Heart Health Plan care planning tool

Te Whatu Ora – Health New Zealand is developing the Heart Health Plan for health consumers who have recently had their cardiovascular disease (CVD) risk assessed.

The Heart Health Plan is a care planning tool designed to: 

• help consumers understand the outcome of their cardiovascular disease risk assessment (CVDRA)
• empower consumers to take steps and set goals to make behavioural changes to lower their risk of a future cardiovascular event
• help healthcare workers support consumers on their heart health journey.

Following a CVDRA, a healthcare worker can discuss and work through the Heart Health Plan with the consumer.

The Heart Health Plan captures a consumer’s five-year CVD risk level, summarises points discussed during the CVDRA, and provides some customisable key advice on actions that can help to lower overall risk. It also records the key goals and next steps the consumer plans to take to support their heart health and lower their risk.

The Heart Health Plan was developed to provide wraparound support for consumers who have had a CVDRA. It could be provided to anyone who is eligible for the CVDRA service.

This care planning process can be delivered in primary and community care. The process can be led by GPs, practice nurses, health coaches, healthcare assistants and kaiāwhina.

The Heart Health Plan API will integrate with practice patient management systems (PMS). It takes the data from a consumer’s CVDRA and the customisable outcomes from the Heart Health Plan discussion with the consumer and presents it in an easy-to-understand two-page form.

The finished plan is presented in PDF form to either print out or email to the consumer to take away and refer to. This helps consumers to stay on track with their CVD risk management and puts them in charge of their own health goals.

The Service is currently being prototype tested with primary health organisations (PHOs) and community providers, to ensure it meets provider and consumer needs. Following this testing process, we will refine the Heart Health Plan template and process in order to make it more widely available.

Adoption of the Heart Health Plan in primary care is voluntary, and consumers can also choose to opt out of working through a plan following their CVDRA, but we encourage its use to support shared care planning and improved health outcomes for consumers.

The Heart Health Plan tool was designed to work with any CVDRA calculator that uses algorithms specific to the New Zealand population. The algorithms were published in 2018 by the School of Population Health at the University of Auckland and are detailed in the Ministry of Health 2019 HISO 10071:2019 Cardiovascular Disease Risk Assessment Data Standard. We recommend that the free Te Whatu Ora CVDRA service, which complies with this standard, is used to calculate the CVD risk score.

If you’re a health provider and are interested in finding out more about the Heart Health Plan, contact our Long Term Conditions team at ltc@health.govt.nz