Living with a complex health condition can have a major impact on a person’s life. Constant appointments, having to repeat information to different care providers, not to mention the travel and home support involved. Without a coordinated care plan, a patient may end up in hospital far more frequently than they need to be, an inconvenience and a waste of time and resources.

For Sam, a male patient in his late 60s who’s just come out of hospital following a serious leg injury and requires support with his rehabilitation, his Personalised Care Plan will assist in a smooth recovery. Members of his care team can coordinate initial home visits, regular check-up appointments and physiotherapy sessions a few weeks down the line. Sam’s personal goals might be to shower without assistance, complete leg strengthening exercises and eventually to walk for 30 minutes a day. Progress would be monitored by members of his care team to ensure he is on track to a positive recovery.

Traditionally, patients who have chronic conditions, are elderly, or have suffered serious injury or illness, have lengthy or repeated hospital stays largely due to a lack of resources for proactive care delivery within the community.

If a patient suffers an exacerbation of a complex health condition, resulting in a visit to an urgent care facility, an Acute Plan informs clinicians about the patient and describes how best to manage an exacerbation. The information within the Acute Plan is created when the patient is well and can cover things like information specific to their conditions, normal observations for that patient and information that is relevant to the ambulance crew. It can also describe what supports may need to be in place prior to discharge to allow the patient to return home.

Shared care plans can help people living with complex health conditions to live a more independent life, by taking care out of a hospital setting and into their community. Working with what matters most to the patient, a shared care plan involves a collaborative approach from a range of health providers to proactively manage a patient’s care. Developing an electronic shared care plan incorporates the patient’s voice, as well as looking at their current and future health to consider any ‘speed bumps’ they might run into and how these could be handled.

Paving the way for other health systems around the world, Canterbury, New Zealand has been committed to redefining the way healthcare is delivered, taking a patient-centred approach to the health system. The vision behind this approach is that a patient receives the right care for them, in the right place, at the right time.

By focusing on the patient outcome, rather than the care setting it has resulted in patients, being taken care of in the community rather than in hospital. Shared care planning takes away some of the inefficiency and large costs associated with treating patients in hospital, and wraps the necessary care around them in their own community so they can stay out of hospital.

Canterbury’s shared care plans incorporate everything from managing medications, home rehabilitation, to Advance Care Plans that help people plan for the end of their life. Accessed through Canterbury’s shared electronic medical record (EMR), clinicians across the system can view and edit a patient’s care plan within the shared medical record. 

A common struggle faced by elderly patients and people with complex health conditions is juggling a number of different medications. Coordination amongst community health providers is important in keeping track of which medications these patients have been prescribed, and also to make sure the patients themselves have a good understanding of their medications. Part of Canterbury’s shared care planning involves medication management in the community. Pharmacists can meet with patients to discuss their medications, and then document a reconciled list that includes any issues or suggested mitigations so patients aren’t overloaded with a cocktail of medicines. This streamlined process improves medication adherence and most importantly, puts the patient’s health progress first. 

The concept of shared care planning, at its core, is designed to enable the delivery of care closer to home. With a strong focus on those who are likely to arrive in hospital, such as people with complex health conditions, the aim is to put the patient at the centre of their care with a proactive approach.

These plans allow all members of a patient’s care team to collaborate, communicate and view the patient’s own priorities and personalised goals. A strong example of how an integrated health system can improve care delivery through a proactive approach, but also save precious health provider resource at the same time.

Watch Gavin Young’s video below: