Health Systems • Networks • Collaborative Care • Implementation
Operationalise collaborative care across services using shared care plans
I work with health systems to implement shared care plans as the coordination layer that makes integrated, multidisciplinary care reliable—across primary care, specialty care, hospitals, and community services.
The health system problem: integrated care without integrated planning
Most health systems deliver “integrated care” through referrals and handoffs across services that run on different workflows and documentation practices. Even within the same system, teams often operate as separate islands.
The result is inconsistent care plans, duplication, unclear ownership of follow-up, and avoidable escalation—especially during transitions between primary care, hospital, and community services.
Shared care plans as system infrastructure
Shared care plans provide a structured, living summary that aligns care teams on goals, roles, actions, monitoring, and escalation pathways. For health systems, this functions as a practical “single source of truth” across sites and services.
- Standardisation without rigidity: consistent structure, locally adaptable workflows
- Clarity of accountability: who owns what, when, and why
- Safer transitions: fewer dropped handoffs between services
- Reduced duplication: fewer repeated assessments and conflicting plans
- Measurement-based review: practical tracking of outcomes and progress
Where shared care planning creates the most impact
Primary care + specialty integration
Unifies care planning across primary care, allied health, and specialty services.
Hospital-to-community transitions
Improves continuity after discharge with clear roles, escalation pathways, and follow-up ownership.
Chronic disease pathways
Coordinates multi-provider care for long-term conditions where drift and duplication drive cost and harm.
Mental health integration
Turns collaborative care from “communication” into a structured, reviewable operational workflow.
Implementation approach
Define the shared plan structure
Minimum viable plan fields, governance, role definitions, and escalation pathways.
Map workflows across services
How primary care, hospital teams, specialists, and community services contribute and review the plan.
Enable reliable updating and visibility
Reduce asynchronous updates and ensure the plan remains unified across sites and teams.
Measure, review, iterate
Establish review cadence, outcome measures, and continuous improvement.
System-level outcomes
- Reduced unwarranted variation in care planning
- Improved continuity across sites, services, and providers
- Fewer avoidable escalations through clearer pathways
- Better governance and oversight without burdening clinicians
- Scalable models of integrated care for complex populations
Build integrated care that works across the real world
If your system is investing in integrated or collaborative care, shared care planning provides the practical structure needed to reduce fragmentation and make outcomes more predictable across services.