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  • Acute Plan
  • Personalised Care Plan
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The Shared Care Planning team transitioned to Pegasus Health in February 2023.

Shared Care Planning describes a way of working which involves community, primary and secondary health services working together to proactively manage and plan care with patients who have complex needs.

Shared care plans enable coordination and improved communication between primary, secondary and community health services and real time information sharing. The shared care plans are accessed through HealthOne and Health Connect South and include the Acute Plan and the Personalised Care Plan.

The Shared Care Planning work focuses on design, implementation and education about shared care plans to encourage the use and integration of the Acute Plan and the Personalised Care Plan throughout the South Island.

The acute plan:

  • is a patient-centred plan which documents the:
    • patient’s underlying complex health conditions, and
    • management of exacerbations of underlying complex health conditions for health providers unfamiliar with the patient.
  • is for patients with moderate to high risk of attending acute services over the next 12 months.
  • aims to support rapid, safe management of patients with complex health conditions, and those who are at moderate to high risk of attending acute services over the next 12 months.

The information is intended to support decision making, regarding the need for admission, investigations, and appropriate setting for acute care.

Contributors may complete only the parts of the plan that they are familiar with, and request colleagues to complete it. The completed plan is shared electronically across the Canterbury health system.

View some demo videos on how to create, edit and print acute plans. 

The Personalised Care Plan:

  • aims 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.
  • is a patient-centred plan which documents:
    • problems the patient currently experiences
    • what they want to achieve with regard to their health or general well-being, and
    • actions the patient and their care team are going to take to achieve these goals.
  • is for patients who have moderate to high complexity health needs, including:
    • frailty
    • 1 or more chronic conditions
    • complex social and medical needs
    • palliative care
    • long-term significant disability.
  • can be created or updated by any clinician.

Plans can focus on a small subset of the patient’s health care or be created across a range of different conditions.

The completed plan is shared electronically across the Canterbury health system.

View some Personalised Care Plans demo videos

Latest News
15Nov

Newest shared care plan gets personal

15 Nov, 2017 | Return|

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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Useful resources

Shared Care Plans brochure

Making a plan for your health and wellbeing. 

VIDEO: using shared care plans

A webinar which walks through the plan and demonstrates how to use them.

PCP tips and tricks

Personalised Care Plan information, including tips and tricks. 

Acute Plan tips and tricks

Acute plan information, including tips and tricks.

Shared Care benefits

Sharing the benefits of Shared Care Plans with Pasifika Matua.

Shared Care Plans

Frequently asked questions about Shared Care Plans.

Identifying vulnerable patients

A guide to help identify patients who may benefit from a shared care plan.