Abstract

For elderly people with complex care needs, working with a treatment plan is a method for offering personalized, proactive, integrated care. The treatment plan works as a ‘compass’ because it indicates the key points to focus on in the care for the elderly person. It can take personal wishes and preferences into account, improve the person’s ability to cope independently and involve family and caregivers in the process. The treatment plan provides an overview of the most important problems in all domains and of the professional caregivers involved. In this article we describe the potential opportunities and action points within working with treatment plans. Opportunities include shared decision making, paying attention to functioning and independent coping, and stimulation of care in the community. Action points include organization of care, registration, education and privacy. Drawing up a treatment plan is not an end in itself, but a working method, which takes into account the diversity of the elderly population and the complexity of care giving.