Good Practices Overview | Basque Country | Czech Republic | Norrbotten | Puglia | Scotland

Care Plan for the Elderly

Summary of the good practice:

This project, aimed at people over 70 years, pretends to prevent or delay the loss of function through preventive interventions and health promotion activities along with control of geriatric syndromes and associated comorbidity. The main objective is to have a homogeneous system of multidimensional assessment and action, in people aged 70 or older, based on current recommendations, oriented to prevention, functionality and adapted to the reality of primary care, allowing classification in typologies of elder people.

This classification will provide us with a better understanding of the health situation of people of health quotas assigned in primary care and can thus establish appropriate interventions in each case and plan activities in an organized way for the different typologies of older people. Also through the Taxonomy NANDA-NOC-NIC will give us the possibility to individualize care plans which will allow better monitoring.

The transferable key issues are the following:

  • Have a program for elderly evaluation.
  • Have a classification model by typologies
  • Associate typologies based on functionality according to NANDA Diagnoses. Have a registration system for monitoring the elderly.
  • Have information to get indicators on health and social situation of the elderly

URL: n/a

Challenge addressed by the good practice

  • Have a screening model and systematic assessment of health in people ≥ 70 years
  • That every health professional knows the health status of persons ≥ 70 years assigned to its quota \ centre • Create synergies to schedule interventions for different types and health problems found.
  • Provide data and indicators that guide new programs and health policies for this group.
  • Sensitizing primary care professionals of the need to work in coordination with the social sphere and with a population approach.

Key innovative elements of the good practice

The Care Plan for the elderly (PAM), born with characteristics that provide topicality, innovation and commitment to quality care and continuity of care for the elderly. Its approach has the following characteristics:

  • It supports the activity and resources of primary care and is based on current recommendations, scientific evidence, and guidelines of Osakidetza, Health Department of the Basque Government, the Ministry of Health, Social Services and Equality, and WHO.
  • It is aligned with the strategy of Euskadi socio-sanitary care.
  • Includes a multidimensional assessment including assessment by NANDA domains.
  • Includes a classification of typology of older people, according to their function: healthy, chronically ill, frail, dependent, at the end of life.
  • Poses indicators for evaluation and monitoring of the program will be drawn from OBI (Oracle Business Intelligence).

Full Scirocco information on the good practice

SciroccoGP-Basque-6-Care-Plan-for-Elderly.pdf [PDF]

Publications and reports on the good practice

Documented evidence. Evidence is based on systematic qualitative and quantitative studies.

To carry out the program, we have relied on scientific evidence on current recommendations of scientific societies and guidelines Osakidetza, Health Department of the Basque Government and the Ministry of Health, Social Services and Equality and WHO. They have been exploited results from the piloting which in turn serve for the research project has been started on this practice; It has been designed and initiated a research project approved by the CEIC- E (Ethics Committee for Clinical Research Euskadi) No. PI2015167. We understand give consistency to the program. It have been presented some results in communication format to different national and international scientific conferences.

Contact point: Mari Luz Pena Gonzalez;

Back to top