Reducing HbA1c with whanaungatanga: the measurable impact of patient-centric primary care

 
28 Mar 2022

“More and more, I’ve realised that the model of health we have in Aotearoa New Zealand is very European-orientated, and doesn’t work for our Māori and Pasifika communities. As health practitioners, we need to change our mindset to meet the needs of the people.” 


Sue van Mierlo is a nurse practitioner based in Taupō, working as part of the Lakes Extended Care Team (ExCT). In her role, she supports people to self-manage long-term conditions and diseases, mostly working with people who have high needs, including managing diabetes. A large number of her clients are Māori.

Thinking and working with an equity focus

Sue’s work is on the frontline of He Ara Whakamua, Pinnacle’s Hauora Māori Health Strategy 2021-2024, which recognises the urgent need to reverse decades of inequity experienced by Māori in the health system. 


“Most of the clients I engage with either have poor outcomes already, or don’t engage with primary care – they’re wary of health providers for many reasons,” says Sue. “Often, the formal process of accessing primary care is a real barrier. People get quite hoha and disengage.” 


That awareness led Sue to join the Lakes ExCT, where she can take a more flexible, patient-centric approach with an interdisciplinary team, providing tailored access to the services clients need. It’s a different approach to healthcare, but the biggest difference Sue says, starts with whanaungatanga. 


“Taking time to get to know people, hearing about their journey, their whānau, and taking that bigger approach before we talk about health, is the start,” says Sue. “I will often first meet with a client in their home, or somewhere they are comfortable. It’s about access and engaging with them wherever they are.” 


There’s a key question Sue asks in those first meetings: What do you need from me, to help you? “Often people have never been asked that. It’s the start of a whole different conversation, one where I learn from them as much they learn from me.”


Different converations, improved outcomes

HbA1c testing is a key measure of how well someone’s diabetes is controlled with diet, exercise and medication. The test measures blood glucose (sugar levels) over 3 months, and a normal, non-diabetes result should be 40 mmol/mol or lower. 


Many of Sue’s clients have diabetes – a disease that’s twice as prevalent among Māori than non-Māori. Māori with diabetes also have disproportionately higher rates of complications such as renal failure and lower limb amputation[1]. 


Lowering HbA1c is a key health measure in diabetes management, and Sue proudly talks about clients like Te Aroha, a Taupō local who has worked to reduce her HbA1c from over 100 to a low of 43. 


“What she’s done is a mammoth achievement, a total mindset change,” says Sue. 


Te Aroha says building a relationship with Sue and having the time to talk through any questions was an important part of her health journey. 


“With Sue, there’s someone there who can I can take that time with. She’s not up there and I’m down here, it’s equal,” says Te Aroha. 


“It’s like a lot of Māori people, I think being told ‘You have to take this drug’, with no time to talk or ask questions later, means the defenses go up: What am I taking? I’m not taking this.” 


“Sue explains it all, what the medications can do and the benefits. How my conditions work. She’s on my side, it helps a lot.” 


The milestones have continued for Te Aroha. Her sugar levels, once 26-28, are now between 5-6. She has changed her eating and become more active, changing her entire lifestyle and increasing her energy levels.


Re-setting expectations shaped by inequity

Health literacy support is a significant part of the time Sue takes in her work, and she says it’s hugely valuable. “How can we ask someone to self-manage if they don’t understand the disease they’ve got, or the medicines? 


“It’s about breaking it down. I spend a lot of time explaining people’s health conditions, how that might be impacting their life and what can help have an effect.” 


In those conversations, Sue often needs to challenge long-held expectations shaped by generations of health inequities, disparities and poor outcomes for Māori. 


“For some patients, having a leg amputated for diabetes is how it has happened for generations and they expect that’s their lot. We need to change that expectation: just because Aunty, Uncle, or Grandpa had a leg amputated doesn’t mean it needs to be this way for you.


“People need to hear, it can be different for you and for the tamariki coming up through the whānau.”


Celebrating the wins

Often it’s about celebrating the small wins, taking it one step at a time with each client. Everything adds up, says Sue. “I tell them: I don’t care how long it takes, as long as you’re doing something.” 


Jarrod, another of Sue’s clients, has celebrated many achievements along his journey. 


“I was in a bad place,” says Jarrod. “Struggling from sleep apnoea, diabetes, I was 152kg, it was terrible, physically and mentally. 


“Sue was on my case, she knew what to do. She said to me ‘You’ve just got to take your meds, just focus on that.’ So I took them, and we fought through that battle.” 


Over 12 months Jarrod worked to lose nearly 30kg. His HbA1c levels, which were originally up over 100, reduced to 51. His blood sugars now consistently sit around 7, down from between 12 and 18.  


At one point, Jarrod arrived to the clinic to find Sue and exercise consultant Wendy waiting for him with a basket that weighed 26kg – all the weight he’d lost so far. “They got me to hold it, I was sweating and holding this 26 kilos, sat down and tried to get off the seat. Amazing! They were there on their holiday, just to show me how much weight I’d lost and celebrate.” 


Perhaps one of the biggest measures of success for Sue is that she has started getting referrals from whānau, through the people she’s worked with. 


“The majority of patients I see get referred from general practice teams, but whānau are starting to ring me now to say ‘This person will be calling you’ or ‘Uncle told me to come see you about this.’ 


“Being in that supporting role, walking the journey, alongside that person and seeing them get more confident, they often teach me as much as I’m teaching them,” she says. 


“Those changes in mindset and self-esteem spread to others in their whānau, to their friends. I think it’s so cool, and such a privilege to be part of.”


[1] Source: Ministry of Health


Te Aroha’s story: Changing a little thought in my head

“Looking after myself. That’s the thing that switched in my mind, that helped me through this whole journey of looking after my health. Just that little thought in your head, it’s amazing what it can do.” 

Te Aroha has lived in Taupō most of her life, with whānau, friends, and familiar routines. Looking after her health wasn’t always a priority. 


“I wasn’t an active person, I was the person who sat down and watched TV all day. I ate anything and everything I wasn’t allowed to have,” says Te Aroha. “I would always get the gout and I knew I had diabetes, bad.” 


She could see things going wrong – her health, her weight, low energy levels – and nothing was changing. Until she changed her mindset. 


“I thought, I’ve got to start looking after myself. I want to be healthy. If the weight comes off, that’s a bonus.” 


Te Aroha contacted Wendy, the Lakes Pinnacle extended care team (ExCT) exercise consultant, to ask for support to be more active. Wendy also connected her with ExCT nurse practitioner, Sue van Mierlo, and from there, Te Aroha says it was “Let’s go.” 


With HbA1c counts above 100 and blood sugar levels between 26-28, Te Aroha started working with Wendy and Sue to find ways that worked for her, focusing on eating and activity. Together, they celebrated every achievement. 


“Wendy got me into a routine of going to the pools, and Sue was always there to explain medicines and different things. Having that back up has been fantastic,” says Te Aroha. “Eating properly and being more active are the big things. Now I’m in a routine and I miss exercise and being in the pool.” She laughs: “Who misses exercise? What a weirdo!” 


It hasn’t been easy, and some things needed time to navigate. Medication in particular was a barrier. “I hate taking pills, I’m dead against them, so when Sue said there’s this new medication for diabetes, straight away I said no, hell no, no way I’m going on that! 


“It’s like a lot of Māori people, I think being told ‘You have to take this drug’, with no time to talk or ask questions later, means the defenses go up: What am I taking? I’m not taking this.” 


Te Aroha’s relationship with Sue, and the ability to come back with more questions, helped. “I can talk to her on the same level, it’s equal and she explains what things do and the benefits. She’s on my side.” 


Wendy also introduced Te Aroha to another client who had taken the same medication. 


“We ended up talking and he told me it’s helping him. After that I got onto the pill and it’s helped quite a bit. I’ve got my HbA1c at 43. That’s a big milestone for me.” 


The milestones have continued as the months passed. Te Aroha reduced her insulin and her sugar levels are now between 5 and 6. With the ability to focus on her health, she’s now able to recognise the patterns of what she eats and what puts her over those levels. Most of all, her energy has returned. 


“With my son, I now take him to the park and to the trampolines, which I didn’t used to do because I was tired. Even my friends when we go out, they say I’ve just go so much more energy. 


“It’s had a huge impact on my whānau, I’m showing them I can do this, and you can do it too. I tell them, be healthy, do your eating and your active things. I’m a classic example of it does work. Just changing that little thought in your head, it’s helping in a lot of ways.”


Jarrod’s story: Having people in my corner, it’s bloody magic

“Once you take that initial step on the path and see those first little results – your bloods come down, you HbA1cs come down, your health goes up – it’s not hard to stay on it. I know where that path leads, I won’t go back.” 


A back and knee injury after falling from his truck cab put Jarrod out of work. Recently returned from Australia, he had no whānau around, and his time in hospital led to the discovery of severe sleep apnoea and diabetes, just before the first COVID-19 lockdown hit. 


“I was in a bad place,” says Jarrod. “Struggling from sleep apnoea, diabetes, I was 152kg, it was terrible, physically and mentally. Life wasn’t much fun.” 


“When the hospital told me I had diabetes I went to the doctor, but I didn’t get much help. I was lonely, I was scared and lost, I didn’t know what to do. Then they put me onto the team here (Pinnacle Lakes Extended Care Team (ExCT)). It was life changing, 100 per cent!” 


Initially referred to ExCT dietitian, Katie, Jarrod quickly connected with nurse practitioner, Sue, exercise consultant, Wendy, and health coach, Troy. They became his team, the people in his corner as he navigated a new health journey and celebrated successes, big and small. 


“I saw Katie first, because I needed a dietitian, so I gave that a shot. Then she put me on to Troy – I opened up my heart to him and he listened. I went to the pool with Wendy and she helped me take care of my back. Then Super Sue came in, and everything changed even more.


 “We tried some meds, I started getting active and got my head in the right place, I began to eat different – all the veggies,” says Jarrod. “I changed my whole lifestyle.” 


Over 12 months Jarrod worked to lose nearly 30kg. His HbA1c levels, which were originally up over 100, reduced to 51. His blood sugars consistently sit around 7, down from between 12 and 18. 


“It wasn’t easy, it’s been bloody hard work, on both sides. I felt accountable to the team, because they knew what to do and they really cared. I didn’t want to let them down. 


“When I was in a bad place and struggling, Sue was on my case, she knew what to do. She said to me ‘You’ve just got to take your meds, just focus on that.’ So I took them, and we fought through that battle. 


“Having the power of that team in your corner, it’s bloody magic! Without them I’d be close to death about now. It’s amazing and I’m so grateful.” 


Over the holidays, Jarrod came in to see Sue and Wendy. They were waiting for him with a basket that weighed 26kg. “They got me to hold it, I was sweating and holding this 26 kilos, sat down and tried to get off the seat. Amazing! They were there on their holiday, just to show me how much weight I’d lost and celebrate.” 


Jarrod says being able to come in and see the team or talk to them gives him a boost, but he knows he needs to go home and do the mahi. 


“My HbA1c goal is to get it between 40-50, and I want to lose another 20kg. It was hard at first but I’ve changed my whole lifestyle. I feel good, I don’t struggle to walk around, or run out of breath walking to the mailbox. I wake up with a smile. 


Jarrod has recently returned to work. 


“Where there is help, there is love, and where there is love, there’s peace. I’m not perfect, but I don’t think I’ll ever go back to the place I was in. Life’s good!”