Clinical Services

Disease State Management (DSM)

The Disease State Management (DSM) Service is part of the wrap-around services at Te Puna Hauora for adults aged 18 and over, with Type 2 Diabetes, Asthma or Heart conditions. Beginning with a holistic assessment with the DSM nurse, you will learn about the disease affecting your health and work together to develop a plan of care “My Health Plan” to best suit your needs.

The DSM nurse will provide the information and support to enable you to make informed decisions about your health care plan “My Health Plan”, with an end goal of successful self-management. Appointments with the DSM nurse can take place either onsite at either clinic or in your home.

Everyone registered with the service is required to have quarterly GP visits and laboratory blood tests for medication reviews and repeat prescriptions. 


  • An explanation of the condition, its symptoms and possible complications.
  • Education and advice about the use of glucometers, the use of oral hypoglycaemic drugs, initiating and monitoring medication and insulin
  • Basic foot and visual acuity checks.

Asthma and Chronic Obstructive Pulmonary Disease COPD

  • Education about asthma and Chronic Obstructive Pulmonary Disease COPD
  • Peak flow meter and spirometry testing
  • Education about medication and administration of preventers and relievers
  • Personalised Asthma Action Plan “My Health Plan”

Cardiovascular Disease Risk and management

  • Education about the specific heart condition affecting you
  • Personalised management plan “My Health Plan”
  • Review of blood test results and medication, including possible side effects

Referrals to Internal Wrap-around Services

  • Dietitian
  • Healthy Lifestyles exercise programme
  • Community Support Services including Adult Mental Health
  • Podiatry Service
  • Green Prescription

Referrals to External Services

  • Diabetes Outpatients Specialist team
  • Retinal Screening