Te Puna Hauora
Māori Community Health Service

Te Piki Oranga provides a range of Māori community health services targeting lung disease (Chronic obstructive pulmonary disease and asthma), diabetes, heart disease and cancer. Referral to the service can be made by any other health professional, whānau or self-referral.

Pūkenga Atawhai / Māori community nursing service

The service consists of a mobile nursing, disease state management service, focused specifically on an enrolled population with lung disease, diabetes heart disease and cancer. This service supports whānau to improve their health outcomes.

Scope of Role

The nursing service includes the following key components:

  • Identification of whānau at risk of lung disease, diabetes, heart disease and/or cancer
  • Assessment and nursing diagnosis
  • Care planning including development of diabetes management plan, asthma action plans and heart disease management plan with whānau involvement and in collaboration with other members of the primary and secondary care team
  • Cancer screening, advocacy and support through the cancer pathway e.g. specialist services;
  • Co-ordination of necessary primary and secondary care, e.g. GP care, diabetes annual review, nutrition advice, podiatry services, eye screening etc.
  • Health advice, follow-up care
  • Health promotion education
  • Ongoing monitoring of conditions e.g. blood glucose monitoring, weight, blood pressure, peak flow, etc.
  • Partnership and co-operation with other primary and secondary health services to promote accessible and appropriate service delivery for whānau
  • Referral to other primary services and advocacy with secondary services i.e. specialist and hospital services

Pūkenga Manaaki / Navigator

The Pūkenga Manaaki might be the first point of call for whānau when accessing the health system and as such, form an important link with health professionals. They are suitably qualified health professional and their main objective is to improve health outcomes for whānau by working in the following manner:

Scope of Role

  • Improve community access to primary medical and community health facilities through effective education and promotion activities and by providing transport assistance where necessary
  • Culturally appropriate whānau support and advocacy services when the need arises
  • Health education to individuals as appropriate to the needs of that individual
  • Facilitating the smooth transition for whānau through the health system
  • Providing links and consultation between whānau, community and service agencies
  • Ensure whānau are properly referred to the appropriate health professional

Kaimahi-A-Iwi / Community Health Social Worker

Kaimahi-a-Iwi works as part of a multi-disciplinary team within Te Piki Oranga services and across agencies to ensure that whānau are able to cope with their social circumstances during and after their experience in hospital and community settings. They assist whānau to access budgeting and financial support, family support, child care, daily and emergency social services, supportive counselling, trauma debriefing, family violence, terminal illness and palliative care, grief and loss counselling and other resources necessary for families.

Scope of Role

The Kaimahi - a - Iwi role is in Care and Protection and may include working with organisations listed below:

  • Education
  • Probation
  • Housing
  • Police
  • Dental
  • Employment
  • Child, Youth & Family
  • Youth Services
  • WINZ
  • ACC
  • IRD
  • Court
  • TPK
  • DHB Health services
  • and other community based agencies


All the above will be provided according to nationally recognised guidelines for best practice.

Referral to the service

A referral to see a social worker can be made by any other health professional or patients can self-refer. Whānau need to have a health issue that is being negatively impacted by their social challenge.