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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

Ensuring vulnerable patients are in safe hands this winter

05 Jul, 2022 | Return|

Jennifer Voice is feeling well cared for this winter, thanks to the support of the Care Coordination Nursing team at Riccarton Clinic.

The team is contacting patients with complex health needs to check on their wellbeing and to go through a checklist of what they may need to stay well during the cold months. 

Care Coordinator Nurse Catherine Jordan says top of that list is to check if they need an Acute Plan created or reviewed. The 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.

“Acute Plans, which are part of a suite of Shared Care Plans, are an important tool we have up our sleeve for this group of patients,” says Catherine.

Jennifer and her husband Ron, who both have mobility issues, appreciate the team checking on their welfare, especially during Winter and with Covid-19 and influenza in the community. 

“We are so pleased that people are thinking of us and that even though our health services are extremely busy, they still take the time to call us,” says Jennifer. 

“Having our Acute Plans makes us feel safe, because we know it’s shared with other health professionals who also need to care for us. When you’re too unwell and can’t speak for yourself, the plan can speak for you.” 

Catherine says that having knowledge about patients’ needs and medical preferences on hand, in one place, for everyone involved in their care means they can provide the best support while saving valuable time and resources.

“We’re focusing on patients with Chronic Obstructive Pulmonary Disease (COPD) and older people who are particularly susceptible to complications from Covid-19 and influenza. We’re also contacting patients with cognitive deterioration, diabetes, heart failure, mental health conditions and those needing palliative care support,” said Catherine. 

“To protect vulnerable patients, particularly during winter, we create Acute Plans with patients over the phone. Once we build that relationship, patients are comfortable to talk over the phone and during follow-up calls, they may share more about themselves and reveal other areas our team can support them with.” 

Riccarton Clinic have more than 350 Acute Plans in place currently. The plans are succinct and pertinent to the main concern, such COPD. Patients like them because it stops them having to repeat their story each time. 

“As well as Shared Care Plans, we also ask questions such as, do they have a plan if they get Covid-19, have they had their influenza vaccination, is their house warm enough, do they have enough food and do they need taxi vouchers to help with transport,” says Catherine.   

“Patients appreciate us reaching out to them. We have the time to build a relationship with the patient and help them to navigate the services and support they need. This is also a great help to our practice team, who do not always have the time to offer this additional support during routine appointments.”

It is a proactive approach to ensure they get the help they need, with the aim that it does not get to a crisis point. Some patients only need one phone call to ensure they have what they need, and others need more support. 

“There is a lot of support out there, but many patients do not know what is available to them or need help accessing services. Sometimes people put these conversations in their back pocket; they may not need to act straight away but find comfort in knowing what their options are when they need them," says Catherine.

“We also do Advance Care Plans, which is about the patient’s choice around their end-of-life care. Our aim is to do more Personalised Care Plans (PCP) to see how these integrate into general practice.  PCPs help patients and their healthcare teamwork towards health and wellbeing goals.”

Pictured above is Jennifer Voice (L) and Care Coordination Nurse Catherine Jordan (R).

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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.