PRO FORMA FOR CONSENT FORM - National Shared Care Plan

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Ethics Committee
NTY/11/06/058
Participant Information Sheet – Health Professionals
Name of the study: Evaluation of Shared Care Planning
Principal Investigator:
Gayl Humphrey
Manager Strategy and Implementation
Contact Phone No: 021 1100901
You are invited to take part in a research study investigating shared care planning supported
by an electronic system.
Shared care is about supporting people to achieve their best health outcomes, by enabling
the sharing of goal orientated care plans, that have been agreed in partnership with the
individual, primary care and the wider multidisciplinary care team. Shared care is based on
the belief that improved health gain will occur if people have their care delivered
collaboratively with each provider complementing, sharing and building on the work of the
other, and is aimed at actively planning and monitoring care outcomes together.
Please take your time to think about it and decide whether you wish to take part in it. Taking
part is completely voluntary (your choice).
Why are you being asked? / What it all about?
Electronic enable shared care presents an opportunity to provide patients with the benefits of
a more connected and wholistic approach to their care. It aims to combine specialist
intervention with the continuity of care and management of co-morbidities provided by their
primary health care doctors and nurses. Ultimately it could also include the wider
involvement of organisations such as Work and Income, Housing, Child Youth and Family.
A critical component of shared care therefore, is the relationships and interactions between
all the individuals and providers involved in a persons care. The shared care model is based
on the premise that with shared information and shared planning, all stakeholders will obtain
additional skills and knowledge to enable them to improve the quality of care and support a
person receives while reducing the overall demand for health services.
This research will assist the research evaluation team to
1. Gain a clearer understanding of the impact of introducing Shared Planning into
the health eco-system in respect to:
a. Patient outcomes
i. Health and social
b. Clinical perspectives and health outcomes
c. System outcomes
d. Workforce outcomes
e. Technology infrastructure
2. Identify the enablers to active and sustainable adoption
3. Identify barriers to adoption and potential resolution strategies
4. Assess validity of the technology solution(s)
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The study will be for approximately 10 months duration.
You are being invited because you / your practice / specialty has self identified yourself as
willing to participate.
Methodology
The evaluation methodology is grounded in Action Research. Action research is “learning by
doing”. There is a dual commitment in action research to study a system and concurrently to
collaborate with members of the system in changing it in what is together regarded as a
desirable direction. Accomplishing this twin goal requires the active collaboration of
researcher and participants, and thus it stresses the importance of co-learning as a primary
aspect of the research process. Much of the interaction with participants is spent on refining
the methodological tools to suit the exigencies of the situation, and on collecting, analyzing,
and presenting data on an ongoing, cyclical basis.
What happens during the study
Participation in this study will involve a range of information gathering from you. Information
will be gathered from survey questionnaires, interviews, (face to face, telephone and /or
workshop forums), correspondence (email, survey monkey), and observation. It is uncertain
the exact time that your participation will take however, it is anticipated that a total of 3-4
hours over the duration of the study will be required. All contact and data collection from
you will be arranged at a time best suited for you. Notes will be taken at each interview but
no identifiable information will be collected.
Your contribution will be combined and will contribute to understanding the impact of
electronic shared care planning.
Compensation
In the unlikely event of a physical injury as a result of your participation in this study, you may
be covered by ACC under the Injury Prevention, Rehabilitation and Compensation Act. ACC
cover is not automatic and your case will need to be assessed by ACC according to the
provisions of the 2002 Injury Prevention Rehabilitation and Compensation Act. If your claim
is accepted by ACC, you still might not get any compensation. This depends on a number of
factors such as whether you are an earner or non-earner. ACC usually provides only partial
reimbursement of costs and expenses and there may be no lump sum compensation
payable. There is no cover for mental injury unless it is a result of physical injury. If you
have ACC cover, generally this will affect your right to sue the investigators.
If you have any questions about ACC, contact your nearest ACC office or the investigator.
Participation
You do not have to participate in all the information gathering methods or answer all the
interview questions if you participate in an interview, and you may stop your participation at
any time.
Results
The action research methodology means that throughout the study you may be part of
discussions and design review forums aimed at improving the shared care planning project
as it is implemented. The outcomes and changes will form part of the regular feedback via
newsletters and web site news pieces.
You can also receive a summary of the evaluation final report if you wish. This will also be
available via the shared care website www.sharedcareplan.co.nz or by phoning 0800 268626
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Who should I contact if I have further questions?
If you have any questions about the study, do not hesitate to contact the Principal
Investigator.
If you have any queries or concerns regarding your rights as a participant in this study you
may wish to contact a Health and Disability Advocate, telephone (Northland to Franklin)
0800 555 050.
Maori Health Support
To ensure ongoing cultural safety the Nga Kai Tataki - Maori Research Review Committee’s
of Waitemata, Auckland and Counties Manukau encourage those who identify themselves
as Maori and who are participating in health research or clinical trials to seek cultural support
and advice from the named resources below or your own Kaumatua or Whaea.
Auckland: Mata Forbes RGON, Maori Health Services Co-ordinator / Advisor, 5th
Level, GM Suite, Auckland City Hospital. Tel 307 4949 extn. 23939 or Mobile 021 348
432
Waitemata: For assistance please contact the Services Clinical Leader for Mo Wai
Te Ora – Maori Health on 09 486 1491 ext: 2324 or the Maori Research Advisor on
09 486 1491 ext: 2553
Counties Manukau: For assistance please contact Te Kaahui Ora on Tel (09)
2760138,
Middlemore Hospital, Western Campus, Building 38b, Otahuhu
Professional support
For professional support or advice, it is recommended you contact your own professional
body or employer.
This study has received ethical approval from the Northern Ethics Y Committee.
Please feel free to contact the researcher if you have any questions about this study.
Thank you for making the time to read about, and consider taking part in this study.
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Ethics Committee Approval No.
NTY/11/06/058
Health Professional: Consent Form
Name of Study : Evaluation of Shared Care Planning
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I have read and I understand the information sheet dated ________________ for
volunteers taking part in the study.
I have had the opportunity to discuss this study. I am satisfied with the answers I
have been given.
I understand that taking part in this study is voluntary (my choice) and that I may
withdraw from the study at any time.
I understand the compensation provisions for this study.
I have had time to consider whether to take part.
I know who to contact if I have any questions about the study.
I understand that my participation in this study is confidential and that no material
which could identify me will be used in any reports or outcomes regarding this study.
I would like a copy of the final evaluation summary
YES/NO
I ________________________ (full name) hereby consent to take part in this study.
Signature _____________________
Date _________________
Project explained by __________________________________________
Project role ________________________________
Signature _______________________________ Date ___________________
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