Tupaia workflow

Background

Tupaia is the name for an expansion of the existing Whanau ora programme, provided through the 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:

1. Tupaia families will usually already be on Penelope, where case notes and assessment must be recorded.
2. Health/clinical interactions will be recorded in our Indici instance. We have full access to this data.
3. 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.

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.

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

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

The workflow for this pathway is shown below.

Legend

• Green = Kotahi
• Blue = Indici

flowchart TB subgraph C0[<b>Health Clinic] direction TB C1[Indici enrolment]-.-> C2[Book appts]-.-> C3[SMS reminder] end subgraph WN0[<b>WO Navigator] WN1[Needs assessment]:::kotahi end subgraph GP0[<b>Clinician] direction TB GP4[Manage patient]-.-> GP1[Record consults/obs]-.-> GP2[MDT meetings]-.-> GP3[Exit from pathway] end WN1--Task notification-->C1 C2-.Coordinate if transport/<br>translation needed .-WN0 GP3-. Summarise for casenote .->WN0 WN0-. Check abnormal <br>bloods .->GP1 C0-->GP4 classDef kotahi fill:#99cc99

Mental health

The workflow for this pathway is shown below.

Legend

• Green = Kotahi
• Blue = Indici

flowchart TB subgraph WN0[<b>WO Navigator] WN1[Needs assessment]:::kotahi-.-> WN2[MH referral task]:::kotahi-.-> WN3[Schedule Psychologist<br>appt]:::kotahi end subgraph GP0[<b>Psychologist] direction TB GP4[Work with patient]:::kotahi-.-> GP1[Record consults]:::kotahi-.-> GP3[Exit from pathway]:::kotahi end WN3-->GP0 classDef kotahi fill:#99cc99

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.

Cervical

Eligibility guidelines are available at Te Whatu Ora.

Workflow for this pathway is shown below.

Legend

• Green = Kotahi
• Blue = Indici

flowchart TB subgraph C0[<b>Health clinic] direction TB C1[Indici enrolment]-.-> C2[Book appts]-.-> C3[SMS reminder] end subgraph WN0[<b>WO Navigator] WN1[Needs assessment]:::kotahi end subgraph GP0[<b>Nurse] direction TB GP4[Complete screen]-.-> GP1[Record outcome]-.-> GP3[Exit from pathway] end WN1--Task notification-->C1 C2-.Coordinate if transport/<br>translation needed .-WN0 GP3-. Summarise for casenote .->WN0 C0-->GP4 classDef kotahi fill:#99cc99

Breast

Eligibility guidelines are available at Breastscreen Aotearoa.

Workflow for this pathway is shown below.

Legend

• Green = Kotahi
• Blue = Indici

flowchart TB subgraph C0[<b>Health clinic] direction TB C1[Indici enrolment]-.-> C2[BSM referral] end subgraph WN0[<b>WO Navigator] WN1[Needs assessment]:::kotahi end subgraph GP0[<b>Health Navigator] direction TB GP4[Support client to <br>screening]-.-> GP1[Record outcome]-.-> GP3[Exit from pathway] end WN1--Task notification-->C0 GP3-. Summarise for casenote .->WN0 C0-->GP4 classDef kotahi fill:#99cc99

Bowel

Eligibility guidelines are available at National Bowel Screening programme.

Workflow for this pathway is shown below.

Legend

• Green = Kotahi
• Blue = Indici

flowchart TB subgraph C0[<b>Health clinic] direction TB C1[Indici enrolment]-.-> C2[Bowel screen<br>registration] end subgraph WN0[<b>WO Navigator] WN1[Needs assessment]:::kotahi end subgraph GP0[<b>Health Navigator] direction TB GP4[Support client to <br>screening]-.-> GP1[Record outcome]-.-> GP3[Exit from pathway] end WN1--Task notification-->C0 GP3-. Summarise for casenote .->WN0 C0-->GP4 classDef kotahi fill:#99cc99

Eye and hearing

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.

Legend

• Green = Kotahi
• Blue = Indici

flowchart TB subgraph C0[<b>Health clinic] direction TB C1[Indici enrolment]-.-> C2[Book screening appt]-.-> C3[SMS reminder] end subgraph WN0[<b>WO Navigator] WN1[Needs assessment]:::kotahi WN2[Monitor progress]:::kotahi-.-> WN3[Update spend]:::kotahi GP3[Exit from pathway]:::kotahi end subgraph GP0[<b>Clinician] direction TB GP4[Complete screening]-.-> GP5[Email outcome<br>notification]:::none end subgraph WA0[<b>WO Admin] direction TB WA1[Book Specsaver<br>appt]:::kotahi-.-> WA2[Record quote detail]:::kotahi end subgraph TL0[<b>WO Team Lead] direction TB TL1[Triage quote]:::kotahi-.- TL2[GM Approval]:::kotahi end WN1--Task notification-->C1 C2-.Coordinate if transport/<br>translation needed .-WN1 C0-->GP4 GP5-. PASS .->GP3 GP5-. FAIL .->WA0 WA2-->TL0 TL2-->WN2 WN3-.->GP3 classDef kotahi fill:#99cc99 classDef none fill:#ffffff

Dental

Workflow for this pathway is shown below.

Legend

• Green = Kotahi
• Blue = Other

flowchart TB subgraph WA0[<b>WO Admin/Navigator] direction TB WA3[Refer to dental clinic]:::kotahi-.-> WA1[Book appt]:::kotahi WA2[Record quote detail]:::kotahi WA5[Book treatment]:::kotahi WA4[Update spend]:::kotahi end subgraph TL0[<b>GM] direction TB TL1[Triage quote]:::kotahi-.-> TL2[GM Approval]:::kotahi TL3[Review spend]:::kotahi end subgraph F0[<b>Finance] direction TB F1[Pick up invoice detail]-.-> F2[Payment] end subgraph D0[<b>Dental clinic] direction TB D1[Initial exam]-.-> D2[Return quote] D3[Treatment]-.-> D4[Invoice] end WA2-->TL1 TL2-->WA5 WA1--SMS reminder-->D0 D2-->WA2 WA5--SMS reminder-->D3 D4--Approved treatment-->WA4 WA4-->F0 D4--Unapproved treatment-->TL3 D3-.Multiple visits.->WA5 TL3-.->WA4 classDef kotahi fill:#99cc99