Mana Tu: how effective is a whanau ora approach to improve HbA1C levels in people with poorly controlled type 2 diabetes mellitus

INTERVENTION: The 20 GP clinics at National Hauora Coalition have been stratified according to number of people with HBA1c >65 who are Maori, Pacific and living in quintile 5 neighbourhoods (clinics with 40+ potential participants only), location (urban and rural) and ‘type’ (Marae and mainstream‐led). There are five pairs or 10 practices that meet these criteria. Practices are then randomised to either receive Mana Tu or to be the ‘control’ for 12 months. The control practices will receive usual care for 12 months. The intervention practices will receive Mana Tu for 12 months. At the end of the trial, the control practices will receive Mana Tu for 12 months. More information about Mana Tu is provided here. Participants will receive an intervention called Mana Tu. Mana Tu comprises: 1. Case Management of‘poorly controlled’ type 2 DM and wider social issues for Maori and Pacific people by health workers called Kai Manaaki. Kai Manaaki will have minimum 5 years’ experience in the management of long term conditions and already working in primary care as community health worker, diabetes educator, primary mental health roles. 2. Integration of Case Management within general practice clinics 3. Support for the KM from a Network Hub. The Hub will support the KM in terms of information management (data is collected via a portal and analysed/reported by an IT team), training, administration and quality assurance Case management (CM) is provided by health workers (called Kai Manaaki) who are located in general practices. The intervention (CM) is provided over a number of visits either in the practice or at the person's home. i. Sampling and recruiting ‐ A list of potential participants (ie Maori, Pacific and quintile 5 with known HBA1C >65 in the past 12 months) is provided to the general practice. The clinical champion at each practice confirms inclusion criteria are met and makes formal approach to potential participant to obtain consent for referral to Mana Tu. All referrals received from the general practice during that week will be assigned to KM within that clinic. ii. Pre and Visit 1 (60‐90 minutes). To occur within 3 months of the study commencing. KM contacts participant (and if requested their whanau) utilising the Hui Process to ensure culturally safe engagement. Verbal and written information about the programme, and its evaluation, will be provided prior to informed consent being obtained. iii. Visit 2 (to occur within two weeks of visit 1) ‐ A standardised Mana Tu Assessment (60‐90 minutes) will be undertaken utilising standard queries for self‐management of type 2 DM including: Clinical indicators – HBA1c, BP, renal function, lipids, CVDRA, oral health medication, health service utililisation, immunisations; Lifestyle factors – height, weight, nutrition, physical activity, smoking; Psycho‐social measures – mood, stress, work, budgeting, whanau ora, QoL; Health literacy This information will provide baseline assessment data as well as inform goal setting with participants and their whanau. iv. Visit 3 (60 minutes to occur within 2 weeks of visit 2). KM will meet with person +/‐ whanau to complete their personalised Mana Tu Plan ‐ a modified version of the NIA Self‐management Plan. The plan will address self‐management of risk factors and LTCs, attainment of goals and regular feedback to whanau, links with appropriate organisations for ongoing support. CONDITION: Type 2 Diabetes PRIMARY OUTCOME: HBA1c using serum sample INCLUSION CRITERIA: HBA1c >65 Ethnicity Maori and/or Pacific Enrolled with National Hauora Coalition PHO v. Further visits (each lasting 30 ‐60 minutes) ‐ Over the next six months, KM will support access to interventions based on the Mana Tu Plan, record progress, collect data, engage with primary care teams, participate in Hub and Quality Improvement activities. The frequency of visits will be determined by the Plan set by the participants working with the KM and at least monthly (though we anticipate this will be more frequent (weekly‐fortnightly) in the beginning). From Month Nine, KM and participants will be planning for discharge from the programme so that the final visit occurs at 12 months when the Discharge Plan is provided and outcome data collected. SECONDARY OUTCOME: Barriers and facilitators to the implementation and uptake of Mana Tu will be evaluated in a qualitative part of the research where providers, funders and experts are interviewed or contribute to focus group discussion. Blood pressure as recorded in medical record Goal Attainment Score Health service utilisation ie number of visits to primary care providers to be obtained by GP medical records Hospitalisation by review of medical records in general practice Lipids serum sample Mortality Satisfaction with 'T2DM' care received in previous 12 months using the Hua Oranga Outcomes Measure Smoking Status using standard question asked of all patients in NZ "have you smoked tobacco in the past 30 days?" and answer is Yes or No