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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

Latest News
23Sep

Electronic shared care plans live across the South Island

23 Sep, 2019 | Return|

Source - eHealthNews.nz

A suite of electronic shared care plans is being rolled out across the South Island, with more than 10,000 active plans now available via the HealthOne and Health Connect South portals.

Personalised care plans, acute plans and advance care plans make up the suite. They are the first documents that both HealthOne and Health Connect South users have the ability to create, edit and read.

The electronic plans were first introduced in Canterbury in 2014 and have been going live across the South Island.

“As DHBs moved to Health Connect South, that gave them access to the plans and they started picking them up and using them themselves,” says Sonya Morice, regional IS portfolio manager, South Island information services SLA.

She says each district has taken its own approach to implementation and day-to-day running of the shared care planning service.

The benefit of this regional approach is that all DHBs are using a consistent platform and template. A new regional group provides quality control over every new advance care plan created.

“Having a regional approach is about the plans not being just viewable, but contributable as well,” says Morice.

“That changes the space because this allows information to be joined up, putting the person in the middle.”

WellSouth PHO director of nursing Wendy Findlay says the region is rolling out the three shared care plans as part of its long-term conditions programme, Client Led Integrated Care.

The electronic plans are being rolled out to 82 general practices, with 56 having transitioned over the past 18 months.

“Each are at various stages of transition. It’s quite a large model of care change so we’re doing a slow controlled roll-out to make sure the project goes well,” she says.

Findlay says the benefit is that a patient’s care plans will be consistent if they move, such as from Invercargill to Canterbury, and new clinicians involved in that patient’s care can view and edit the plans.

Canterbury Clinical Network GP liaison Rose Laing says clinicians have always exchanged information about vulnerable patients who may turn up a lot to A&E clinics and emergency departments, but these used to be faxed on paper.

“They were often out of date or no one knew where to find them, so it was a poorly used but understood way of working,” she says.

The acute care plans are essentially an electronic version of the paper form, created after a comprehensive discussion about what people need when they are in a crisis.

They range from very simple, such as alerting staff that a pain plan exists and how to find it, to more complicated social situations or medical problems.

Laing says an expanding pool of people is keen to create these plans for their vulnerable patients, such as palliative care staff.

There is a small subsidy for GPs to create them in Canterbury because they are seen as contributing to admission avoidance.

The most recent plans to be rolled out in Canterbury are personalised care plans, which are patient-centric and can be edited and viewed by any member of the care team at the same time.

The South Island Alliance is working with WellSouth Primary Health Network to test making care plans available to patients via their patient portals.

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Useful resources

Shared Care Plans brochure

Making a plan for your health and wellbeing. 

VIDEO: using shared care plans

A webinar which walks through the plan and demonstrates how to use them.

PCP tips and tricks

Personalised Care Plan information, including tips and tricks. 

Acute Plan tips and tricks

Acute plan information, including tips and tricks.

Shared Care benefits

Sharing the benefits of Shared Care Plans with Pasifika Matua.

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.