X
A A A
GO

AManaaki mahi tahi

  • About
  • Acute Plan
  • Personalised Care Plan
  • Latest News

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
10Apr

All you need to know about Personalised Care Plans

10 Apr, 2019 | Return|

Electronic shared care plans are ‘living documents’ which give multiple professionals across different services consistent and coordinated access to their patient’s documented healthcare plans.

The suite of shared care plans includes the Advance Care Plan, the Acute Plan and the newest plan – the Personalised Care Plan (PCP), all hosted in Health Connect South.

The PCP is a patient-centered plan which documents patient concerns, what they want to achieve with regard to their health or general wellbeing, and actions the patient and their care team are going to take to achieve these goals. The aim is to facilitate a collaborative partnership between the patient and their care teams; to coordinate rehabilitation around their needs and priorities, and to make the goals and activities visible to other clinical teams.

The long-term aim is to reduce duplication of information, release clinical care time and provide a seamless transfer of consistent information with a single point of access.

The PCP can be accessed via Health Connect South under the ‘Care Plans’ tab and can be created or updated by the clinician actively involved.

PCPscreengrab

More than 1,500 people in Canterbury now have a PCP from the Community Rehabilitation Enablement and Support Team (CREST), General Practice, and Allied Health including Burwood Allied Health teams and Allied Health within the acute services who have been using it for discharges to CREST and transfers of care to Burwood. Over the coming months the plan will be rolled out across other services and teams.

For more information please visit health or hospital pathways or contact: Rebecca.Muir@ccn.health.nz or Rowena.woolgar@cdhb.health 

About the Author

Related

Acute Plan Info Sheet for Clinicians

Acute Plan Info Sheet for Clinicians

The Collaborative Care team has released an updated Acute Plan information sheet for clinicians.

Read More >
Communicating patient preferences and key medical decisions

Communicating patient preferences and key medical decisions

With COVID-19 at the forefront of everyone’s minds, we’ve been exploring ways to increase the visi...

Read More >
Reducing stress in times of need with Shared Care Planning

Reducing stress in times of need with Shared Care Planning

When you’re not well it can be stressful and communicating is not always easy, which can sometimes ...

Read More >
COVID-19 update from South Island Alliance - Capturing patient preferences and key medical information

COVID-19 update from South Island Alliance - Capturing patient preferences and key medical information

During the COVID-19 response, Acute Plans (on Health Connect South/ HealthOne) are the digital solut...

Read More >
Canterbury’s use of Acute Plans during covid-19 highlighted at hui

Canterbury’s use of Acute Plans during covid-19 highlighted at hui

Canterbury Clinical Network Senior Project Facilitator Rebecca Muir presented at the Ō tātou hiran...

Read More >
Sharing the benefits of Shared Care Plans

Sharing the benefits of Shared Care Plans

Pasifika elders and health and wellbeing services participated in a Pasifika Matua Fono (elder's...

Read More >
Useful resources

Shared Care Plans brochure

Making a plan for your health and wellbeing. 

Shared Care benefits

Sharing the benefits of Shared Care Plans with Pasifika Matua.

Acute Plan information

Information sheet for Clinicians about Acute Plans.

Acute Plan tips and tricks

Acute plan information, including tips and tricks.

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.