Resources for the Comprehensive Geriatric Assessment based
Proactive and Personalised Primary Care of the Elderly
Proactive Care
Case Management
Individual case mananagement includes :
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Individualised goal setting in collaboration with the patient and carers if appropriate.
Go To : Personalised Care Planning
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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 :
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a more in-depth CGA, if medical problems dominate, and who will be involved in carrying it out.
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changes in medication and joint care arrangements with carers and pharmacist
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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