Table 2:

Current process map for reliability and sustainability.

System	Site	Responsibility	Frequency	Comments
Triage and identification of patients needing home care	HBCHRC	D, N, MSW	Daily	Triage and identification: D Data Documentation: N/MSW
Communication to the CBO	HBCHRC&CBO	N/MSW at HBCHRC N and Designated Volunteer at CBO	Daily	Information exchange through WA
Planning and coordination of the visit	CBO	N and designated volunteer at CBO	Completed within a week of receipt of information	Geographical mapping Creation of a unique patient ID Home visit plan drawn for the week and visit completed by the team
Feedback after completion and documentation	CBO	N and D at CBO N and D at HBCHRC	On completion of the visits	Communicated by the D/N at CBO to the D/N at HBCHRC and documentation is completed by the N/MSW
Special circumstances: In case, the visit is urgent, this information is communicated by the doctor, process is fast tracked and visit is prioritised Daily/weekly exchange of information and reviews by the team are held through WA groups and in person The Google Sheets with the UID and information is accessible to the D/N/MSW at the CBO and HBCHRC to enable continuity of documentation at follow-ups and monitoring the process regular up gradation and communication is on-going between the CBO and HBCHRC

N: Nurse, D: Doctor, MSW: Medical social worker