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Resources for the Comprehensive Geriatric Assessment based
Proactive and Personalised Primary Care of the Elderly

Proactive Care

Case Management

Individual case mananagement includes :


  • Individualised goal setting in collaboration with the patient and carers if appropriate.

personalised care planning

Go To : Personalised Care Planning

  • Generation of a personalised care plan.

My Health Plan - int'l

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

Advance Care Planning

Go To : Advance Care Planning

Proactive Care Team, CGA based Proactive Primary Care of the Elderly

This is one of four Read More sectors of the

Proactive Care chapter of this toolkit

Back To : Proactive Care

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