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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
19Jan

Shared care plans key communication tool during pandemic

19 Jan, 2022 | Return|

Since COVID-19 first reached our shores, the way we use technology to support patients has been firmly in the spotlight.

As we enter the third year of a global pandemic and a new variant is at the forefront of everyone’s minds, the Shared Care Planning team is exploring how shared care plans can support health care teams to have important conversations about medical decisions with their at-risk patients.

“The shared care plans, particularly the Acute Plan, proved really effective during the first lockdown as they provided a place to record information about patient preferences and key medical decisions for everyone involved in care to access,” said Rebecca Muir, Shared Care Planning Programme Lead and Product Manager.

“The Acute Plan supports clinicians to make decisions around the safe and effective management of patient’s complex health conditions by sharing important information that can be updated in real time.”  

During 2020, 3,764 Acute Plans were created or updated to share critical information for people who may have presented acutely unwell to emergency services and were particularly at risk of serious infections with COVID-19, such as people with respiratory or other complex conditions.

Rebecca continued: “This year, more than ever, there will be a need to support and manage patients at risk of an acute exacerbation. We recognise that there will be an increase of unwell patients living in the community, so we need to manage our resources effectively to reduce pressure across the system and ensure we can manage our most vulnerable patients as close to home as possible.”

The suite of shared care plans also includes a Personalised Care Plan (PCP) and the Advance Care Plan. 

Acute Plan

  • Can support decision making regarding the need for admission, investigations, and appropriate setting for acute care.
  • Information recorded could include reference to other medical care plans, patient preferences, baseline functions, clinical risks, and reference to any other care plans that sit within Health Connect South.

Personalised Care Plan

  • Aims to support patients to work with care teams to coordinate care around their needs and priorities, making goals and activities visible to other clinical teams.
  • Focuses on a subset of the patient’s health care or can be created across a range of different conditions.

Advance Care Plan

  • Works through the process of thinking about, discussing, and legally documenting a person’s wishes about the type and level of medical care and treatment they want to receive at the end of life (or) when they can’t speak for themselves.

Benefits of using the plans

  • A single place to capture key information for acute teams that can be kept up-to-date and relevant to the patient - clinician to clinician communication. 
  • Enables secure information sharing between hospital, primary and some community care providers.
  • Simple to complete and amend, can assist in streamlining patient care.
  • Provides guidance to clinicians who are unfamiliar with the patient.
  • Can proactively support the communication of information for vulnerable cohorts of patients e.g., for people receiving palliative care.
  • A way to support and advocate for people who do not have support people with them e.g., visitor restriction at hospital.
  • The plans are used across other South Island regions. 

Creating an Acute Plan is free for the patient and now is an opportune time for health care teams to talk to their patients about making one. For more information visit the Shared Care Planning page on the CCN website.

* Image from Freepik 

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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.