PIKI TE ORA NURSING SERVICES LIMITED Maori Mobile Disease State Management Nurse CHRISTINE NICHOLAS

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PIKI TE ORA NURSING SERVICES LIMITED Maori
Mobile Disease State Management NurseCHRISTINE
NICHOLAS MN, PGDipHsc, BN, RN.
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Wakataka te au

• Wakataka te au ki te uru
• Wakataka te au ki te tonga
• Kia makinakina ki uta
• Kia mataratara ki tai
• Kia I ake ana te atakura
• e tio, e uka, e au u
• Tie Mauri ora!

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Wakataka te au

• Cease o winds of the west
• Cease o winds of the south
• Let the bracing breezes flow over the land
• Let the bracing breezes flow over the sea
• And let the red tips dawn come
• With a sharpened touch of frost
• The promise of a glorious day

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DEFINITION of DISEASE STATE MANAGEMENT NURSING

• Works across the spectrum of health promotion
  through to secondary care
• Dont just manage the disease
• The nurses assist the clients to maximize their
  wellness
• Use holistic assessment model and holistic
  intervention

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Historic

• Maori not benefiting from mainstream health
  industry
• Maori Mobile Disease State Management (DSM)
• A service developed by MOH 2000
• To improve the health status of adult Maori who
  suffer from at least one or more of the three
  chronic diseases
• PTO is contracted to provide the services in
  northern and coastal Taranaki.
• To ensure that the required outcome is achieved,
  PTO also develops and establishes early
  intervention programmes.

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Contract

• The three diseases include
• Cardiac
• Diabetes
• Lung
• Focus group Maori and pacific peoples
• Adult age group

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Specification

• THE NURSE WILL BE A RESOURCE FOR PROVIDING HEALTH
  AND WELLNESS EDUCATION WITHIN THE COMMUNITY OF
  TARANAKI.
• A NURSING MODEL OF CARE IS IMPLEMENTED TO ENSURE
  OPTIMAL OUTCOMES FOR BOTH DISEASE PREVENTION AND
  MANAGEMENT.
• ADVANCED NURSING PRACTICE UTILISING CASE
  MANAGEMENT AND BEST PRACTICE GUIDELINES.
• (WITHIN PTO NURSES SUPPORTED TO COMPLETE CLINICAL
  MASTERS STUDIES).

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Possible outcome measures

• Increase patient and whaanau participation in
  self management plans through
• EMPOWERMENT
• Lower HBA1C
• Lower body mass index (weight)
• Lower rates of smoking
• Raise physical activity
• Lower hospital admissions
• Reduce incidence of unstable diabetes or diabetes
  complications
• Reduce acute episodes

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Location specifications

• GEOGRAPHICAL SERVICE AREA IS
• MOKAU, WAITARA. NEW PLYMOUTH, INGLEWOOD, OAKURA,
  OPUNAKE, KAPONGA,

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THE PROCESS

• Referrals (NON ACUTE)
• Assessment
• Plan of care
• Implementation
• Evaluation / Report
• Discharge

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TIMEFRAMES

• Contact within 48hours
• Assess usually within five days
• 11 face to face visits in 12 months

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REFERENCE LIST

• Ministry of Health, (2001). The Primary Health
  Care Strategy. Wellington. NZ MOH.
• Quality Health New Zealand Standards
• Nursing Council of New Zealand

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Knowledge is a Taonga/Gift Rapua te ara tika mou
ake Seek the path that is right for you