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.

It 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.

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 enable 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 complex or specific health needs. The patient consents to the sharing of this information and may be involved in writing the plan. This allows safe, effective, patient-centred decision making with regard to assessment, management and transfer of care.

The Advance Care Plan outlines a patient’s wishes about the level and setting of 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.

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

Example:56-year-old Bridget has social anxiety and inflammatory arthritis. Using the PCP, the care teams can work with Bridget to establish how they can support her to achieve her health goals.

What matters most to the patient at the moment?

To feel confident enough to go to the mall with her daughter

Goals (supporting goals)

1. Emotional wellbeing/ mental health (life area)

Issues: social phobia, self-conscious of teeth

Goal: to be able to go out comfortably

2. Managing medicine and other therapy (life area)

Issues: Forgets to take medications

Goal: Take meds as prescribed at least 80% of the time

Actions (needed to achieve goals)

1. Emotional wellbeing/ mental health

Follow up with the oral health department

Referral Anxiety Disorders Unit

2. Managing medicine and other therapy

Pharmacy to blister pack medicines