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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
21Dec

Locked and loaded for Christmas with shared care plans

21 Dec, 2021 | Return|

Kidney transplant recipient Don Saxon is grateful that he can look forward to time with his whānau and a spot of camping this Christmas, comforted by the knowledge he has a health plan at the ready if needed.   

Don’s transplant means he’s immunocompromised and susceptible to infections, which can be very dangerous if they aren’t treated quickly. 

“Infections can swiftly become dangerous for me, and I need to be given antibiotics quickly. I can’t afford to lose valuable time by having to repeat my story to health staff – I have only hours and not days,” says Don. 

That’s why Don’s practice team at Travis Medical Centre suggested he create an Acute Plan to outline how he presents and agreed treatments. Don and his wife refer to it as their ‘action plan’ as it helps clinicians involved in his care respond quickly when he needs acute care. 

“It allows medical teams to see information at a glance about my condition, treatment plan, medications, allergies, resuscitation wishes and my next of kin and GP contact details. As I experience different health issues, we learn from it and tweak the details of the plan,” said Don.

“Before we had the plan, I used to have to wait in the Emergency Department waiting room often vomiting and in a lot of pain, but now I’m fast tracked through. It opens the team’s eyes to what the situation is for me, and they act on the plan quickly.”

The Acute Plan provides information that supports clinicians to make decisions around the need for admission, investigation, and appropriate setting for acute care. It aims to support safe and effective management of patient’s complex health conditions and who are at moderate to high risk of requiring acute services. 

It’s one in a suite of shared care plans, which also includes a Personalised Care Plan (PCP) and the Advance Care Plan. 

Travis Medical Centre Practice Nurse Nicky Scott says the plans are valuable to both patients and staff.  “These plans sit well with the work we do in practice around prevention and managing of complex patients. It helps stop the repeat story telling from the patient’s point of view and gives a good holistic snapshot of what’s happening and what and who is important to them,” she says. 

Shared Care Programme Lead and Product Manager Rebecca Muir says feedback from urgent care clinicians is that they find Acute Plans useful for complex patients they are often not familiar with, particularly over Christmas or other times when general practice hours are reduced. 

For Don and his whānau, the plan provides reassurance. 

“I was sceptical about having my information out there, but its only visible to those caring for me and they need to know, so I’m pleased I swallowed my pride and got a plan.

“With this plan I’m locked and loaded. It gives me and my wife solace that we don’t have to answer hundreds of questions, especially when I’m often too sick to answer.

“I recommend people have copies of their plan printed and available on their phones, – I take mine with me in the caravan in the first aid kit and to Australia. It’s like my bible or fire extinguisher that we have on us all the time.”

At this time of year, when patients are seeking care from places they might not usually present to, it’s helpful for both clinicians and patients if current information and agreed treatments are documented and easy to access. The plans can be viewed by clinicians anywhere in the South Island. 

With Covid-19 possibly in the community it’s more important than ever that those most at risk of exacerbation from it, have an Acute Plan.  This will help to manage resources and reduce pressure across the system and ensure those most vulnerable are cared for.   

For more information about the plans visit the Shared Care Planning page on the CCN website.

There is also a webinar now available for clinicians that can be viewed here and the handout here. Primary care clinicians who participate in the Pegasus Education programme can access here.

Photo above: Don Saxon with his wife Janine enjoying Nelson's waterfront on one of their caravan holidays. 

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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.