adherence with medication regimes
• living in socially isolated situations
• pressing issues (wider than health)

Tairāwhiti approach – Adult Service

• Multi-model trialling four “pathways”
• Kaiāwhina-led supports (external referral model)
• Kaiāwhina-led supports (“in-house” model)
• Social worker-led supports (“in-house” model)
• Primary MH service only – more flexible approach
• Approaches to reflect whānau needs and aspirations firstly
• Supported by:
• Clinical champion
• Hua Oranga assessment tool
• Workforce development

Tairāwhiti approach

Mihi and time to connect is crucial Small wins “Translator approach”

Tairāwhiti’s achie ievements – early days yet

A case study – Mark in kaiāwhina programme: Before Now – six weeks later

No interest in preparing meals Engaged in sandwich club Difficulty shopping Kaiāwhina supermarket tours, gaining confidence in buying right food within his budget Little contact with whānau Joined lunchtime walking group Overweight (127kg), no exercise Losing weight (125kg) Uncontrolled diabetes (HbA1c 86) Reducing HbA1c (now 82) Wanted to lose weight and sort Feeling happier and has a plan towards new

• ut his lounge. Felt hopeless.

lounge suite.

• 2013 census population of about 151,692, predicted

to increase to 171,100 by 2018.

• A high proportion of Māori - Nga Iwi o Te Tai Tokerau

comprises 30% of Northland’s population.

• An ageing population – driven by decreasing

numbers of children.

• A higher proportion of economically deprived

communities than New Zealand as a whole

• A dispersed rural population – poverty and lack of

public transport can make it difficult for people living in rural localities to access some services.

• Two PHOs – Manaia Health and Te Tai Tokerau
• Three programmes – the tamariki, the rangatahi, the

adult programme

Northland’s approach – about Northland

Northland’s tamariki programme

Whānau with child newly diagnosed with T1 DM in previous year

• n = 7
• HbA1c = 47-94mmols
• Average HbA1c = 65mmols
• European/ Samoan/Other = 5
• Maori = 2

Whānau with Child with poorly controlled T1 DM high HbA1c

• n = 11
• HbA1c = 67 to >130 mmols
• Average HbA1c = 91 mmols
• European / Other = 2
• Maori = 9

Hine’s story

Whānau with child newly diagnosed with T1 DM in previous year

• Hine: 10 yrs old
• Solo mother on benefit
• Lives with Grandmother (2 years)
• T1 DM. Dx 2013. HbA1c = 93mmols
• Agency involvement: Police, CYF, Community Mental Health, NDHB Diabetes Team,

NDHB Psychologist, Grandparents Raising Children, GP, School

1. How well do you understand your child’s diabetes?

Not at all Yes – I fully understand 1 2 3 4 5

• 2. How well do you know what to do to care for your child’s diabetes?

Not at all Yes – I fully understand 1 2 3 4 5

• 3. Do you feel your whānau/family know how difficult it is to care for a child with

diabetes?

Not at all Yes - they fully understand 1 2 3 4 5

• 4. How well do you think your child is coping with diabetes?

Not at all well Very well 1 2 3 4 5

• 1. Do you feel that looking after your child’s diabetes is taking over your life?

No - never Yes – almost all the time 1 2 3 4 5

• 2. Do you feel angry, scared and/or sad when you think about your child (tamaiti)

/family/whānau living with diabetes?

No - never Yes – almost all the time 1 2 3 4 5

What parents said

What would help? Not having it at all Being closer to support – Normal things Technology to assist with lows at night Support with other diabetes families More education Pump Tax free healthy food

What children said

Do you know what to do for your diabetes?

No Some of it Yes

How often do you do what you are supposed to when caring for your diabetes?

Not often Sometimes Most of the time

How often do you feel sick because of the highs and lows from your diabetes?

Very often Sometimes Not often

How often does having diabetes stop you from doing something you want to do?

Very often Sometimes Not often

How well do you think you are coping with diabetes?

Not very well Okay Very well

Do you feel that diabetes is taking over your life?

Yes Sometimes No

Do you feel angry, scared or sad when you think about living with diabetes?

Very often Sometimes Not often

Does your whānau/family know how difficult it is for you to live with diabetes?

No Maybe Yes

Do your parents worry about your diabetes?

They worry way too much A little too much About the right amount

What would help? Having new and different strategies to help me take every injection and blood sugar levels Not taking injections To get a routine quickly because I think that routine will help me get used to my diabetes Having a monitor to see my levels Having friends who have diabetes

Northland’s rangatahi programme

• Aims: Innovative ways to engage with youth with diabetes
• Activities:
• A series of workshops delivered by the Company of Giants theatre group
• Bring together clinicians and patients in a new model of care that removed

barriers of access, and where the clinicians were naïve participants – engaging in full and level playing field

• Progress to date:
• First cohort – Five youth
• Second cohort – Nine youth; five continuing from cohort one

A little something fr from our participants

Meet Heath and Mataara

Northland’s rangatahi programme - feedback

Evaluation of the first cohort found:

• The group’s size, age and composition all worked
• Inclusion of the clinical team as active and equal participants was important.

Youth appreciated family/whānau not being included

• Awareness of diabetes and being part of a group with other young people with

diabetes was important but youth were not very positive about a ‘formal’ or ‘explicit’ focus on diabetes

• Flexibility to design and adapt the content to meet the needs of the youth

attending is important

• Planned transitions are important for participant safety and to build on the

progress made in the workshops

Northland’s rangatahi programme - evaluation

The workshops made a difference for youth: Feedback from youth

It made me feel not quite as alone. They made me get out of my comfort zone and gave me motivation for the next step in life… I learnt don’t let diabetes hold you back – you’re not the only one with it. There was a fair amount of discussion about

• diabetes. It wasn’t the focal point but it was good

just knowing they were diabetics and knew about what I was going through… A lot of diabetes situations that made me feel lonely before don’t now because I know someone else is going through it.

Objective measures (Hua Oranga)

Northland’s adult programme

• Consultation: Identifying gaps and managing different perspectives
• Aim: to include six general practices with high proportions of patients with

diabetes and HbA1c above 64

• The adult programme provides:
• funding for e-therapy with clinician oversight
• sessions with mental health credentialed primary care nurses
• acceptance and commitment group sessions
• a flexifund to respond to identified needs
• whakamana hauora (development of a diabetes specific module)
• the whakawhānaungatanga programme (a culturally appropriate whānau focused

programme)

• some additional specialist mental health support.
• Progress: currently 20 patients enrolled; significant activity to implement

Learnings

Design:

• 12-month pilot – innovation takes time, time limited funding creates recruitment and buy-

in challenges

• Co-design included local provider organisations and clinicians
• Time limitations
• What is the best use of resources for time-limited pilot projects

Management

• Funding and time to involve a project manager from the start

Implementation:

• Contracting and agreements
• Appointing new roles
• Buy-in from managers versus frontline staff
• Competing demands
• Promotion and communicating what is required to practices – keep it simple
• Resourcing – PHO additional support for practices, impact on other programmes
• Recruiting patients – screening

• The two DHBS now have a number of different interventions

in place – positive feedback about the need for the pilot interventions

• To address mild to moderate mental health a holistic model

is required – whānau ora approaches, integrated responses, system wide change

• Benefits for people taking part
• Learning from innovative approaches:
• kaiāwhina role in primary and secondary service
• Rangatahi programme – taking risks with different models of care

It has opened our eyes to a new model

Summary ry

Thank you

For more information contact:

Ministry of Health: Megan Grant – megan_grant@moh.govt.nz Northland: Ian Hartley-Dade – ian.hartley-dade@northlanddhb.org.nz Ph 09 430 4101 ext 60475 Tairāwhiti: Matt Tong – matt.tong@tdh.org.nz Ph 021 193 0373 Evaluation: Debbie McLeod – debbie.mcleod@malatest-intl.com. Ph 021 873 572