The document describes a shared care planning program in New Zealand that aims to improve health outcomes through integrated care, shared access to patient information, and the use of technology. The program provides a shared care record and communication tools to enable coordinated care across providers. Early results show increased communication and task coordination among care teams, as well as improved care plan development. Recommendations include establishing clear governance, understanding funding models, and taking an iterative approach to technology and workflow refinements.

1. healthAlliance Care Connect
To deliver outstanding shared services that enable healthcare
excellence for the Northern Region’s population.

2. Purpose
The New Zealand National Shared Care Planning
Programme (NSCPP) is an clinically led IT-enabled
approach to address the growing problems of
•ageing population,
•more chronic conditions
•fragmented general and specialist care.
To deliver outstanding shared services that enable healthcare
excellence for the Northern Region’s population.

3. 3 Concepts to improving
Health Outcomes
• Shared access to common information by care
providers
• Integrated care planning and communication across
multidisciplinary teams
• Using technology as an enabler
To deliver outstanding shared services that enable healthcare
excellence for the Northern Region’s population.

4. What does Technology
provide?
The technology provides a shared care record and
coordination capability, including careplans, messaging
and task assignment, for multidisciplinary care teams.
•Integration with general practitioner’s (GP’s) Practice
Management System (PMS) and browser access to
shared record for community-based providers, hospital
providers and patients.
To deliver outstanding shared services that enable healthcare
excellence for the Northern Region’s population.

5. Goal
Enable a patient-centred approach to care irrespective
of the current care provider.
To deliver outstanding shared services that enable healthcare
excellence for the Northern Region’s population.

6. Shared Care - Overview
• Enables sharing of summary health information and
improved communication between shared care team
members across Primary, Secondary and Community
health providers
• Patients with LTC benefit from a patient centred care
plan developed in partnership with their care team,
improving co-ordination of care and communication
• Patient access to own record
To deliver outstanding shared services that enable healthcare
excellence for the Northern Region’s population.

7. Key Principles of Shared Care
• Patient/whanau centred
• Collaborative, integrated
• Partnership based shared decision-making
• Self-management support
• Incorporates behaviour change methodologies
• Interdisciplinary teamwork
• Same-page care
To deliver outstanding shared services that enable healthcare
excellence for the Northern Region’s population.

8. Expected Benefits
• Reduced delay in treatment decisions – info 24/7
• Improved safety, quality of care, communication,
coordination & interdisciplinary teamwork
• Reduction in readmissions
• Patients - increased independence and sense of
control
• Increase in virtual consults, case-review & follow-up
• Improved crisis management, reduced ED visits
• Potential to reduce medication errors & improve
quality of care and safety
To deliver outstanding shared services that enable healthcare
excellence for the Northern Region’s population.

9. Key Components
• Generic care planning approach that enables care
coordination & case management
• Clinically-led
• Change management specialists
• Quality improvement framework
• Patient portal
• IT platform that integrates information across system
to enable new models of care
To deliver outstanding shared services that enable healthcare
excellence for the Northern Region’s population.

10. Shared Care - Progress
• >400 patients enrolled
• >40 patients using the patient portal
• Additional secondary and allied health teams
• Increasing general practice numbers to encompass
both urban and rural shared care
• Linking patient identification to various initiatives
– 20,000 unplanned hospital admissions
– Patients at Risk of Readmissions
– Pharmacy services agreement
– Localities
To deliver outstanding shared services that enable healthcare
excellence for the Northern Region’s population.

11. Our Stories – Botany Cluster
Primary Driver = 20,000 Bed Days
•Using Shared Care as the tool to link:
– 4 EastHealth GP practices
– 4 pharmacies
– Howick Home Health Care team
– VHIU & PARR CMDHB patients
– Secondary teams: Renal, Rheumatology, Diabetes, NASC,
Community geriatrics
To deliver outstanding shared services that enable healthcare
excellence for the Northern Region’s population.

12. Our Stories – Grey Lynn
Primary Driver = PARR
•Using Shared Care as the tool to link:
– Heart Failure service
– Grey Lynn GP practice
– Grey Lynn pharmacies x 2
– 38 patients enrolled
To deliver outstanding shared services that enable healthcare
excellence for the Northern Region’s population.

13. Our Stories – Coast to Coast
Primary Driver – Rurality, Primary Secondary
integration and communication
•Using Shared Care as a tool to link:
– 6 rural practices and pharmacies
– LTC WDHB patients
– Secondary NSH diabetes with satellite clinics
– Virtual consults through secure communications
To deliver outstanding shared services that enable healthcare
excellence for the Northern Region’s population.

14. Our Stories - Tom
To deliver outstanding shared services that enable healthcare
excellence for the Northern Region’s population.

15. Overview Screen
To deliver outstanding shared services that enable healthcare
excellence for the Northern Region’s population.

16. Summary Data in Concerto
To deliver outstanding shared services that enable healthcare
excellence for the Northern Region’s population.

17. Patient Portal
To deliver outstanding shared services that enable healthcare
excellence for the Northern Region’s population.

18. NIHI Evaluation Logic
To deliver outstanding shared services that enable healthcare
excellence for the Northern Region’s population.

19. Findings in Brief
Technology: User growth pattern
To deliver outstanding shared services that enable healthcare
excellence for the Northern Region’s population.

20. Social: Tasks assigned by role
To deliver outstanding shared services that enable healthcare
excellence for the Northern Region’s population.

21. Outcome: Care Plan Development
To deliver outstanding shared services that enable healthcare
excellence for the Northern Region’s population.

22. Technology: Summary page viewing
To deliver outstanding shared services that enable healthcare
excellence for the Northern Region’s population.

23. NIHI Recommendations:
Policy
Shared care is complex and multi-faceted; it requires
significant efforts to implement
Evaluation findings to date, have highlighted
– The creation of clear governance framework is essential to
ensure sustainability and ongoing buy-in
– Understanding different funding models to support
sustainability and maximise value proposition
– Understanding and informing the medico-legal processes as SCP
progresses
– An iterative approach to review and monitoring processes for
privacy & security is needed
To deliver outstanding shared services that enable healthcare
excellence for the Northern Region’s population.

24. NIHI Recommendations:
Implementation
• Evaluation findings to date, have highlighted that there is a need to have
clear direction for
– Mapping and understanding current clinical workflows to see where
the touch points for change are
– Determining a shared model of care from multi perspectives
– Identifying the commonalities of care planning across the health
sector
– Key steps to maximising the work flow of shared care against current
work processes
– Understanding expectations of communication, coordination across
multi organisational teams
– Understanding expectations of accountability
To deliver outstanding shared services that enable healthcare
excellence for the Northern Region’s population.

25. NIHI Recommendations:
Technology
• The need for an on-going iterative approach and review of the
technology that reflects learning's
• Understand value of Patient Portal
– Explore the patient role and establish broader experiences with
patients
– Understand the links to patient contribution to the shared care
record through online input into the Patient Portal and
wellbeing
• Software Focus is essential
– Confirm outcomes from Intra-team communication
– Link in with existing activities to maximise efforts for common
areas e.g. Medication lists
To deliver outstanding shared services that enable healthcare
excellence for the Northern Region’s population.

26. Current Focus
• Care Planning
• Keep refining tools and process
• Patient Portal
• Interaction with their Care Plans, resource library available, and
messaging between patients and care team members.
• Pharmacy Engagement
• Increase the engagement and activity for pharmacist and test the
feasibility of program to enable Medicines Management Plans
• Loading stratified patients in Shared Care

27. Transition to June 2013
• A tool that enables the community pharmacy services
agreement
• Enhance clinical integration with members of
Multidisciplinary teams in localities
• Enable current DAP deliverables with reference to
National Health Targets, clinical integration and Northern
Region Heath Services Plan Clinical Networks
• Continued technology refinement
• Continue to reflect on evaluation findings to shape
direction
To deliver outstanding shared services that enable healthcare
excellence for the Northern Region’s population.

28. Contact
• eMail: info@sharedcare.co.nz
• Website: www.sharedcareplan.co.nz
• Programme Manager: Sarah Tibby
• Evaluation: GaylH@adhb.govt.nz
Acknowledgments
• The evaluation study was funded by the New Zealand National IT Health
Board. We extend our thanks to all the users, patient participants and
their families, project team members, software vendor team, steering
group members and all the stakeholders interviewed to date for
accommodating our study. We extend our thanks to the metro Auckland
DHBs & NHITB for funding this project over the last 2 years