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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
15Mar

Access to Health Connect South and HeathOne via Ambulance tablets for Paramedics ICPs and ECPs

15 Mar, 2021 | Return|

Paramedics, Intensive Care Paramedics (ICPs) and Extended Care Paramedics (ECPs) across the South Island now have access to Health Connect South (HCS) and HealthOne.

This means paramedics will have a greater understanding of the patient’s background to help guide treatment decisions and allow for more robust clinical decision making on whether the patient should be transported to an  Emergency Department (ED), managed in primary care, or remain the in the community.

Paramedics are almost the only health professionals providing urgent, unplanned care in the out-of-hospital setting, seeing and treating approximately 1,475 additional patients per week in their home nationally. Previously paramedics have not had point of care access to shared health information which has added complexity to patient assessment and decision-making regarding treatment which can result in unnecessary transports to health facilities.

Benefits to the ambulance service 

  • Greater understanding of the patient’s background to guide treatment decisions. 
  • Allows for more robust clinical decision making on whether the patient should be transported to an ED or managed in the community. 
  • Efficient access to acute plans, advance care plans and crisis plans to enable prompt and appropriate management for these complex patients. 
  • Reduction in calls to the Clinical Desk allowing clinical desk personnel to manage the increased ambulance workload as more people call 111. 

Health system benefits 

  • Reduction in transportation to ED by ambulance, reducing the strain on EDs and the hospital system. 
  • Patients being able to access the right care, closer to home without transport to hospital. 
  • Reduced need for patients to visit their GP or an urgent care clinic for simple clinical problems that are known to be normal for the patient, supporting the capacity of primary care.  

Benefits to the patient

  • Comprehensive and safer treatment, transport, and referral decisions. ​
  • Complex patients not having to repeatedly explain extensive detailed history which can be frustrating for them. 
  • Efficient access to acute plans, advance care plans and crisis plans to enable prompt and appropriate management for these complex patients. ​
  • All health providers in the patient's clinical course have access to their health information allowing for consistency and improved collaboration.

This is a huge step forward for prehospital care and has the ability to enhance our patient’s experience. Having access to HealthOne at point of care will allow Paramedics a greater understanding of the patient’s medical history, help guide treatment decisions, and allow for more robust clinical decision making on whether the patient should be transported to an Emergency Department (ED), managed in primary care, or remain the in the community.

For more information contact Orla Fowden, Right Care Advisor (South), St John at Orla.Fowden@stjohn.org.nz

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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.