Huakina-Opening Doors to Care: Understanding the wellbeing of older people and the role of kaiarahi in Wairoa District.

Screening: Kaiarahi (health navigators) with relevant training and training in the research protocol will undertake 'interRAI Check Up Self-Report Assessment (CUSR)' (Version 10.1; internationally validated) and also ask study specific questions. The interRAI CUSR assessment consists of just under 100 questions although there is some logic embedded so not all questions are answered, depending on previous responses. The interRAI CUSR measures functional and psychosocial wellbeing and the results can be used for care planning. Kaiarahi will ask the exact question from the assessment and record the participants response. The assessment will occur once and take approx 60mins in total. It will occur face to face or via the phone. If undertaken face-to-face, it will occur at the persons home or at a mutually agreed community location. The data will be collected on a study-specific electronic tool. Care planning: Participants have the option to consent to care planning. Those who elect not to continue with care planning, wil lcomplete the study assessment and then be thanked for their participation. (This is a similar approach to pure epidemiological studies which do not have intervention components). For those who consent to care planning, Kaiarahi will complete care planning using a tool from their place of employment and in conversation with the participant. They will make referrals to relevant health practitioners/practices, social services and community organisations using results from the interRAI assessment, and their knowledge of care planning and available services. There knowledge of care planning will be used to set goals and refer on to other services. They will do care planning once although follow up of referrals to ensure these are actioned may occur. A 30minute care planning will occur face to face or via the phone, either at the time of assessment or within one month, as agreed between the participant and kaiarahi. After care planning, the kaiarahi will make referrals and then follow these referrals up within one month.. If undertaken face-to-face, it will occur at the persons home or at a mutually agreed community location. Kaiarahi will meet once for assessment, once for goal setting (which could happen in the same visit as assessment) and there will be on follow up contact (phone or in person). A record will be kept to document completed assessment, completed care planning and completed followup which will be used to monitor fidelity to intervention. The kaiarahi reflective journal will also be used to inform this at a study level Examples of services that participants may be referred to are general practitioner, full interRAI assessment from trained assessors, and group strength and balance programmes. Provision of resources: Kaiarahi will provide a Navigating Wellness book to all participants. https://thirdagehealth.co.nz/navigatingwellness/