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Developing a Care Plan

A geriatric care plan is a way to help aging individuals ensure continued good health, and according to, “improve their overall quality of life, reduce the need for hospitalization and/or institutionalization, and enable them to live independently for as long as possible.”  Stemming from a geriatric assessment, a care plan ensures that families, aging individuals, and health care providers are all on the same page regarding health care and living arrangements, and that each knows his or her role in managing the needs of the aging individual.
Step One:  The Geriatric Assessment
  • A geriatric assessment is performed by a geriatric care manager or licensed social worker.  The goal of the geriatric assessment is to evaluate the current and future medical, social and emotional needs of the aging individual.  A geriatric assessment should include:
    • A complete physical, mental and psycho-social evaluation
    • An assessment of the individual’s personal care competencies, known as actvities of daily living (ADLs)
    • An evaluation of current living arrangements and access to support services
    • Identification of existing problems
    • Listing of anticipated problems
Step Two:  Developing a Care Plan
The geriatric assessment should give families and caregivers all of the information needed to develop a solid, comprehensive care plan for their loved one.  According to the American Association of Retired Persons (AARP), a care plan “assesses an individual's medical and social service needs, and then coordinates assistance from paid service providers and unpaid help from family and friends to enable persons with disabilities to live with as much independence as possible.” Such a plan should include:
  • Help managing personal care responsibilities, medication delivery, and general physical, mental and psycho-social issues.  For some families, a home health aide or an assisted living environment addresses these issues.
  • Anticipate changes needed in living arrangements developed to ensure the continued safety and health of the aging individual.  Sometimes, simple attention to geriatric home safety is all that a family needs to ensure the continued health and safety of their loved one.  Other times it may be necessary for the older individual to be moved to a smaller housing unit, apartment or other one-level living arrangement (including assisted living options and/or nursing homes).
  • Managing the connections between support services, healthcare providers and the aging individual to ensure that the loved one receives the necessary care and monitoring.
  • A plan for ongoing monitoring and reassessment.  Families, especially those who don’t live nearby their aging parents, should make sure that they receive periodic reports about their loved ones.  Regular reassessments should be scheduled to address any changes in the older person’s physical, mental or psycho-social needs.  Special attention should be paid to the need for immediate modification in the event of a drastic change in the older person’s health.