Home-Based Treatment in Te Tai Tokerau

Background

Northland DHB, NDHB is implementing a Home-Based Treatment HBT model of support for Tangata Whaiora ( service users) who are experiencing mental health and or addiction challenges in Te Tai Tokerau

HBT is a widely used model in New Zealand and around the world. It utilises a range of treatment options and intensive supports delivered

• within the homes of Tangata Whaiora or
• in another homelike environment ( situated away from the hospital campus)

Working over a 12-hour day, seven days a week a mix of clinical, cultural and support staff spend long periods with Tangata Whaiora / service user and their Whanau/family, building rélationships and providing a range of clinical, cultural, and practical activities that support Tangata Whaiora with their recovery.

Emphasis is placed on working with Tangata Whaiora and their whanau, to build skills, provide tools to nurture resilience and educate about the challenges that have brought about the need for intervention and supporting a recovery journey.

HBT is a treatment and support option that is a critical element of a whole system approach to delivering mental health and addiction care. The original rationale was - by providing intensive acute treatment in the community the need for hospital admission would be significantly reduced. In addition to this outcome and some would say more importantly Tangata Whaiora and whanau who have used the HBT service - supported the provision of HBT as congruent with the recovery approach to care as stated in He Ara Oranga' the government inquiry into Mental health and Addiction Treatment and Support.

Raranga Tahi approach

NDHB also recognised that inequities for Maori continue to be disproportionate. This is evident across Aotearoa as indicated in the data reported by the Ministry of Health on Maori admission rates, the use of seclusion and Compulsory Treatment Orders on Maori.
With a commitment to building Maori equity NDHB has partnered with Te Awhi Whanau Charitable Trust, a Kaupapa Maori Provider who specialises in the care and support of those with mental healthand or addiction challenges.

This partnership will see the respectful braiding and balancing of te ao Maori and non-Maori worldviews, knowledge, and practices. The term Raranga coined by Sharon Shae" describes this partnership while acknowledging the independent integrity and importance of both perspectives and practices, and how a positive intersection can provide appropriate and effective solutions for Maori.

Te Awhi has been in Te Tai Tokerau for twenty-four years delivering services from a Māori way of being, thinking and doing. This approach is founded on te ao Māori i.e. a Māori worldview and perspective, that describes a range of actions that express Mātauranga Māori in practice.

The Raranga Tahi; Home Based Treatment Team

This team will provide an alternative to inpatient care by offering short-term intensive and assertive community support.

Raranga Tahi aims to provide a service to people within their community, preserving the strengths of family/whanau support and the support of local social networks, hapu and Iwi. Having the support of family/whanau around can be reassuring and helpful during an acute phase of mental health difficulties. Conversely, separation from family/whanau can add to the distress, and after admission, restoring relationships and contact with a person’s community is a difficult task, made even more difficult by the stigma attached to a psychiatric admission.

Raranga Tahi emphasises that Whanau/family are

• active collaborators
• active partners in decision making and arrangements in support planning.

Principles of Care

• Access to a 12 hour, 7 days a week service
• Rapid response following referral
• Culturally inclusive and responsiveIntensive intervention and support, especially in the early stage of the recovery journey
• Active involvement of the tāngata whaiora, whānau/family and carers
• Minimising disruption and maintaining natural social supports
• Flexible visiting
• Maintaining a bio-psycho-social perspective
• Providing practical support and assistance with problems of daily living
• A style based on partnership and negotiation, aiming to offer choice and uphold the Tangata Whaiora and their whanau/family’s autonomy
• Time-limited intervention of two weeks with a possibility of extension for a further two weeks dependent discussion

Inpatient admission or respite services can also be accessed depending if needed via a family covenant

Tangata Whai ora And Whanau

Acute mental illness can present a significant burden to the community, families/whanau and carers. Worry, anxiety, uncertainty and disruption are all consequences of supporting a family/whanau member through an acute episode.

Whanau are often more willing to help with the reassurance when immediate access to a support team is at hand. Also, the burden and practical difficulties for families/whanau can be addressed directly, in the context of a partnership approach towards the resolution of the immediate needs.

Raranga Tahi - will assertively engage with Tangata Whaiora in a mental health crisis while minimising the degree of disruption to their lives and offering clear information to promote choice

Tangata Whaiora & whanau aims

• Provide Tangata Whaiora and family/whanau with a choice of care options
• Engaged family/ whanau
• Build Tangata Whaiora and family/whanau resilience, tool kit and knowledge
• Tangata Whaiora remain engaged in whanau and community life
• Provide Te Ao Maori worldview, connection and supports as requested/recommended

Service Long-term aims

• Provide a service that provides choice and strengthen Maori equity
• Enhance Tangata Whaiora experience of acute treatment and support
• Reduced incidents of repeat presentations to ED
• Improved health outcomes for Maori
• Reduce admissions
• Read missions
• Reduce the length of hospital stay

Improve health outcomes for Māori

Racism, attacks rangatiratanga and prevents Maori from living their lives in ways that are Maori.

Racism, enables and maintains existing power structures that systematically disadvantage Māori

Racism damages connections with Tipuna and compromise Maori ability to pass on Māori ways of knowing and being to future generations

Racist, biased,and discriminatory narratives directed towards Māori contribute to society and the system that perpetuates( consciously and unconsciously) intergenerational inequity, ill health, and lack of well-being. This current state is unacceptable and undesirable.

Raranga Tahi HBT provides a narrative change that allows

•  A shift in language, thinking, and practice
• A shift in the equity and wellbeing dial
• A culture and behaviour change

Changing the narrative

• embraces and celebrate Māori as the unique indigenous people of Aotearoa/ New Zealand.
• Protects and nurtures the beauty and wisdom of Te Ao Māori
• Demonstrates NDHBs commitment to the opportunities afforded by the Korowai of Te Tiriti o Waitangi.

Potential Risks

Service provision

• Whanau is unable/unwilling to engage in the recovery journey
• Whanau home environment is not conducive to a positive recovery journey
• Lack of respite beds/support
• Workforce capacity
• Unable to secure a homelike environment as a work base

Methods of Evaluation

• Number of Tangata Whaiora who:Readmitted to the IPU
• Capacity for IPU
• Tangata Whaiora questionnaire to gauge treatment outcome objective specific to Tangata Whaiora
• Length of admissions to IPU

NDHB reporting platform

• contacts made
• Equity stats within IPU (Seclusion, Admission)
• Readmission statsLength of stay
• Capacity of IPU statsinterventions delivered
• Utilising Feedback informed practice – e.g., ORS or SORS

An evaluation investigates how well objectives have been met, what has changed for the community/patients as a direct result of this project and what could be done differently.