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.