Personalised Care Plan – what matters most to the patient

A new electronic shared care plan was added to the Canterbury Health System’s suite of patient care plans on 14 February. The Personalised Care Plan (PCP) is designed to help people with moderate to complex health needs who use primary, community and secondary health care services.

The PCP sits alongside the Acute Plan which has been created through collaboration and integration with Canterbury Health System partners under the umbrella of Canterbury Clinical Network (CCN).

An Acute Plan is put together detailing the complex and/or specific health needs of a patient during an acute episode of care. If the patient is treated by a health provider who is not the patient’s regular provider, the Acute Plan provides the means to support safe, effective and patient specific assessment, management and transfer of care. The patient may be involved in the writing of the plan and they give their consent to have this information shared.

The Personalised Care Plan outlines the patient’s needs and goals to achieve better daily health. It also documents who is involved in the care of the patient and how each team member contributes to the goals and action negotiated with the patient and whānau allowing visibility of team activity and collaboration between services.

Here’s a fictional example of how a PCP can help

56-year-old Bridget has social anxiety and inflammatory arthritis. She struggles to get out and about and often fails to take her medication.

Bridget’s health care team can work with her to put together her PCP and then support her to achieve her health goals.

What matters most to the patient at the moment?

Bridget would like to feel confident enough to go to the mall with her daughter.

Goals (supporting goals)

  1. Emotional wellbeing/ mental health (life area)
    Issues: social phobia, self-conscious of teeth which are painful and several are rotten
    Goal: to be able to go out comfortably
  2. Managing medicine and other therapy (life area)
    Issues: Forgets to take medications
    Goal: Take meds as prescribed at least 80% of the time

Actions (needed to achieve goals)

  1. Emotional wellbeing/ mental health
    • Follow up with the oral health department and Work and Income re: dental care
    • Referral Anxiety Disorders Unit
  2. Managing medicine and other therapy
    • Pharmacy to blister pack medicines

The Collaborative Care Team from CCN says the PCP is a great addition to the suite and is an extension of a trend towards a more integrated approach to health care.

A poster, outlining how the PCP works won an accolade at Health Informatics New Zealand’s (HiNZ) conference in October last year.

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View the poster.

CCN’s collaborative care team, in partnership with the wider Canterbury Health System and Orion Health were also finalists in the NZHIT Innovation Awards at the Conference for the Shared Care Planning Service.

 

Read more about the Personalised Care Plan

Read more about Canterbury Clinical Network’s Strategic Focus

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Rebecca Muir (Collaborative Care Liaison, CCN) and Donna Hahn (Collaborative Care Liaison, CCN) being presented with the certificate for the PCP poster at the HiNZ Conference.

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