Learn more about shared care plans
The acute plan
Is a person-centred plan which documents the:
- Person’s underlying complex health conditions, and
- Management of exacerbations of underlying complex health conditions for health providers unfamiliar with the person.
- Aims to support rapid, safe management of people with complex health conditions, and those who are at moderate to high risk of attending acute services over the next 12 months.
Eligibility
People must be at least one of the following:
- Moderate to high risk of requiring acute services over the next 12 months, or
- Accessed acute services (such as ED, Urgent care clinics or St John) in the last 12 months.
And must have at least one of the following long-term conditions:
- Respiratory Condition e.g. Asthma, COPD, Bronchiectasis
- Cardiovascular Disease (including Heart Failure)
- Gout
- Stroke
- Diabetes
- Severe and enduring mental illness or addiction
- Neurological or Neurodegenerative Disorders e.g. Epilepsy, Cerebral Palsy, Autism Spectrum Disorder (ASD), Parkinsons Disease, Motor Neurone Disease (MND), Dementia
- Other e.g. Cancer, Anxiety, Rheumatoid Arthritis, Frailty, Chronic Pain.
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 demo videos on how to create, edit and print acute plans:
How to create an acute plan (YouTube)
How to edit an acute plan (YouTube)
How to print an acute plan (YouTube)
The personalised care plan
Aims to support people 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. It is a person-centred plan which documents:
- problems the person currently experiences
- what they want to achieve about their health or general well-being, and
- actions the patient and their care team are going to take to achieve these goals.
Eligibility
People must be at least one of the following:
- Māori
- Pacific
- Former Refugee
- Quintile 5 (Q5)
- Community Services Card holder.
And must have at least one of the following long-term conditions:
- Respiratory Condition e.g Asthma, COPD, Bronchiectasis
- Cardiovascular Disease (including Heart Failure)
- Gout
- Stroke
- Diabetes
- Severe and enduring mental illness or addiction
- Other e.g. Cancer, Anxiety, Rheumatoid Arthritis, Frailty, Chronic Pain.
The plans can be created or updated by any clinician. Plans can focus on a small subset of the person’s health care or be created across a range of different conditions.
The completed plan is shared electronically across the Canterbury health system.