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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
05Jul

More information means better support for Age Residential Care residents

05 Jul, 2022 | Return|

Staff working in aged residential care facilities across the South Island are finding it easier to make informed decisions about their residents’ care with newly granted access to Health Connect South / HealthOne.

CCN’s Shared Care Planning team, the South Island Alliance and the Health Connect South (HCS) / HealthOne (H1) teams are leading the roll-out to provide key staff at ARC facilities with access to their residents’ shared electronic health record and comprehensive training.

This ensures ARC staff have access to up-to-date information including lab results, transfer of care letters, outpatient appointments, and shared care plans to aid with planning and managing their residents’ care.

Val Whatley, Clinical Manager at Elmswood Retirement Village, says access to additional information in real-time is already making a significant impact for residents and staff.

“There have been several scenarios in the last month where we have been able to make a real difference for our patients because we’ve had quick access to information it would previously have taken us a while to get hold of,” said Val.

“This is particularly evident when patients are discharged from hospital back to one of our facilities. Recently we had a resident discharged back to our care quite late in the day, without instructions about the care for their chronic, long-term wound. The geriatric nurse specialist (GNS) involved in this resident’s care was able to talk us through where we could find the information we needed, and we found information which helped us decide what care to deliver next.”

Val says the process around residents being discharged from hospital is now much more streamlined. “Previously we had to follow up with the GNS or the discharge summary team at the hospital, but now we can access records, see what they are doing, when they are doing it, it is much quicker and means we can prepare what the resident needs before they arrive back into our care.”

Another success story came through one of the weekly GP-led clinics at the village when access to the up-to-date information helped the team understand and plan investigations. “It was the first clinic since we were given access and we were able to look at one of our resident’s previous bloodwork. Having access to the results meant we could decide to alter the blood tests taken in our clinic so we did not have to repeat tests and could explore a different avenue,” added Val.

Shared Care Planning Programme Lead and Product Manager Rebecca Muir says the rollout has vast benefits for the wider system. “Having access to their resident’s health record can assist in informing care decisions, which can lead to reducing unnecessary or inappropriate treatments and hospital transfers. It also means ARC staff can view, create and review their residents’ Shared Care Plans, including Advance Care Plans, Shared Goals of Care and Acute Plans.”

This is the next step for Val and the team at Elmswood Retirement Village, who plan on developing Acute Plans outlining the approach to care for several residents who have catheters, saving them unnecessary trips to the Emergency Department.

The Ministry of Health (MoH) has committed funding for the initial HCS/ H1 connection for up to ten staff per ARC facility, as part of the COVID-19 response. There are now 102 ARC facilities across the South Island that have access and training for HCS/ H1. The roll out to the rest of the facilities is expected to be complete by September 2022.

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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.