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

Background: 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. Understanding how frailty impacts goal-based care planning in regional geriatric services is key to improving patient care.

Methods: In this "Go-Along" method of data collection, nine observational 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.

Results: Although the Geriatric Clinicians indicated that goal-based care planning and frailty were central to practice, the observations 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.

Conclusions: 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.