Foundations of General Practice : A workbook for nurses
Patient Centred Model of Care for the 75+ Population - Chris Ash
Australian general practice has no system to routinely identify elderly patients at risk of hospitalisation. These high risk patients aren’t routinely offered priority access to the general practice team. Annual over 75 health assessments are often based on checklists to identify disabilities and needs with no established system to intervene.
Care plans focus on medical needs related to patient’s most significant disease despite multimorbidity being norm. Patient values and priorities are rarely recorded. Goals are often set for, not by patients, and goals are mostly aimed at medical process rather than improved quality of life.
There’s a need for systematic review with a view to de-prescribing and simplifying the medical package in line with patient values. Medication related harm monitoring, falls prevention, adult immunisation, end of life planning, deterioration action plans and self-management support should be imbedded in routine proactive care for high risk elderly patients. The Complex Care Project addresses these issues.