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. 2025 Apr 24;9(1):BJGPO.2024.0163.
doi: 10.3399/BJGPO.2024.0163. Print 2025 Apr.

Personalised care planning for older people with frailty: a review of factors influencing implementation

Anne Heaven  1 , Marilyn Foster  2 , Robbie Foy  3 , Rebecca Hawkins  4 , Claire Hulme  5 , Sara Humphrey  6 , Jane Smith  4 , Andrew Paul Clegg  4
Affiliations

Personalised care planning for older people with frailty: a review of factors influencing implementation

Anne Heaven et al. BJGP Open. .

Abstract

Background: Frailty increases vulnerability to major health changes because of seemingly small health problems. It affects around 10% of people aged >65 years. Older adults with frailty frequently have multiple long-term conditions, personal challenges, and social problems. Personalised care planning (PCP) based on 'goal setting' and 'action planning' is a promising way to address the needs of older adults living with frailty.

Aim: To identify and explore factors that influence the implementation of PCP-style interventions for older adults.

Design & setting: We conducted a scoping review and identified a small number of interventions that explicitly employed goal setting and action planning.

Method: We used a range of sources to identify relevant material. We included all interventions inclusive of patients aged ≥65 years and reported in English. We excluded end-of-life care interventions, group education, and/or those that did not involve one-to-one engagement. We explored all related articles that described, examined, or discussed implementation. We constructed a thematic framework in NVivo (version 11). Findings were narratively synthesised.

Results: We identified 18 potentially relevant PCP-style interventions and 13 of these met the inclusion criteria. Within these, were seven main categories of potentially modifiable influences relevant to older adults with frailty related to the following: primary care engagement; delivery staff characteristics; training; patient engagement; collaborative working; organisation and management; and systems.

Conclusion: Many modifiable factors can influence the implementation of PCP. We identified several influences that have informed the development and implementation of a novel intervention PeRsOnaliSed care Planning for oldER people with frailty (PROSPER).

Keywords: aged; frail older adults; frailty; general practitioners; implementation; patient care planning; primary healthcare.

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Conflict of interest statement

The authors declare that no competing interests exist.

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