Te Kōhao Health offer a free service to all people living within the Waikato DHB region to support the development of an Advance Care Plan.
The team of Advance Care Planning Navigators will contact your patient and work with them to develop their Advance Care Plan. If the patient completes their Advance Care Plan, this will be uploaded onto their patient record on Waikato DHB Clinical Work Station (CWS).
The Advance Care Planning Navigator will send a referral reply to indicate that the Advance Care Plan is completed and uploaded to CWS. They will include a PDF copy of the ACP in their reply that can then be viewed by the patient if your practice shares inbox documents to the patient portal. The Navigators will follow up with those patients with an ACP after 12 months to review the ACP and update the plan and load another version to CWS if required.
Once an ACP is completed it is important it is identified on the patients record in CWS and in the patient’s primary care record.
When you receive notification back from the ACP Navigator please code that the patient has a completed ACP, so this information moves with them and can be easily identified in their record.
If you refer to other services this information will be included in the referral (MedTech mark long term).