Resources for the Comprehensive Geriatric Assessment based
Proactive and Personalised Primary Care of the Elderly
Individual case mananagement includes :
Individualised goal setting in collaboration with the patient and carers if appropriate.
Go To : Personalised Care Planning
Generation of a personalised care plan.
My Health Plan - international version
Personalised Care Plan template
x min. variable
Selecting the appropriate care pathway, may include :
a more in-depth CGA, if medical problems dominate, and who will be involved in carrying it out.
changes in medication and joint care arrangements with carers and pharmacist
referral to allied service providers for further investigation or management of identified needs including
- optimisation and implementation of self-management measures
- specialist intervention for specific medical needs
- third-sector/community care and support for issues such as social isolation and loneliness
- social services care and support for social and environmental needs
- Advanced Care Planning support
Go To : Advance Care Planning
This is one of four Read More sectors of the
Proactive Care chapter of this toolkit
Back To : Proactive Care