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

The Personalised Care Plan is now live

The newest in the suite of electronic shared care plans, the Personalised Care Plan (PCP), went live on 14 February.

The plan, which is accessed via HealthOne or Health Connect South, documents patients’ needs and goals to achieve better daily health with complex health conditions. The aim is to support patients to work with care teams to coordinate care around their needs and priorities and to make the goals and activities visible to other clinical teams.

The plan includes an overarching statement of what matters most to the patient. Under this sit 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.

For more information about the plan, including frequently asked questions and a quick guide to creating/ adding to a PCP, visit the Collaborative Care pages on the CCN website. A step-by-step guide is also available on HealthPathways. 

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