The result of the screening and assessment process is the development and implementation of a care plan in conjunction with the patient and their family.

The aim of a care plan is to meet the individual patient’s needs and goals. When compiling a care plan, take the time to get to know what matters to your patient and what they would like to achieve. Maximise their opportunities to participate in their care, tailor simple evidence based strategies to their needs and encourage them to play an active role in maintaining their health. Revisit and update the care plan following reviews of progress or changes in the patient’s status.

Interventions identified in a care plan can involve:

  • curative care - to improve specific conditions
  • comfort care - to improve quality of life when an older person is receiving palliative care
  • preventive strategies to minimise risk of functional decline such as pressure care, nutrition and hydration, regular mobilisation, maintaining continence, pain management, orientation and cognitive functioning, and maintaining social connections both during and after a stay in hospital.

Once we have introduced the interventions, we need to regularly assess the older person’s ability to participate in the implementation of the plan and adjust the interventions as required.