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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
17Dec

Sharing is caring with shared care plans

17 Dec, 2020 | Return|

As things ramp up for the silly season and many of us plan a well-deserved break, our colleagues working in urgent care are preparing ways to make the festive period simpler and safer for staff, patients and their whānau.

One tool they can leverage is the suite of electronic shared care plans – The Acute Plan and the Personalised Care Plan (PCP) – a place for clinicians from a number of health services to share important information that can improve patient care.

That’s the case for Keziah Jones, a nurse coordinator in the Emergency Department (ED), who spends a day a week focusing on creating shared care plans for regular attendees to ED.

“The Acute Plan is the most relevant for us in ED. When a patient comes in, the doctor will look to see if there is an Acute Plan in place, and if there is, they will look at it, in preparation for treating that patient,” says Keziah.

“Often we don’t have a holistic view of the patient, so the general practice team input is really great, as it gives us background from a different perspective, so we can tailor our approach.

“With medical presentations, we can make them nice and streamlined. There might be medications that aren’t that effective, or investigations that have already been carried out, so we can skip those and try other things.”

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

The Acute Plan provides information which is intended to support decision making regarding the need for admission, investigation and appropriate setting for acute care. It aims to support safe and effective management of patient’s complex health conditions and who are at moderate to high risk of requiring acute services over the next 12 months.

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.  It is a patient centred plan, which documents what the patient wants to achieve and the actions the patient and their care team are going to take to achieve their identified goals. This plan is for patients who have moderate to high complexity health needs.

For patients who regularly attend ED, Keziah can document information that’s useful for clinicians to aid decision making around future treatment in the Acute Plan.

“I think patients genuinely have a positive outcome from using these plans. It speeds up the process, so they get cared for quickly and if they’re likely to get admitted, that process is faster.

“It’s also really helpful in a busy emergency department to have guidelines around treating patients with more complex conditions. When everyone owns the document, clinicians are empowered to make updates and changes in real time – the collaborative nature of the plans means that no information is outdated,” adds Keziah.

Rebecca Muir, Senior Project Facilitator in Shared Care Planning at Canterbury Clinical Network says the plans are especially helpful to clinical staff over holiday periods because they contain up-to-date information about clinically agreed actions around that patient’s care.

“At this time of year, when patients are seeking care from places they might not usually present to, it’s really helpful for both the clinicians and patients if current information and agreed treatments are documented and easy to access,” says Rebecca.

“The plans also came into their own as part of our response to the Covid-19 pandemic. During April/May health providers were encouraged to expand their use of the Acute Plans to include setting parameters for unwanted or unwarranted interventions for vulnerable patients if they contracted Covid-19, or needed to be admitted to hospital during this high risk period.”   

The audit of new Acute Plans created during this time showed that in most cases clinicians took the opportunity to create comprehensive plans with information on the patient’s risks, specific needs and agreed management strategies; rather than limit the Acute Plan to outlining goals of care only.

Currently 5,388 patients in Canterbury have an Acute Plan and this number continues to rise as more health professionals get involved in proactively planning the care of vulnerable patients and making this information available to clinicians across the system.

For more information about the plans download the patient leaflet; visit the Shared Care Planning page on the CCN website or read more on HealthPathways.

Picture:  Keziah Jones, nurse coordinator in the Emergency Department (ED) and Scott Pearson, Consultant Emergency Physician.

About the Author

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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.