Background:

In Aotearoa NZ, persistent inequities in health outcomes impact Māori, Pacific, and those experiencing socioeconomic deprivation, with resulting burden for communities, the health sector and society. Healthcare design contributes to these inequities, particularly through inappropriate and siloed services, and missed opportunities for holistic care to address broader determinants. The Whiri programme responds to this challenge as a Kaupapa Māori enhanced access pathway using hauora navigators, holistic assessments, and clinical coordination. Implemented across hospital, community, and research programmes in the Waikato region, Whiri has been adapted for diverse contexts including maternity, long-term conditions, paediatrics, and primary care. This study develops a merged Whiri dataset to examine programme reach and secondary care outcomes using linked data.

Methods:

Data from 15 Whiri projects was merged to create a new register. Sociodemographic analysis assessed programme reach. A retrospective cohort study examined Waikato hospital admissions data for those who received a Whiri assessment between 2018 and 2024, linking Whiri records with hospital records via the National Health Index.

Results:

A total of 4,074 individuals received at least one Whiri assessment. Most (79%) were Māori, and 71% were female, reflecting programme eligibility criteria and reach into underserved communities. Two thirds (2,714 people) had hospital admissions during the study period, with 72.6% hospitalised after their Whiri assessment. There were 7,076 post-Whiri admissions. Median time to first admission was 588 days, with 65.4% occurring after one year. Healthcare engagement patterns varied by Whiri type.

Conclusion:

Whiri programmes have had significant reach over the last 6 years. Establishing a linked dataset enables understanding this impact, and tracking health system engagement of the Whiri cohort. Given the known potential of Whiri services to improve health outcomes and enable health equity, this new Whiri register also supports future research on long term Whiri outcomes and recommendations for service development.