Communicating patient preferences and key medical decisions

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Acute 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.

Communicating patient preferences and key medical decisions

02 Apr, 2020 | Return|

With COVID-19 at the forefront of everyone’s minds, we’ve been exploring ways to increase the visibility of key medical decisions and important conversations for at risk patients. These conversations are already happening and include discussion around resuscitation and goals of care, and the patient’s treatment goals and priorities.

We recommend the use of the Acute Plan to document and share this important clinical information, and assist health professionals working across the health system with decision making.

Which patients?
Any patients who you’d normally consider writing an Acute Plan or Advance Care Plan for: vulnerable patients who might present acutely to emergency services and, in the current environment, those who are at risk of serious infections with Covid-19.

In community care, we know the patients well who may be at the centre of difficult decision making if our health care system becomes overwhelmed by patients infected with Covid-19 or with other serious illnesses which will continue to occur during the outbreak. We have a window of opportunity to document and share this knowledge of our patients with acute services.

This information could include patient preferences and key medical decisions - unwanted and unwarranted treatment if their condition deteriorates, no resuscitation/ ventilation/ no antibiotics etc. or critical information about vulnerability that a very ill or delirious patient might not be able to communicate for themselves. For example, brittle/ severe asthma which is likely to need a more urgent response than may be apparent, mental health or social issues which could affect the help seeking strategy of patients and their response to treatment, community supports which might allow a patient to be managed at home rather than admitted to hospital.

Consider acute plans for any patients who are likely to have complex or specific vulnerabilities if they present acutely.

Creating Acute Plans is a funded activity in primary care. There may be times during the current lock down when primary care teams have capacity to document these issues with or for their patients. See HealthPathways for information about funding and how to find, amend or create a plan.
In the current crisis, conversations about unwanted or unwarranted treatments if their condition deteriorates, are being prioritised. These people may already have had these conversations with their whānau and health care team and made enduring decisions etc.

The Shared Goals of Care Document, and the Serious Illness Conversation Guide (SICG) will support you to have and document these conversations. If a patient has COVID-19, there is an alternative SICG document to help you navigate the conversation.

What should I document?

Key patient treatment goals and priorities;
Current clinical decisions/guidance resulting from goal of care discussions, such as curative or quality of life focus of care;
Enduring not for resuscitation (DNACPR) decisions (Community teams and staff in ED do not have access to handwritten DNACPR forms e.g. the yellow QMR0217 form where enduring resuscitation decisions are recorded in the hospital setting.);
Specific medical interventions that are either indicated or not indicated e.g. IV antibiotics, non-invasive ventilation.

Where should I document patient preferences and the key medical decisions?
In the ‘Key Issues’ section of the Acute Plan template. This section is intended for important information if this patient were to present in an emergency.
Further details can be added elsewhere in the plan if needed.

Why use Acute Plans?

They provide visibility of key medical decisions and patient priorities in a clinician-to-clinician format;
They are easy to create and amend;
Key information for acute teams can be kept up-to-date and relevant to the patient;
Provides secure, auditable information sharing between hospital, primary and community based clinicians.

Who can access or contribute to an Acute Plan?

All clinical staff with access to Health Connect South / HealthONE
This includes hospital based health care teams, general practice teams, St John, some ARC facilities

How do I create a new Acute Plan?
https://canterbury.communityhealthpathways.org/search?q=acute%20plan%20

How do I read or amend an Acute Plan?
https://canterbury.communityhealthpathways.org/search?q=acute%20plan%20