Editing Tupaia workflow

==Background==
Tupaia is the name for an expansion of the existing [https://www.tpk.govt.nz/en/nga-putea-me-nga-ratonga/whanau-ora Whanau ora] programme, provided through the [https://pasifikafutures.co.nz/ Pasifika Futures] (PFL) commissioning agency.

==Available pathways==
The following support pathways are available for Whanau ora clients:
* Long-term condition management in primary care
* Mental wellbeing support
* Oral health
* Optometry
* Support to screening
* Hearing.

==Key systems for data capture==
There are 3 systems for data capture:
# Tupaia families will usually already be on [[Penelope]], where case notes and assessment must be recorded. 
# Health/clinical interactions<ref>Apart from mental health/psychology.</ref> will be recorded in our [[Indici]] instance. We have full access to this data.
# All other data will be captured in [[Kotahi]].

==Enrolment and setup==
For eligible families, we need to formally allocate them to the Tupaia service. This helps us to count and manage families at any point in time.

Subsequently, each family member undergoes a structured needs assessment. This captures data specifically about each of the Tupaia pathways that are available, as well as some additional info to help support them.

An overview of key tasks needed at this stage is shown below.

{{#display_diagram:BPMN:Tupaia enrolment}}

==Needs assessment==
This is a structured set of questions, undertaken by the WO Navigator with family members, aiming to identify which specific needs they have which can be serviced under a Tupaia pathway.<ref>In the pilot this was done via MS Forms, where responses were coded and used in reporting. This is obviously handled much better in Kotahi.</ref>

Current version of the needs assessment implemented in Kotahi asks the following questions (note that question wording has been modified for brevity):

{| class="wikitable"
! Item || Description || Example
|-
| Assessment date || Timestamp of completed assessment || 
|-
| Client name ||  || 
|-
| Current GP || Presume this can be from NHI FHIR lookup || 
|-
| WO Case name || Manual entry from Penelope || 
|-
| Immigration status || Needed to determine eligibility for public health services || Resident/non-resident
|-
| Long-term conditions || Pick list of specific conditions || Diabetes/asthma
|-
| Children's vaccination status || If tamariki are up to date or not || 
|-
| Cervical screen status || For women 25-69 only || Overdue
|-
| Breast screen status || For women 45-69 only || Overdue
|-
| Bowel screen status || People 50-74 only || Overdue
|-
| Have you had eye check in last year? ||  || Y/N
|-
| Do you want a free eye check? ||  || Y/N
|-
| Have you had dental check in last year? ||  || Y/N
|-
| Do you want a free dental check? ||  || Y/N
|-
| Are you waiting for any surgery? ||  || Y/N
|-
| Do you need any help with transportation? ||  || Y/N
|-
| Have you experienced anything challenging recently? ||  || Y/N
|-
| Do you want a free MH appointment? ||  || Y/N
|}

At the end of this stage, we will have collected core information on the family in Kotahi (personal details, demographics, whanau relationships, NHI), as well as a summary of their needs. If any need requires follow-up then the individual is assigned (referred) to one or more of the Tupaia pathways.

The following sections provide detail on each of the pathways.

==Pathway detail==
===Long term conditions===
{{See also|BPMN:Tupaia LTC}}

{{Ambox
|nocat=true
| text  = <div>
Activated if:
* Client needs assessment shows any Long Term Condition, AND 
* Client accepts offer of free GP consultations (some prefer to stick with their own current GP).
</div>
}}

The workflow for this pathway is shown below.

<b>Legend</b>
* <span style="background-color: #4e914e">Green</span> = Kotahi
* <span style="background-color: #aeaeea">Blue</span> = Indici

{{#display_diagram:Mermaid:Tupaia LTC}}

===Mental health===
{{Ambox
|nocat=true
| text  = <div>
Activated if:
* Client needs assessment shows any issues indicative of mental health, AND
* Client accepts offer of free Psychologist consultations.
</div>
}}

The workflow for this pathway is shown below.

<b>Legend</b>
* <span style="background-color: #4e914e">Green</span> = Kotahi
* <span style="background-color: #aeaeea">Blue</span> = Indici

{{#display_diagram:Mermaid:Tupaia mental health}}

===Screening===
Clients are asked whether they are up to date with screening they are eligible for at the needs assessment stage. Please be aware that - in most cases - we can only refer on to Screening services where the client is eligible to receive publicly funded health services in New Zealand.

{{Ambox
|nocat=true
| text  = <div>
Activated if:
* Client needs assessment shows they are eligible for screening programme, AND 
* Client is not up to date with a screening type.
</div>
}}

====Cervical====
Eligibility guidelines are available at [https://www.tewhatuora.govt.nz/health-services-and-programmes/ncsp-hpv-screening/screening-eligibility-and-funding Te Whatu Ora].

Workflow for this pathway is shown below.

<b>Legend</b>
* <span style="background-color: #4e914e">Green</span> = Kotahi
* <span style="background-color: #aeaeea">Blue</span> = Indici

{{#display_diagram:Mermaid:Tupaia screening cervical}}

====Breast====
Eligibility guidelines are available at [https://www.tewhatuora.govt.nz/health-services-and-programmes/breastscreen-aotearoa Breastscreen Aotearoa].

Workflow for this pathway is shown below.

<b>Legend</b>
* <span style="background-color: #4e914e">Green</span> = Kotahi
* <span style="background-color: #aeaeea">Blue</span> = Indici

{{#display_diagram:Mermaid:Tupaia screening breast}}

====Bowel====
Eligibility guidelines are available at [https://www.tewhatuora.govt.nz/health-services-and-programmes/national-bowel-screening-programme/about National Bowel Screening programme].

Workflow for this pathway is shown below.

<b>Legend</b>
* <span style="background-color: #4e914e">Green</span> = Kotahi
* <span style="background-color: #aeaeea">Blue</span> = Indici

{{#display_diagram:Mermaid:Tupaia screening bowel}}

===Eye and hearing===
{{Ambox
|nocat=true
| text  = <div>
Activated if:
* Client needs assessment shows they have outstanding optometry/hearing needs, AND 
* Client consents to screening.
</div>
}}

Note that these are both functionally the same and, additionally, Specsavers perform both variants. Also note that the process generally is that Specsavers require prepayment - therefore it is the quote that is approved and paid, before the client goes to have the work done and we receive an invoice. The Kotahi workflow here mainly follows 

Workflow for this pathway is shown below.

<b>Legend</b>
* <span style="background-color: #4e914e">Green</span> = Kotahi
* <span style="background-color: #aeaeea">Blue</span> = Indici

{{#display_diagram:Mermaid:Tupaia eye hearing}}

===Dental===
{{Ambox
|nocat=true
| text  = <div>
Activated if:
* Client needs assessment shows they have outstanding dental needs, AND 
* Client consents to dental exam.
</div>
}}

Workflow for this pathway is shown below.

<b>Legend</b>
* <span style="background-color: #4e914e">Green</span> = Kotahi
* <span style="background-color: #aeaeea">Blue</span> = Other

{{#display_diagram:Mermaid:Tupaia dental}}

==References==

[[Category:Kotahi]]