Te Whiringa Ora: person-centred and integrated care in the Eastern Bay of Plenty, New Zealand

Te Whiringa Ora is a community-based programme in New Zealand that facilitates interdisciplinary care for patients and their family. It targets those with a chronic disease whom have high inpatient admissions or emergency department presentations. It is based in a rural part of New Zealand that has a large indigenous population, and a relatively high level of social deprivation. The programme makes use of culturally appropriate care coordinators, and uses telephone support and tele-monitoring to aid self-management. The programme has been running for three years and has shown a reduction on hospital presentations, as compared to an equivalent population (not enrolled in the programme). This case study outlines the programme, and focuses specifically on the implementation processes, and lessons learnt.