Long-term Conditions Support

A registered nurse working with the patient and family, alongside their GP and practice team, to develop an integrated care plan.

By working together in this way, the areas that are having an impact on a person’s life are addressed, which often results in improved quality of life.

This service works across various health and social sectors, such as housing, employment, Work & Income NZ, and involves advocacy and support for the patient and their family.  As well as supporting general practice to develop innovative solutions.

This service has a team approach and supports you and/or your family/whanau to manage more effectively by:  

  • Providing information to help people make informed decisions and support them to set goals for themselves.
  • Encouraging people to attend the ‘Self Management - Piki Te Ora’ programme and the ‘Living with Diabetes’ programme.


The primary health nurse spends time in the hospital setting working with inpatients, but can also be accessed through referral from the GP or practice nurse.