Principle 1: Recovery Orientated

• Support should promote hope, autonomy, self-determination and optimism
• Tāngata whaiora and whānau should be active partners in decisions about their support.
• People with lived experience should have meaningful leadership and workforce roles across the system.
• Care should be trauma informed, collaborative and use the least restrictive approach 
  possible. 

Principle 2: Community Based

• Support should be available as close as possible to where people live their lives. This includes services working alongside primary care, social services, cultural groups, community organisations and existing local networks.
• Community-based support is particularly important for rural and remote areas, where local relationships, flexible delivery and accessible care connection are essential. 

Principle 2: Culturally Safe and Appropriate

People should be able to access care that recognises and responds to their culture, identity, values and circumstances. 

This includes: 

• visible pathways to Kaupapa Māori and rongoā Māori services
• Māori workforce capacity and leadership
• culturally relevant environments
• culturally safe and responsive practice
• Māori cultural support within crisis, sub-acute and community care
• services that are welcoming and accessible for rangatahi, diverse
• cultures and communities of identity.  

Principle 4: Referrals and Care Connection 

Services should work together as one system around the person and their whānau. A key 
part of Connecting Care is the development of a more coordinated referrals and care 
connection function.  

Connected care includes: 

• clear referral and access pathways
• care coordination
• warm connections between services
• shared and joint care
• collaborative care and transition planning
• co-location and shared resources where appropriate
• shared governance, workforce development and training. 

Principle 5: Stepped Care Approach

• Support should be available across a continuum, from everyday wellbeing and community 
  connection through to specialist and highly specialised services.
• People should be able to move between different levels of care as their needs change, 
  without unnecessary delays or disconnection.
• People may also receive support from several levels at the same time.
• The levels describe different types and intensities of support. They are not fixed stages that 
  everyone must move through in order.

Stepped Care Levels

Level one: Wellbeing, self-help and self-management 

This includes: 

• whānau, friends, peers and social networks
• the Five Ways to Wellbeing
• physical health and wellbeing services
• self-management resources
• apps and digital tools
• everyday community connection. 

Level two: Social services and community organisations 

This includes: 

• community and social services
• mental health promotion
• community groups and clubs
• education, training and classes
• group programmes 
• schools and workplaces
• faith-based and cultural organisations
• communities of identity. 

Level three: Primary, Kaupapa Hauora and community-based services 

This includes: 

• primary care
• Kaupapa Māori and hauora services
• peer and cultural support
• counselling and brief interventions
• community mental health and addiction services 
• care navigation and coordination
• group programmes
• whānau support
• rehabilitation and recovery support
• respite, residential support and community-based detox options. 

Level four: Specialist mental health and addiction services

This includes:

• specialist assessment and treatment
• psychological therapies
• medication support and clinical oversight
• care coordination
• rehabilitation and recovery
• crisis response
• Māori cultural support and interventions
• access to respite, acute inpatient care or medical detox where required. 

Level five: Tertiary and sub-specialty services 

This includes highly specialised services, generally accessed outside the West Coast, such 
as: 

• sub-specialty assessment and treatment
• specialist consultation and therapies
• secure inpatient care
• extended-stay care
• specialist rehabilitation and detoxification services.

Principle 6: Locality hub-and-spoke delivery

Services will be organised across West Coast localities using a mix of:

• community hubs
• local spokes and pop-up services
• mobile and outreach support
• telehealth
• regular community clinics
• interdisciplinary teams working across organisations.

This approach allows services to be tailored to the needs of different West Coast 
communities.

Connecting Care is intended to strengthen the relationships, knowledge and services that 
already exist across the West Coast. 

Providers will retain their own expertise, responsibilities and established access pathways. The model will help create stronger links between them. 

For providers, Connecting Care will support: 

• clearer information about available services
• more consistent referral pathways
• a central person to contact when the appropriate pathway is unclear
• greater visibility of community and non-clinical support
• supported connections rather than unsupported redirection
• better communication across organisations
• shared and collaborative care
• improved transition planning
• access to specialist consultation and liaison
• more coordinated responses for people with complex or changing needs.

The Referrals Coordinator will be particularly useful when: 

• a person’s needs span several services or sectors
• a provider is unsure where a referral should go
• a previous referral has been declined or redirected
• social, cultural or practical needs sit alongside clinical needs
• several organisations need to agree how they will work together
• someone needs to step up to more intensive care
• someone is transitioning back into primary or community support
• there is a risk that the person may disengage or become lost between services.

Collaborative care and transitions 
Some people will need support from more than one organisation. 

Under Connecting Care, providers will be encouraged to work together through:

• the Referrals Coordinator may help bring relevant services together, but connected care remains a shared responsibility across the whole system.
• every provider has a role in helping ensure people experience support as 
  coordinated, respectful and easy to navigate.