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Self-management support

in New Zealand

This section provides some context for chronic care and self-management support (SMS) within primary care in New Zealand. It includes links to case studies, local, regional and national initiatives.

The health system is increasingly under pressure, with an ageing population and increasing rates of long-term conditions as just some of the challenges to be addressed. This is a common phenomenon being experienced worldwide and has led to extensive research as countries struggle to align public expectations with the reality of accelerating health costs and an inexhaustible driver for increased health care. 


Ten characteristics of high performing chronic care systems


A report to the NZ Treasury by Professor Nicholas May in 2013 reviewed the international literature and highlighted Chris Ham's ten characteristics of a high performing chronic care system as a useful model to guide health system reform within NZ. These characteristics are: 

  1. Universal coverage.

  2. Care free at the point of use.

  3. A delivery system that focuses on the prevention of ill-health and not just the treatment of sickness.

  4. Priority is given to patients to self-manage their conditions with support from carers and families.

  5. Priority is given to primary health care, particularly multi-disciplinary team work in chronic care led by nurses.

  6. Population management is emphasised by stratifying people with long term conditions according to their clinical risk and supporting them commensurately.

  7. Care is integrated so that primary health care teams can access specialist advice and support from outside primary care when needed.

  8. Information technology is used to improve chronic care

  9. Care is effectively coordinated, particularly for people with multiple conditions who are at greater risk of hospital admission, including across the health and social care (disability support) divide.

  10. Systems approach. The other nine characteristics are linked into a coherent whole as part of a strategic approach to change that addresses several characteristics at the same time.


As organisations have focused on each of these areas, the area of self-management support has emerged as a key 'cross-cutting' strategy that is relevant for all ages, stages, conditions and specialties. 


The New Zealand Health Strategy 2016

In 2016, the Ministry of Health released 'The New Zealand Health Strategy: Future direction'. This document outlines the high-level direction of New Zealand’s health system over the 10 years from 2016 to 2026. It also "lays out some of the challenges and opportunities the system faces; describes the future we want, including the culture and values that will underpin this future; and identifies five strategic themes for the changes that will take us toward this future."

The strategy has two parts:

  1. New Zealand Health Strategy: Future direction

  2. New Zealand Health Strategy: Roadmap of actions 2016 which identifies 27 areas for action over five years to make the Strategy happen.

The 5 action areas relate closely to the principles of self-management support and are:

  1. People-powered

  2. Closer to home

  3. Value and high performance

  4. One team

  5. Smart system

Read more on the Ministry of Health website


Health Care Home and service integration

Implementing self-management support within a primary care practice often requires organisational and systems change. The Health Care Home initiative requires practice teams to implement improved care and business methods. Many of these improvements will also help build both self-management support capacity and capability within the practice.

Pioneered in the USA, the Health Care Home model was introduced and adapted for New Zealand by the Pinnacle Midlands Health Network and trialled in some of their general practices. As interest in this approach grew, a national collaborative was established and Health Care Home programme initiatives are now in place or under development across much of New Zealand with 89 practices now using some or all of the Health Care Home model of care.


In June 2019 the collaborative members include:

  • Pinnacle Health Network

  • Compass Health

  • Pegasus Health

  • ProCare Health

  • Northland DHB

  • Manaia Health

  • Te Tai Tokerau PHO

  • Central PHO

  • Royal NZ College of General Practitioners

  • GPNZ

  • DHB Partners

  • Wellsouth Primary Health Network

The national collaborative has developed a set of national credentialing and operational guidelines and identifies 4 key focus areas (domains):

  1. Ready access to urgent and unplanned care.

  2. Proactive care for those with more complex need.

  3. Better routine and preventative care.

  4. Improved business efficiency & sustainability.

Read more about the Health Care Home national collaborative


Service improvements

Practice level changes

Some of the service improvements that impact on the delivery of self-management support include practice level changes such as: 

  • strong leadership and whole-of-team vision and participation

  • continuity of care for people enrolled in the practice

  • increased use of electronic decision aids and shared care planning tools

  • whole-of-team training

  • providing nurses with dedicated time to do care planning with complex patients

  • flexible funding at practice level

  • use of a patient portal

  • all team members working at the top of their scope.

Integrated services

Increasingly, services across primary and secondary services are becoming more integrated.


Service improvements that make a difference include:

  • Supporting nurse specialists to run clinics in the community and provide training and mentoring for primary care nursing teams.

  • Enabling hospital specialists to provide clinical mentoring and support for the wider primary care team including joint clinics within GP clinics.

  • Facilitating multidisciplinary teams (MDT) within primary care including a range of medical, nursing, and allied health specialists from secondary care and members of the primary care team.



Health coaches, Kaiawhina, navigators...

Reducing inequities and increasing access to healthcare for culturally, linguistically and socially diverse populations in New Zealand has become a priority for primary health organisations (PHOs) and district health boards (DHBs). Health workers who are not clinically trained but have strong social and cultural skills are proving to be valuable members of the practice team. 

Some of the benefits identified include:

  • time to support people and discuss issues

  • holistic and culturally appropriate approach

  • increased community and social support links

  • more flexible and tailored approach.

Examples & related areas


Changing role of the primary care nurse

Delivering self-management support services with primary care has provided many opportunities for practice nurses to extend their role and work at the top of their practice scope.


Examples of this include:

  • coordinating care for people with complex conditions

  • leading the practice care planning process

  • developing a special interest e.g diabetes

  • running nurse-led clinics

  • coordinating and delivering self-management education.



Care planning


Care planning for people with long-term conditions is increasingly common across New Zealand. Care planning is underpinned by a philosophy of looking at the patient as a whole, which is important for everybody but particularly relevant for people with multiple comorbidities and complex social issues.

Advantages of person-centred care planning:

  • ‘Same page care’ single plan shared by everyone

  • Supports new integrated models of care such as Health Care Home

  • Improves care coordination and continuity

  • Person-centred and underpinned by patient-driven goals



Patient portal electronic tools and apps

Secure online sites such as patient portals where patients can access their health information and interact with their general practice are growing in popularity and are business as usual for some practices.

In recent times, the number of health apps and their usage has surged.

Health apps have the potential to positively impact health and well-being by encouraging lifestyle changes such as increased fitness and providing understandable health information. 

People are working with their healthcare teams via the patient portal and when using apps. Some healthcare providers prescribe/recommend apps as part of a treatment or care plan.


Read more about patient portals and online tools and apps

Self-management education groups

Group self-management education (SME) has proven to be an effective and popular initiative internationally. Many organisations run SME programmes throughout New Zealand, with varying success.

Key learnings from some of the organisations who successfully run SME include:

  • sustainable funding

  • a central coordinator

  • electronic referral from practices to a central point

  • continuous evaluation and improvement

  • a range of SME options – Stanford, diabetes-specific, etc.

  • structured mentoring and support for group facilitators and peer leaders

  • feedback to referrer about individual progress

  • regular communication to practice teams about the availability of SME services

  • have a range of options to offer people who do not want to attend a group (web-based, health coach etc.)


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