Canterbury Clinical Network launches latest shared care plan

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Adapted from Orion Health’s Coordinate functionality, the newest in the suite of electronic shared care plans, the Personalised Care Plan (PCP), went live in February.

The plan, accessed via HealthOne or Health Connect South (Orion’s Concerto), documents patients’ needs and goals to promote better daily health for people who have complex conditions.

The PCP sits alongside the Advance Care Plan and the Acute Plan; a summary of issues and information to assist health providers unfamiliar with a patient who may present with an exacerbation of their underlying health condition.

The focus of the PCP is on what matters to the person at the centre of the plan, rather than what is the matter with them.

Beneath the overarching statement of what matters most to the patient at the moment sit 14 life areas such as food/drink/healthy weight and legal/financial. Within each of these life areas, clinical teams can document current issues for the patient, agreed goals to work towards and the actions to be taken by either the care team or the patient themselves which underpin the goals.

There is a shared progress note attached to the PCP which can be filtered by service to track interventions by specific teams.

The plans can be read, created or edited by clinicians in primary, secondary and community settings, allowing clinicians to view the activity of other teams and collaborate around the patient’s own goals and needs. The access criteria follow the same parameters as HealthOne. Currently all doctors, nurses and pharmacists who access HealthOne can use the plans, as can some other allied health professionals and some clinicians in non-government organisations (NGOs), as well as the clinical desk of St John Ambulance.

Bringing on more allied health providers, NGOs and aged residential care facilities is part of HealthOne’s ongoing development. Other regions in the South Island who use Health One/HCS are considering taking up the PCP.

Community teams in Canterbury DHB’s Older Persons’ Health, including the Community Rehabilitation and Enablement Support team (CREST) that supports patients after discharge from hospital, are rolling out the use of the PCP as their care plan document.

Canterbury Clinical Network’s Collaborative Care Team is working with palliative care, pain management services and disability service NGOs to explore how they might use the plans.

The initial roll out of these plans has focused on the secondary and community teams who have collaborated in the development of the plans. However, some primary care teams are already making use of the planning tool which can either be a reflection of a comprehensive assessment or be used in a modular fashion, addressing one or two aspects of a person’s daily life as they are affected by chronic illness.

For more information, visit Canterbury Clinical Network.

Source: Canterbury Clinical Network article, 4 May 2018

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