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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
29Apr

COVID-19 update from South Island Alliance - Capturing patient preferences and key medical information

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Why use Acute Plans?  

  • Key information for acute teams can be kept up-to-date and relevant to the patient.  
  • They enable secure information sharing between hospital, primary and some community-based clinicians across the South Island.  
  • Health professionals can easily read, write and edit plans as appropriate, even if they are not the original author.
  • St Johns clinical control centres can access Acute Plans.
  • There is an alert in Health Connect South to inform clinicians that the patient has an Acute Plan. 

What should I document in an Acute Plan? 
Acute Plans can contain simple information, such as alerting staff that a pain plan exists and where to find it, through to more detailed information about social situations or complex medical issues. For example:

  • current clinical decisions/guidance resulting from goal of care discussions for this episode
  • enduring not for resuscitation (DNACPR) decisions
  • specific medical interventions that are either indicated or not indicated e.g. IV antibiotics,  non-invasive ventilation
  • key patient treatment goals and priorities
  • decisions or actions captured in other forms (such as COAST in Southland, Shared Goals of Care in Canterbury DHB and OtTER in Nelson Marlborough Health), so the information is regionally consistent and accessible across the health system
  • any social or medical information that would be useful to acute services treating the person in an exacerbation of their illness.  

Acute plans are part of the South Island suite of electronic shared care plans. They are hosted on Health Connect South and accessible across the South Island health system via HealthOne. 

Advance Care Plans (ACP) are the place to document in detail patients’ needs and wishes for end-oflife care and have legal validity.  
 
For more information about shared care plans in your area: 
Nelson Marlborough Health: acp@marlboroughpho.org.nz  

Canterbury DHB: info@ccn.health.nz

West Coast DHB: Helen Rzepecky helen.rzepecky@westcoastdhb.health.nz

South Canterbury DHB: Paula Hogg phogg@scdhb.health.nz  

Southern DHB: AdvanceCarePlanning@southerndhb.govt.nz 

Download this information.

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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.