With the silly season almost upon us, it’s timely to remember the useful tools of the trade that makes sharing and collaboration that bit easier for staff and patients over the festive season.  

The suite of electronic shared care plans – The Acute Plan, the Personalised Care Plan (PCP), and the Advance Care Plan – enables clinicians from different health services to collaborate and share important information that can improve patient care.

The plans, accessed via HealthOne or Health Connect South, empower patients to work with care teams to coordinate care around their needs and priorities.

Acute Plan

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.

Personalised Care Plan

The Personalised Care 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.

Advance Care Plan

The Advance 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.

Rebecca Muir, Collaborative Care Liaison, says that these plans can be particularly helpful to clinical staff over holiday periods because they contain up-to-date information about clinically-agreed actions around that patient’s care.

“The plans have a host of information from clinicians about what the patient really needs.  As well as benefitting the clinicians, patients who have a plan have told us they improve access to the care they need from the right people at the right time.

“These plans are an extension of a trend towards a more integrated approach to health care.”

What the patients say

Katherine, Acute Plan

“Creating the plan has been a really inclusive process – I’ve been able to contribute along the way. If I encounter someone who doesn’t know me I can ask them to look at my plan without having to repeat my history again and again. My experience of accessing care has also improved, and I’m getting to the right place faster than ever, which has been invaluable.”

Steve, Acute Plan

“If the doctor or nurse can’t find a plan, I can tell them exactly where it is. The details that are relevant to them should miraculously appear. Since it was developed, I’ve spent less time in ED waiting and the process for direct admission has improved significantly. As a result, I suffer less.”

Find out more

For more information about the plans, including frequently asked questions, visit the Collaborative Care pages on the CCN website. If you have any other questions or comments, email Rebecca Muir, Collaborative Care Liaison at rebecca.muir@ccn.health.nz