He Kokonga Ngākau began in January this year and is currently targeting 10 families in the suburbs of Merivale, Gate Pā and Greerton.
Families are referred by social housing provider Accessible Properties and Te Runanga o Ngāi Te Rangi Iwi Trust's social workers go into those homes and work with whānau under the Whare Tapa Whā model of health – the four dimensions of Māori wellbeing including Taha tinana (physical health), Taha wairua (spiritual health), Taha whānau (family health) and Taha hinengaro (mental health).
"We look at everything," Te Runanga o Ngāi Te Rangi Iwi Trust manager of health and social services Trish Britton said.
That included training and education, and ensuring they are enrolled with a GP and attending health appointments.
"Our main health focus is kids' eyesight, respiratory conditions and dental, making sure teenagers are enrolled with a dentist," Britton said.
They also make use of the Ngāi Te Rangi/Western Bay of Plenty Primary Health Organisation's mobile health unit.
"We find the information, give it to them and follow up to make sure they've attended. We try to make them as independent as we can," Britton said.
The He Kokonga Ngākau social workers also tap into Budget Advisory Services to help whānau manage their budget, help them access drug and alcohol services, liaise with tenancy managers, and there are plans in future to help whānau access parenting courses.
"Quite often they are lacking food, heat and sometimes, furniture so we can help organise that too," Britton said.
One of the families He Kokonga Ngākau is working with is a solo parent who recently took custody of four children. The children hadn't been attending school and had missed hospital appointments.
"We got the children into local schools, organised school uniforms and sanitary packs for the girls, and generally ensured their physical and mental wellbeing was being taken care of," Britton said.
The children were now attending school on a regular basis and getting to their hospital appointments.
"I believe we've made a big impact already with the whānau that are engaging. We've built a rapport with them and I see people who now have pride in their home, and their children are healthy and well-kept," she said.
Britton said He Kokonga Ngākau was a motivation for change and engagement for these families and aims to build independence and resilience.
"We have people that really want to get ahead but don't know how to. For them we are a light at the end of the tunnel," she said.
WBOP PHO interim chief executive Phil Back said He Kokonga Ngākau was helping to improve access to primary healthcare for these families where and when they need it.
"We are constantly adapting to the varying needs of our communities and we are pleased to be including these families in that tailored approach," he said.