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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
03Aug

Reducing stress in times of need with Shared Care Planning

03 Aug, 2020 | Return|

When you’re not well it can be stressful and communicating is not always easy, which can sometimes be the case for New Brighton Health Care patient Michael who has Cerebral Palsy, which is a permanent condition that affects movement and posture. 

“When I get nervous or I’m in pain my speech becomes hard to understand and my body tenses up,” says Michael. 

Gina Connolly, Care Coordinator and Registered Nurse at the practice knew Michael would benefit from having an Acute Plan in place, which is part of a suite of electronic Shared Care Plans. There is also a Personalised Care Plan and Advance Care Plan and Gina is a strong advocate of these plans.

Acute Plans include important information about a person’s health and what treatment they need if they become unwell and need after hours or urgent care. Ambulance, hospital and urgent care staff can see the plan, which is especially important when the patient can’t easily speak for themselves.

“I made an Acute Plan with Gina who asked me questions about me and my health. We included information about my condition, speech, medications, and allergies and who to contact if I’m unwell,” says Michael.

“It’s a big relief to now have a plan and it means less stress and worry for me.”

Gina added: “It’s all about advocacy and ensuring the plan is in the patient’s voice, which empowers them and reduces barriers and anxiety. It also helps to reduce a distressing hospital admission and/or ambulance call out, because the patient is more aware of the steps they need to take to help themselves.”

 “Most patients express relief when we explain that they might benefit from having one of the suite of Shared Care Plans, as they won’t have to keep repeating their story, especially when they are acutely unwell.”  

“Because the patient helps to create the plan, they are more likely to be engaged in their own health and they are given clear guidelines of what they need to do if their health deteriorates.” 

“Patients with respiratory, cardiac, mental health or other complex health/social needs can benefit from having a Shared Care Plan. We proactively contact patients whom we feel would benefit from having a plan.” 

The plans include clinical information useful for secondary services. Part of New Brighton Health Care’s Acute Plan consult is telling the patient about relevant health and social agencies available to support them alongside their general practice. The information can also help with discharge planning, as it’s clear what services and supports are already in place.

“The plans can also include specific cultural needs the patient may have, as well as what language they use. We have had good success with some of our patients who are deaf, by ensuring their plan includes the interpreting service they use to translate. This applies to all our patients who come from culturally and linguistically diverse communities,” says Gina. 

 New Brighton Health Care have always made Shared Care Plans for their patients, but like other practices during the Covid-19 response the number of plans they made increased. 

“We did phone consults with our patients with respiratory conditions to check on them. We told them which respiratory symptoms needed medical attention, talked about their medications and the benefits of having a Shared Care Plan,” says Gina.

“No one during this time declined having a plan made, as they all saw the value in them.”

 “Initially during the response patients were to be admitted without family and/or support people, so if they couldn’t speak for themselves having a Shared Care Plan would be very important.”

“Some patients asked for their resuscitation or ventilation wishes to be included in their Acute Plan. We then followed up to see if an Advance Care Plan was appropriate for them.”

People should talk with their general practice team about whether a plan is right for them. There is also a brochure available. 

Photo above: Michael at the gym.

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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.