Child Health  |  Referrals - Healthy Housing

Child Health

Referrals - Healthy Housing

BOP Extended Healthy Homes Initiative
Whare Kaitiaki


Referrers Information Pack for Extended Programme 2016-2020         

Overview of the service

The extension to the Healthy Homes Initiative (HHI) is a new service starting on 1 October 2016 and operating across the entire Bay of Plenty Health Board District. The focus is on improving housing conditions and therefore, helping to prevent respiratory and other infectious conditions, and acute rheumatic fever. Family/whanau living in inadequate housing with children from the ages of 0-4 years old i.e. < 5years old, will be eligible for home assessments and a range of possible interventions;

  • home placement (relocation to more suitable housing)
  • insulation,
  • heating and/or other solutions to help make the home warmer, drier and healthier
  • connection to other support services to reduce the negative impact of inadequate housing (agreed with the family/whanau).

The Bay of Plenty District Health Board (BOPDHB) is contracted by the Ministry of Health to deliver and oversee the service in the Bay of Plenty. To achieve the best outcomes for homes with overcrowding concerns, the BOPDHB has contracted the expertise of Tauranga Community Housing Trust (TCHT) and Sustainability Options (SO) to deliver the services across the region. 


  • Reduce acute rheumatic fever in children
  • Reduce hospital admissions from infectious respiratory and skin conditions
  • Improved family health
  • Assist in reducing power bills
  • Improve warmth and comfort in the home
  • Reducing days off pre-school, school or work
  • Improve home appropriateness to family needs


About SO and TCHT

Sustainable Options (SO) is a charitable business with a focus on improving housing conditions for the most vulnerable and at risk, seeking to relieve fuel poverty and increase positive health outcomes. SO have extensive background in assisting families with concerns and solutions around; better heating, insulation, ventilation, saving on power costs, and tackling the cold and damp.

TCHT is a registered social housing provider and charitable Trust that provides housing and housing related services.  TCHT works with people on low incomes who have a serious unmet housing need.  TCHT background is in working with disabled single people and families/whanau with a household member with a disability.  TCHT clients include people with physical, intellectual and sensory disability as well as people whose disability is age, accident or mental health related.  In August 2009 the Trust broadened the criteria to include others in the community who could not access decent, affordable housing with the priority being households on low incomes.


With family/whanau consent, referrers (health service) gather information in regards to family/whanau health and housing concerns. The completed referral forms are signed by the family/whanau and the referrer. All referral forms are to be emailed to the Healthy Homes Administrator (contact details bottom of referral form).

Once the referral is received, the details will be checked, and the Healthy Homes Administrator may contact the referrer or the family/whanau to ensure all relevant details are correct and the form has been signed.

All family/whanau who meet HHI eligibility criteria can expect a phone call from a Housing Needs Assessor to arrange a time for Housing Assessment to be completed. The family/whanau and Assessor will consider the whole home, and identify the pressing issues and housing requirements. Together, the family/whanau and Assessor will develop a Housing Intervention Plan outlining the agreed interventions and/or actions required.

Housing Needs Assessment focuses on;

  • Insulation
  • Heating
  • Crowding
  • Dampness
  • Bedding
  • Floor covering
  • Work with family/whanau to improve health outcomes and reduce hospitalisation
  • Develop housing solutions with family/whanau


The Housing Needs Assessor will work with other community organisations and co-ordinate home improvement such as;

  • improve home heating,
  • insulation,
  • curtains,
  • ventilation,
  • bedding/beds,
  • floor coverings or
  • Refer to other housing providers if alternative accommodation is required.


Services will be delivered in a manner that is:

  • Suitably responsive and flexible,
  • Family/whanau centered and driven,
  • Strengths focused, and
  • Responsive and evidence-based.


Information Sheet for referrers

Healthy Homes Initiative - Eligibility criteria


Identification and referral criteria

Families eligible to receive support from the Services will be eligible on the basis of the following:

  1. The family lives in the DHB catchment area.
  2. One member of the household is a New Zealand citizen or permanent resident.
  3. The family has low income – defined by the financial limits for the eligibility for a Community Services Card:
  4. Yearly income (before tax) is less than (as at 1 April 2016):

Family of 2


Family of 3


Family of 4


Family of 5


Family of 6


For families of more than six, the limit goes up another $7,898 for each extra person.

5. One child aged 0-4 years in the household.

The Healthy Homes Initiative determines how eligibility will be assessed and what verification is required in collaboration with the Services governance/advisory group. The identification and referral stage will include collecting information from the family/whanau to confirm eligibility, an invitation to be part of the Services, and obtaining consent.

In the initial stage of the Services, there will be three points of referrals, they are as follows:

1)   Referrals from the hospitals

  • Have at least one child up to 4 years of age, i.e. not yet reached their 5th birthday
  • Are on low income (see above)
  • One of the children, aged between 0-5 whilst living in that house, has been hospitalised overnight (acute or arranged overnight admission) at the hospital with one of the following indicator conditions:
    • Acute Rheumatic Fever, or
    • Infectious lower respiratory tract conditions (including bronchiolitis, pneumonia, other lower respiratory tract conditions, such as bronchiectasis), or
    • Meningitis.

There are specific ICD codes that match the indicator conditions above (as set out in Appendix 2 below) – these are the codes that will be used to qualify for referral to the Services. Overnight hospitalisations include acute and arranged admissions. Non-residents and transfers (i.e., from outside of the DHB catchment area) are not eligible for referral to the Services.

Appendix 2


1.Respiratory tract infections

ICD codes



Acute bronchiolitis


Unspecified LRTI + Bronchitis

J20, J22




ICD codes

Meningococcal disease


Bacterial meningitis (including pneumococcal, streptococcal, other)


Viral meningitis


Meningitis unspecified


3.Invasive and post streptococcal diseases (GAS)

ICD codes

Rheumatic fever

I00, I01, I02

Acute nephritic syndrome

N00, N05

Septicaemia from group A streptococcus



2)   Referrals for at risk mothers and new borns. These referrals may be from:

  • maternity services;
  • well child and tamariki ora providers delivering a service to 0-4 year olds;
  • post-natal mental health services;
  • Eastern BOP Children’s team;
  • Whanau Ora providers;
  • child development services;
  • paediatricians, paediatric nurses and paediatric social workers in children’s wards at Tauranga, Whakatane and Opotiki Hospitals;
  • other providers invited to make referrals


3)   Referrals for at risk 0-4 year olds in families for whom at least two of the following risk factors apply:

  • CYP finding of abuse and neglect;
  • Caregiver with a Corrections history;
  • Mother has no formal qualifications; and
  • Long term benefit receipt.


All referrals and referral queries are to be directed to;

BOP Healthy Homes Administrator
Phone: 07 571 5390
Please scan and email referral to:

Last updated : Thursday, July 12, 2018
Next review date : Friday, July 12,2019

Disclaimer: This site is intended to be flexible and frequently updated. While every effort has been made to ensure accuracy, all information should be verified.