What is a Geriatric Assessment and Care Plan?

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Oct 31, 2017

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A geriatric assessment is a multidimensional assessment which is designed to evaluate an individuals or couples current functional ability, physical health, cognition and mental health, social environment, legal, financial status and environmental safety. Information is gathered from the individuals themselves and may be solicited from family and other key members in the persons life. The goals of the assessment are to maintain, improve, and enhance those areas which can be affected, and to minimize risk and potential harm to the individuals under assessment. Additional goals are to reduce the burden on the family caregiver(s) and provide support for the family.
The Care Manager gathers the information needed for the geriatric assessment in the home of the individual or couple over several meetings. The assessment begins with comprehensive data gathering using interviews, screening techniques and instruments, data review and observation. The starting point is the gathering of personal information, medical history, review of medications, current medical concerns, including cognition, and client goals. The Care Manager also conducts functional assessments such as the ability to bath, dress, shop, prepare meals, handle finances, and live at home safely. They review the presence and completeness of advanced directives and powers of attorney as well as financial data; i.e., income, expenses, and assets.

The initial meeting with the client(s) and whomever they would like present last 1.5 to 2 hours. We review our services, sign contract document and conduct the initial interview to get to know the client a bit. There are 2 to 3 additional meetings of 1.5 to 2 hours each to cover the topics outlined above. With couples, we may need an additional meeting. We can meet once or twice a week depending upon the clients schedule and energy level.

After the assessment, the Care Manager organizes and documents all key information and identifies those areas that are going well and those that that needs to be addressed, or shored up. A plan is then developed in each area that needs to be addressed with goals, priorities, recommendations and potential resources.

The final meeting of the assessment and care plan is with the client(s) and whomever they would like to attend to hear the summary and recommendations of our assessment; typically, 1 to 1.5 hours per person assessed.

The Care Manager is available to implement or assist in the implementation of the recommendations agreed upon by the client. The care plan provides a roadmap for the caregiver and family about what needs to be done next and in the near future. When clients are working with a Care Manager, the assessment and care plan evolves over time as client needs change.

At Life Changes, we provide exceptional care management services.


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