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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
23Nov

Lights, camera, action for shared care planning team

23 Nov, 2021 | Return|

It was lights, camera, action for the shared care planning team as they presented a webinar to help colleagues from across the health system learn more about our suite of shared care plans last month.

Rebecca Muir, Programme Lead and Product Manager and Rose Laing, Clinical Lead, ran the webinar for all primary, community and secondary care services across the system via Mobile Health.

The webinar, which has Continuing Medical Education (CME) points allocated, provided an overview of the Acute Plan and the Personalised Care Plan, exploring:

  • how primary care teams and others use plans currently
  • patient groups for whom care plans are useful
  • use of plans in a pandemic
  • how to access training materials to use plans

Rebecca said the team chose to record the webinar so it could be used as a training aid to support health professionals who want to use the plans in the future, or those who need a refresh.

“Practice teams who watch the webinar in the future will earn CME points, which is a real bonus as we move into a space where more health and education tools go online.”

The team used the webinar to explain how much value the plans can add when used as part of a pandemic response.

“Both the Acute Plan and the Personalised Care Plan are seen to be key tools that could be used as we prepare to manage COVID-19 in the community. For example, health professionals can complete Acute Plans as a preventative measure for patients with complex health conditions who may be at risk of presenting acutely unwell. This will help clinicians who are unfamiliar with the patient as they can provide information that may help with decision making regarding the need for admission, investigations, and appropriate setting for acute care. It also provides a smoother patient experience and saves everyone valuable time.”

For more information about the suite of shared care plans visit the CCN website or view the webinar here and the handout here. Primary care clinicians who participate in the Pegasus Education programme can access here.

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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.