Action plan for elderly care in Primary Care settings

Action plan for elderly care in Primary Care settings

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Activity details

An action plan for elderly care in primary care setting is being deployed currently in Osakidetza, according to the priority area 3 (active and healthy ageing) of “The Health Plan 2013-2020” of Basque Country. The goal is to have a homogeneous system for multidimensional assessments of patients over 70 years old across the entire Primary Care. It is based on evidence based recommendations on prevention, adapted to Primary Care Health Centers day-to-day practice. The multidimensional assessment allows to: • Define personalized care plans • Identify the causes and risk of disability, dependency or disruption of health • Establish procedures to prevent or delay the onset of disability and/or dependency • Classify patients (at the end of life, dependent, fragile, with chronic disease, healthy), enabling the creation of individual interventions • Know the social and health situation of the Basque population The assessment is made by physicians and nurses every 3 years. The information is registered in Osabide and Osanaia (EHR of Basque Healthcare System) to be available for the follow up of patients in the different care levels. This commitment responds to the specific objective 1.2 of the Renovated Action Plan A3.
Action Group:
Lead organisation name: 
Ministry for Health of Basque Country
Organisation country:
Contact person: 
Jon Darpón Sierra (Health Minister of the Basque Country)
Contact person email:
Activity type:
Start date: 
Last update: 27/02/2019

Current Status

After piloting the action plan for elderly care in Primary Care settings, the conclusions are: •The multidimensional assessment of the plan allows: (i) a better understanding of the situation of the elderly regarding their health and their social environment, (ii) to identify risks and plan care and continuity plans to delay the onset of the fragility and (iv) to monitor health problems and complications. •The systematization of the evaluation has had a very positive impact on the level of registration of the clinical-preventive and functional variables. The improvement areas and the recommendations to incorporate the plan into the offer of the health centers have been also identified. The actions performed during 2016 and 2017 (January to May 2017) can be summarized: -Re-elaboration of the PAM document including changes in the multidimensional assessment proposed in the piloting. -Elaboration of corporate forms for registration at Osabide Global -Adequacy of Osanaia to the proposed changes in the valuation -Design and preparation of the On-line training course -Elaboration of the deployment schedule in the different organizations.


Title Planned Deadline Current Status Category Attachments
Oral presentation. I Nursing Congress, 2016. Osakidetza’s Elderly care plan (PAM). Mechanizing the diagnosis of typologies of elderly. 01/01/2016 Achieved Dissemination: Meetings, events, conferences
Conclusions after the piloting of the action plan 01/01/2017 Achieved Research: Data (assessments/screenings/reviews/ data collections)


Indicator Target indicator Current status
Number of elderly persons with multidimensional assessment 16454 1370
Number of Integrated Healthcare organizations involved 13 13
Number of primary care centers involved 324 7
Number of primary care centers participating in the on line training for the deployment of the action plan 26 primary care centers 0