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Care Plans 

In order to best co-ordinate your care we would like to work with you to create a plan designed to improve our ability to meet your health needs. 

The Personalised Care Plan 

  • Aims to support patients to work with care teams to coordinate care around their needs and prioritises 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 wellbeing, 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. 

  • Plans can focus on a small subset of the patient's health care or be created across a range of medical conditions. 

The completed plan is shared electronically across the Canterbury health system. 

The Acute Care Plan 

  • 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. 

The completed plan is shared electronically across the Canterbury health system. 

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