Collaborative Care

About

Working in partnership with the patient, Collaborative Care describes a way of working which involves community, primary and secondary health services working together to proactively manage and plan for complex needs. Coordinating input into a single proactive shared care plan allows for improved communications and real time information. The shared care plans are accessed through HealthOne and Health Connect South.

To promote and encourage collaborative care in Canterbury, the Collaborative Care team’s current activities include facilitation of collaboration, sharing of lessons learnt across general practice, facilitating collaboration across secondary, primary and community services, education, training and encouraging the use of Acute Plans and Personalised Care Plans.

Latest News

Newest shared care plan gets personal

The newest in the suite of electronic shared care plans, the Personalised Care Plan (PCP), goes live early next year.

The plan, which is accessed via HealthOne or Health Connect South, documents patients’ needs and goals to achieve better daily health in spite of chronic conditions. The aim is to empower patients to work with care teams to coordinate care around their needs and priorities.

The plan includes an overarching statement of what matters most to the patient. Under this sits 14 life areas such as food/drink/healthy weight or legal/ financial.  Within each of these life areas, clinical teams can document current Issues for the patient, agreed Goals to work towards and the Actions taken by either the care team or the patient themselves which underpin the goals.

The Personalised Care Plan is the next step towards achieving our long-term vision of putting the patient at the centre of everything we do and empowering clinicians to understand what the patient really needs from them.

 

Other shared care plans

The plan is the newest addition to a suite of electronic shared care plans, including the Acute Plan and the Advance Care Plan, which are an extension of a trend towards a more integrated approach to health care.

The Acute Plan provides information to health providers unfamiliar with a patient who may present with exacerbations of their underlying complex health conditions. The patient consents to the sharing of this information and may be involved in writing the plan. This allows the sharing of information that supports safe, effective, patient-centred decision making with regard to assessment, management and discharge.

The Advanced Care Plan outlines a patient’s wishes about the type of medical care and treatment they want to receive in the future, particularly towards the end of life or when they are not able to make their own decisions.

The shared care plans enable clinicians from different health services to collaborate and share important information which can improve patient care.

Read more information about the plan here, including frequently asked questions and a quick reference guide. If you have any other questions or comments, email a member of the Collaborative Care Team via rebecca.muir@ccn.health.nz or Donna.hahn@ccn.health.nz

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Documents

Brochure for Patients
Brochure for Clinicians
Acute Plan Demo Videos
  • KEY CONTACTS

Donna Hahn

E:  donna.hahn@ccn.health.nz

Rebecca Muir

E:  rebecca.muir@ccn.health.nz