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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
09Mar

Key milestone reached in roll out of HCS / H1 across South Island ARC facilities

09 Mar, 2023 | Return|

More than 90 percent of Aged Residential Care (ARC) facilities across the South Island are now key players in the Health Connect South (HCS) / HealthOne (H1) space, which allows ARC teams to access their residents’ shared electronic care records.

Shared Care Planning Programme Lead and Product Manager Rebecca Muir says this equates to 715 key staff at ARC facilities now having access to HCS/H1 from across 185 facilities across the South Island with 87 of those in Canterbury.

“This milestone means more ARC residents are benefiting by receiving timely and informed care, because their carers can view their up-to-date health information at the press of a button,” says Rebecca.

“This information includes lab results, transfer of care letters, outpatient appointments, as well as shared care plans, which is an exciting development because it means ARC teams can view, update and create plans to help manage their residents’ care.”

“Part of the shared care plan ethos is that everyone involved in a person’s care, is involved with their plan/s, so for them to be a truly useful tool we need all health teams to play their part.” 

The four shared care plans are: Acute Plan, Personalised Care Plan, Advance Care Plan (ACP) and ARC Shared Goals of Care, which is a plan that the resident, clinicians and whānau create together, which includes the resident’s values and treatment options while they are living in the ARC facility.

“This project has illustrated several benefits for residents and staff. It is anticipated that ARC facilities having access to HCS/H1 will have system wide benefits moving forward, particularly with regards to time saving and informing decisions made around treatments,” says Rebecca. 

For further information contact Catherine Jordan or go to Shared Care Planning page on the CCN website.

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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.