KM integrated with each general practice (GP) clinic randomised to the Mana Tū intervention.

Hub clinical leadership team (CLT) provides to each practice randomised to the Mana Tū intervention a list of all of the people enrolled at that practice with confirmed eligibility for the trial.

Primary care clinician from the GP clinic contacts every person on the list to discuss the Mana Tū programme with them and to invite them to participate in the Mana Tū programme.

KM contacts potential participant and arranges first visit.

At first visit (in home or clinic or other site), KM engage with person±whānau, using the ‘hui process’ or similarly safe clinical engagement process.23

Informed consent for participation in Mana Tū is obtained.

KM undertakes the Mana Tū Assessment with participants (a formal assessment of clinical and wider determinants relevant to the self-management of type 2 diabetes mellitus (T2DM), online supplementary appendix).

KM meets with person±whānau to complete the Mana Tū Plan (a plan incorporating aspects of self-management designed for indigenous people with T2DM24 and life domains that impact on social determinants as identified in the Mana Tū Assessment) including:

• goal setting with the person±whānau for self-management of risk factors and long-term conditions (including T2DM).

• identification of patient±whānau circumstances that impact negatively on life domains (social determinants) and ‘walk alongside’ whanau to facilitate resolution of issues.

• identification of cross-sector organisations required to support person±whānau.

KM works with participants and whānau to achieve goals based on the Mana Tū Plan. KM will be integrating relevant services to provide appropriate care (eg, health literacy, smoking cessation) into the participant’s Mana Tū Plan.

KM will contact participants±whānau either in person or by phone when delivering the intervention and to provide information or feedback. Progress is recorded in the person’s Plan and the KM database which is shared with the person and their whānau.

KM will meet regularly with the primary care team at the GP clinic and cross-sector organisations to provide updates and, as required, seek their input.

KM has access to the Hub CLT for additional support as required.

Full review of participant (including attainment of goals) with primary care team at the GP clinic and Hub CLT.

At midpoint (6 months), a full meeting with participant and whānau to review progress and update plans.

From 9 months on, KM to start planning the participant’s discharge from Mana Tū.

Once discharge appropriate, KM completes discharge plan with person±whānau, general practice and relevant cross-sector organisations. Note this may occur at a time between 9 (minimum) and 12 (maximum) months from enrolment.

A final assessment (data collection) at 12 months.