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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
13Jan

Sharing the benefits of Shared Care Plans

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Pasifika elders and health and wellbeing services participated in a Pasifika Matua Fono (elder's meeting) to find out more about health services available to them and how to look after themselves and their families. 

The fono, held in September, was part of a series connected to the Tutupu Project – a collaborative partnership involving several health organisations who deliver health education to Canterbury's Pasifika communities through churches. The Matua fono focuses on information especially relevant for older people.

Jules Wilke, Canterbury Clinical Network (CCN) Project Facilitator talked to the group about Shared Care Plans, particularly the Acute Plan and Personalised Care Plan.

"The day provided a great opportunity to talk directly to members of the Pasifika community about the benefits of having a plan," says Jules.

The group heard how having a plan can make visits to after hours facilities and the Emergency Department easier, because you don't need to constantly retell your story. 

"The plan tells it for you and you can feel safe knowing all your important health information is stored safely in one place.”

A handout was given to members of the group, which included questions about their health, what they want to do if they are sick, traditional Pasifika treatments they use, what they need to feel culturally safe, what is important to them and who can help them with their health.

Tangata Atumotu Trust Health Promoter Losana Korovulavula, who helped to organise the event, said it was valuable to have the handout, because it meant they had something to take home to discuss further with their family and their general practice team.

“Information is so important to empower ourselves. We are not only taking this information for us, but also for our community, families and friends,” says Losana.

“This fono is good way to bring the elders together because they are comfortable in their own space. They ask questions and learn from each other, so it’s important these types of fonos take place.”

Seulata Fui who supported some of the matua at the event and helped to translate, said the Shared Care Plans are useful for this group, because many of their whānau and children speak on their behalf to health services.

“But, the Shared Care Plan includes what they want. It speaks for them. That’s their voice,” says Seulata.

“It also stops them having to repeat their information to each person they meet when they go to the doctors, which can be frustrating for them.”

The day was rounded off with Melissa McCabe from the CCN’s Community Respiratory Programme, getting the group on their feet dancing to some of their favourite tunes, including John Rowles and Elvis. She showed them how they can move and have fun, without realising they were exercising.

"The laughter and warmth in the room was contagious and I think we all learnt a lot from each other," says Jules.

More information about the Shared Care Plans can be found on Healthinfo.

View a video with some of the day’s highlights 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.