Capturing key medical information to protect the vulnerable during lockdown

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Acute Plan
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The Shared Care Planning team transitioned to Pegasus Health in February 2023.

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.

Capturing key medical information to protect the vulnerable during lockdown

08 Jul, 2020 | Return|

During Alert Levels 3 and 4, acute plans were promoted as a solution to record decision-making, investigations, and goals of care that needed to be communicated to clinicians not familiar with the patient.

“This was a combined effort with the Shared Care Planning team and the Advance Care Plan team,” says Senior Project Facilitator at Canterbury Clinical Network Rebecca Muir.
An acute plan contains information about a person’s health condition and the recommended treatment if their health suddenly gets worse. It is especially beneficial for people who are likely to need emergency or after-hours medical care.

Health professionals can easily read, write and edit plans as appropriate, even if they are not the original author. The plans enable secure information sharing between hospital, primary and some community-based clinicians across the South Island.

Promoting acute plans during lockdown was essential as they are recognised as a key tool during uncertain times, Rebecca says.

“They’re used across the system and are intended to support decision making regarding the need for admission, investigations and the appropriate setting for acute care.”

During lockdown it was especially important that resources were used effectively to reduce pressure across the system and ensure the most vulnerable patients were managed as close to home as possible.

A small working group, formed from the Urgent Care Service Level Alliance group, pulled together data that identified patients who had previous hospital admissions in the last three years with chronic obstructive pulmonary disorder (COPD) flare-ups.

The patients’ general practices were contacted and encouraged to offer these people preventative and proactive measures.

These included:

COPD blue cards (action plans) being sent to general practices
flu vaccinations
‘back pocket’ prescriptions for antibiotics and prednisone
acute and advance care plans.

St John was also asked to only transport patients with a severe flare-up of COPD to the Emergency Department. For all other cases St John was asked to call the person’s general practice team (urban and rural), followed by urgent care clinics.

“This was to ensure that all cases of mild or moderate exacerbations were managed in community settings,” Rebecca says.

(The above article was published in the CEO Update on 6 July 2020.)