Care Planning
Policy
Care plans help us maintain oversight of any healthcare needs not provided by the practice, and support continuity of care when a patient is transferred to or from different services.
A care plan is a living record, stored securely, that we review and update as needed. It can incorporate input from other clinicians, the patient's other healthcare providers, and their wider support team, family/whānau, and carers.
Issues that arise concerning care plans are discussed at team meetings, to support learning.
The practice uses the HealthOne system to record the shared care plan and ongoing health information, goals, tasks, and other related data.
Care plans (including documents for activation of EPOA and Medical Care Guidance plans) are also filed in the Care Plan folder in the patient inbox for ease of access. A tab on the patient dashboard indicates whether an Advance Care Plan or Medical Care Plan is in place.
Developing and sharing a care plan
Patients who may benefit from a care plan are identified by clinicians during routine health care, and are likely to also be placed in the practice's programme for patients with chronic, long-term conditions, which offers subsidised appointments. This may include patients with complex/long-term health needs.
The nurse manager is their principal coordinator of care and is the primary point of contact within the practice about the patient's care plan.
Consider discussing with the patient
- Why their condition means they might benefit from a care plan.
- What is most important to them: consider problems, goals, and actions.
- How their health information may be shared with other healthcare providers.
- Whether they wish to share the plan with family/whānau.
If the patient wants to proceed with a plan
- Have them provide verbal consent.
- Document that a care plan has been developed: include the outcomes of your discussions.
Maintaining a record
- Update the patient record each time the plan is updated. The most recent plan in the patient record is the active plan.
- If the patient opts out of the plan at any stage, document this in the patient record along with their reasons.
Check HealthPathways: Care Plans for your region, and Collaborative Aotearoa: Care Planning in General Practice for more information.
Patient privacy
We take steps to protect patient information in the plan against unauthorised access and misuse. Only information relevant to the patient's condition is included.
The principal coordinator of care:
- gets the patient's informed consent for other clinicians to access the plan, and for family/whānau to view it
- documents the patient's consent in Indici
- decides how much information should be accessible via the plan
- designates levels of access within electronic systems so that some parts of the plan may remain confidential.
See also: Shared Electronic Health Record
Keywords: shared care, shared care plan