Care plans Ngā whakamaheretanga manaaki

A care plan is a document that your healthcare provider can create with you or a whānau member. The plan can contain information about:

• your health condition
• the plan for what to do if your condition changes
• what your goals are for your health
• what your preferences, priorities and wishes are in managing your health.

Care plans make it clear what your health needs are to whoever is providing you with care.

A version of your plan will be stored securely, so only health professionals caring for you can access it.

There are different types of care plans including:

• acute plans to manage flares ups of a specific complex health issue
• personalised care plans for you to set goals when you have long term or complicated health challenges
• advance care plans to identify your preferences for your future healthcare including end of life care
• shared goals of care plan for if you become very unwell while in hospital or in aged residential care.

If you think a care plan would be helpful for you or someone you know, talk to your healthcare provider.

If you know you are likely to need emergency or after-hours medical care in the coming year, you may benefit from an acute plan.

Healthcare providers involved in your care can create and update an acute plan for you.

An acute plan allows your health care team to quickly find information about your health condition and the recommended treatment if your health suddenly gets worse.

The team may include:

• ambulance services
• hospital emergency departments
• after-hours services
• health providers who are not familiar with you.

You may have only one health problem that health professionals need to know about. For example, someone with severe asthma might have an acute plan. If they were to collapse, the plan would tell emergency services what the problem is likely to be, and what the recommended treatment is.

Other people with acute plans may have several health conditions. Their acute plans tell emergency services and their healthcare providers:

• what plans are in place if their health gets worse
• whether they prefer to be cared for in hospital or at home
• what extra support and treatment they usually need.

If you have complicated or long-term health challenges, you may benefit from a personalised care plan.

A personalised care plan is a way to help you and your healthcare team work towards your health and wellbeing goals. The plan outlines actions to help you achieve your goals.

The plan can be used across different areas of your life, such as: 

• home environment 
• mobility 
• social connections. 

The goals in your plan may be big or small, such as:

• walking to the bus stop
• driving
• changing what you eat and drink
• managing your medicines.

The plan helps you and your care team know what actions and support you need to meet your goals. Your care team might include your whānau, friends, nurses, doctors, physiotherapist, pharmacist and others.

Your healthcare provider can create or update a personalised care plan for you.

Advance care plans identify your preferences for your future health. Anyone can benefit from an advance care plan. You may be healthy and want to prepare for if you ever become seriously ill or injured, or you may have a long-term condition or life-threatening illness.

Advance care planning is a process of thinking and talking about your values and goals and what your preferences are for current and future health care. It helps you to understand what the future might hold and say what health care you would or would not want, including end-of-life care.  

You should think about advance care planning before you become seriously ill or injured. It is especially important if you: 

• have a terminal condition 
• are very frail 
• have strong opinions about how and where you want to be treated at the end of your life. 

There are several steps in advanced care planning that you can learn about on the Advance Care Planning website.  

What is advance care planning 

An advance care plan is where you can write down the things that are important to you for your care in the future. The plan will make sure your whānau and your future healthcare teams know what your wishes are, especially if you can no longer speak for yourself.   

Creating your advance care plan 

If you are admitted to hospital or move into a rest home facility, you will have a shared goals of care plan.

Shared goals of care are discussions with your health care team about what matters to you and your whānau. This includes what care and treatment you want to receive if you become very unwell during your hospital admission or time in aged care.

This is your chance to talk about:

• your understanding of your medical condition and anything else you would like to know about it
• your priorities if your health changes
• what worries you and what gives you strength
• what abilities are so important to you that you could not imagine life without them
• how much you would be willing to go through for more time.

A shared goals of care plan is the document where your health care team write down a summary of your discussion and the shared goals of care decision.

If you become very unwell, the plan will make sure all of your care team know what the agreed goals are for your treatment and care.

The shared goals of care plan is for each admission to hospital. If you go back to hospital in the future your health care team will talk to you again.

If you are moving to an aged residential care facility you can expect to have a discussion about goals of care when you first arrive. Your shared goals of care plan will be regularly reviewed.