Shared Care Planning

Shared Care Planning involves community, primary and hospital health care providers working together to proactively manage and plan care with patients who have complex health needs.

Shared care plans enable coordination and improved communication between health providers and up-to-date information sharing. The shared care plans are accessed electronically, through HealthOne and Health Connect South - these are the digital health records health providers - and include Acute Care Plans and Personalised Care Plans, as well as the Advance Care Plans. 

Acute Care Plans

  • Acute Care Plans 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. 

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.

Personalised Care Plan

Advance care planning involves thinking and talking about what is important to you as you age, including your goals, values and preferences. If you wish, this can include creating an advance care plan as a way to record your wishes in terms of current and future medical care

Advance care planning gives you a chance to say what treatment you would and would not want, particularly for future and end-of-life care.

Having your wishes in writing helps your loved ones, whānau , and your health care team, if there come a time when you have to make a decision on your behalf.