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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

Proacrive care

This is one of four Read More sectors of the

Proactive Care chapter of this toolkit

Back To : Proactive Care

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