Goal-Based Care Planning in Regional Geriatric Services for Older Persons Living with Frailty

Laura I.L. Poulin, Mary E. Blinkhorn, Stacey A. Hawkins, Kelly A. Kay, Mark W. Skinner



Older adults living with frailty represent a complex group who are increasingly accessing regional geriatric services. Goal-based care planning is the industry standard in the care of older adults, yet few studies illustrate how goal-based care planning is being conducted with this population. Understand-ing how frailty impacts goal-based care planning in regional geriatric services is key to improving patient care.


In this “Go-Along” method of data collection, nine observa-tional experiences were conducted, nine responses from the Interprofessional Role Shadowing Tool were obtained, and eight responses to follow-up questions were received. Open coding of the data was performed retrospectively, and indexed themes were identified.


Although the Geriatric Clinicians indicated that goal-based care planning and frailty were central to practice, the observa-tions indicated no clear process to patient-centred goal-setting or frailty identification in practice. The results infer a gap between theoretical knowledge and practical application.


A clear process to goal-based care planning in interprofessional geriatric services is needed. This objective requires practical education that emphasizes the skills necessary to implement goal-setting within unique, interprofessional care environments. Further research is necessary to establish if frailty identification is necessary in goal-based care planning, or if a patient-centred approach is more advantageous in practice.


frailty; goal-based care planning; older adults; goal-setting; geriatric services; patient-centred care

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DOI: https://doi.org/10.5770/cgj.21.318


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ISSN: 1925-8348 (Online)