Whānau Ora Kaiarahi Guide
Applies to: Version 6.23 and later
Last updated: 20 July 2021
Engage
The following explains how to use the system during the Engage and Assess phases.
I've received a new referral
Go to Whanau Ora > Referrals - Incoming Referrals
Overview: Complete the Enrolment
- Open the Referral from the list (or from your email link)
- Click on the "Enrolment Activities" tab
- Your goal is complete ALL the YELLOW activities. Turn them into GREEN by completing each activity. This is explained in more detail in the sections below.
- When you have completed the activities, you can Enrol the client. Press the ENROL button at the top of the referral. This is explained in more detail in the sections below.
Tip
You will need to complete the following enrolment activities
- Consent
- Whakawhanaungatanga
- Baseline Whānau Situation
The client has consented to receive the service
Do the following on the Referral Enrolment Activities tab
Record Consent
- Open the Consent activity
- Attach documents (if any)
- Press SAVE
- Press COMPLETE
What if they didn't consent?
Close the Referral
- Click on the "Enrolment Activities" tab
- Add a new Case Note to explain why they are not continuing
- Complete the case note to explain why they didn't consent and what advise (if any) you gave.
- Press SAVE
- Press COMPLETE
- Click CHANGE STATUS (at the top menu)
- Select "Client Declined" and CONFIRM
Note
When you do this the referral will be closed and it will disappear from your active referrals list. No plan will be created.
I've completed Whakawhanaungatanga
Complete Whakawhanaungatanga
- Open the Whakawhanaungatanga activity
- Write up any applicable case notes in the "Case Notes" box
- Attach the Moemoea document
- Press SAVE
- Press COMPLETE
Complete the Baseline Whanau Situation
- Open the Baseline Whānau Situation Activity
- Click on the "General Tab"
- Fill out the form
- Press SAVE
- Press COMPLETE
Note
When you write your case notes, you don't need to double up explaining the whanau situation. You'll do that in the next step.
I've completed the enrolment activities and am ready to Enrol my client and create a Plan
Enrol the Client in the Whānau Ora service and create a plan
GO to Whānau Ora > Referrals – Incoming Referrals
- Open the referral
- Press the ENROL button at the top of the referral.
- A yellow bar appears at the top to say the enrolment is being processed. Please wait for the yellow bar to go away before doing anything else. This might take a minute.
Important
When you Enrol a client, a new plan will be created (or, if they already have an active plan, Whānau Ora will be added to their plan) When you press the ENROL button, be patient. It can take a few moments to complete the enrolment process. Don't close your browser until the enrolment is completed. If you didn't complete all the yellow enrolment activities, then you'll see a message here reminding you that you have do that first.
Supporting Whānau
Now that the client is enrolled, a whānau plan exists, the following shows how you work with the Plan during the Plan, Support, Review, and Evaluation phases.
I have some outcomes (high level goals) to be added to the plan
Add outcomes to the plan
Go to Whānau Ora > Whānau Ora - Plans
Add an outcome to the plan
- Open the plan
- Click the Whānau Ora service yellow dot. Make sure the dot gets bigger (that's how you know it's selected)
- Click the CREATE OUTCOME button at the top of the activity grid. A new outcome from will open.
- In the Outcome box, type the name of the outcome in the words of the whānau (as expressed in their moemoea).
- In the Predefined Outcome box, enter * and your search word, e.g "*house". Choose the appropriate outcome.
- In the Referral box, click the magnifying glass and choose the correct Whānau Ora referral to link this outcome to.
- In the Outcome Indicator box, type the agreed indicator for outcome success.
- Optional: Add more details in the Detailed Description box
- Press SAVE & CLOSE
Repeat this for each outcome in their moemoea/plan
Select the pre-defined outcome that most closely matches the outcome the whānau want. Use the Outcomes Menu as a reference.
Tip
Become familiar with the Outcomes Menu to make it easier to choose the right one.
Next steps
After you've created a new outcome, you should add
- One milestone goal
- Optional: Additional non-milestone goals
- Optional: Resources
- Optional: Outgoing Referrals
I want to add a goal to an outcome that I created
Go to Whānau Ora > Whānau Ora: Plans
Add a goal
- Open the Plan you want
- Click on the Outcome that the goal is for (dark blue dot). Make sure the dot gets bigger.
- On the activity grid, select the Goal activity type
- Press CREATE ACTIVITY. The goal activity form will open.
- In the Summary box, type a brief one-line summary of the goal.
- In the Due Date box, choose the date that the goal should be completed by.
- Optional: Provide more details in the Goal Description, Objective, and Intervention boxes.
- In Milestone Goal choose YES if this is the milestone goal for this Outcome, or NO if not.
- Press SAVE & CLOSE
Tip
Remember that you can only have ONE milestone goal per outcome. This is the goal that represents the 50% mark (or close to it) of achieving the Outcome. You can have as many non-milestone goals as you like. Later you can return to this Goal and update the "Goal Achieved" to Yes or No, then press COMPLETE to finish the goal.
I'm connecting my client to a service
Connection to services is done using an Outgoing Referral.
Go to: Whānau Ora > Whānau Ora: Plans
Add an outgoing referral
- Open the Plan you want.
- Click on the Outcome that the referral relates to (dark blue dot). Make sure the dot gets bigger.
- On the activity grid, select the Referral activity.
- Press CREATE ACTIVITY. The Outgoing Referral form will open.
- In the Summary box, type a brief one-line summary explaining the referral.
- Check the Key Service box if this is a connection to Key Service.
- In the Comments box, provide any other information that might help the person handling this referral.
- Check the Internal Referral box.
- In the Referral To box, select the service that you are referring the client to.
- Press SAVE
- Press COMPLETE
There should only be ONE key service per outcome. If you later add additional referrals to the same Outcome don't check the key service box on those other referrals.
I've providing a resource to my client
Go to Whānau Ora > Whānau Ora: Plans
Add a resource
- Open the Plan you want.
- Click on the Outcome that the referral relates to (dark blue dot). Make sure the dot gets bigger.
- On the activity grid, select the Resource activity.
- Press CREATE ACTIVITY. The Resource form will open.
- In the Summary box, type a brief one-line summary explaining the resource.
- Check the Key Resource box if this is a Key Resource.
- In the Comments box, provide any other information that might help the person handling this referral.
- Check the Internal Referral box.
- In the Referral To box, select the service that you are referring the client to.
- Press SAVE
- Press COMPLETE
There should only be ONE key resource per outcome. If you later add additional resources to the same Outcome don't check the key resource box on those other resources. |
I've had a contact with Client
Go to Whanau Ora > Whanau Ora: Plans
Add a case note
- Open the Plan you want
- Click on the Outcome your case note relates to. If the case note relates to multiple outcomes or no outcome in particular, you can click the Whanau Ora service (yellow) dot. Whichever dot you click, make sure it gets bigger.
- On the activity grid, select the Case Note activity type
- Press CREATE ACTVITY. The case not form will open.
- In the Summary box, type a brief description of your case note.
- In the Case Note box, type the full text of your case note.
- Press SAVE
- Press COMPLETE
- On the plan, you can press Refresh on the activity grid see your case note activity.
I've completed a 90-day follow-up review
Go to Whānau Ora > Whānau Ora: Plans
Complete the 90-day follow-up review
- Click on the Whānau Ora service yellow dot.
- Locate the Whānau Situation 90-day Review activity. Press the OPEN button. The Whānau Situation form will open.
- Click the GENERAL tab.
- Complete the form.
- Press SAVE
- Press COMPLETE
Schedule the next 90-day review
- The yellow Whānau Ora service dot should still be selected.
- On the activity grid, select the Assessment activity type.
- Press CREATE ACTIVITY. The assessment activity form will open.
- In the Summary box, provide a summary of the review. E.g., "October 2021 90-Day Review"
- In the Assessment Start Date , choose the future date (90 days from now) that the review should happen on.
- In the Due Date , choose a future date two weeks after the assessment start date that you just selected.
- In Assessment Tool select WOCA Whānau Situation
- In Assessment Type select Follow-Up
- Press SAVE & CLOSE
Note
The very first 90-day review gets created for you by the system during the enrolment process. After that, you create additional 90-day review activities as outlined in step 7-15. Don't do these steps if you are sure that the client will be discharged before the next 90 days are up.
I want to discharge a Client from the Whānau Ora service
Discharge a client when there is an agreement to exit the service, or if there is some other reasons – e.g. lost contact, they have moved out, they've decided not to continue, etc.
Go to Whānau Ora > Whanau Ora: Plans
Complete case notes and goals
- Check if there are any outstanding activities that have not been completed. (i.e., they are not green).
- Open and Complete each of those activities
- Pay special attention to any outstanding goal activities: open them and mark if the goal has been achieved or not before completing it.
Complete an Evaluation Survey
- Select the yellow Whānau Ora service dot. Make sure it gets bigger.
- On the activity grid, select the Assessment activity type.
- Press CREATE ACTIVITY. The assessment activity form will open.
- In the Summary box, type "Exit Evaluation"
- In Assessment Tool select WOCA Whānau Survey
- In Assessment Type select Evaluation
- Press SAVE
- Press CLICK HERE TO OPEN ASSESSMENT TOOL
- Click the General Tab
- Complete the suvery form
- Press SAVE
- Press COMPLETE
Add an Exit activity
- Click on the Whānau Ora service yellow dot.
- On the activity grid, select the Exit activity type.
- Press CREATE ACTIVITY. The exit activity form will open.
- In the Summary box, provide a summary explaining the discharge.
- Choose the appropriate Exit Reason. This is usually Normal Exit.
- In the Note box, type any additional details to describe the discharge.
- Press SAVE
- Review the Outcomes that appear. Change the Achieved setting for each achieved outcome to YES.
Important
Don't skip this step
- Attach documents if any.
- Press COMPLETE
See also the Outcomes Menu