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Developing the comprehensive care plan

Integrated screening and assessment processes are used in collaboration with patients, carers and families to develop a goal-directed comprehensive care plan.

Every patient receiving health care in Australian health service organisations deserves comprehensive care, but some patient groups are particularly vulnerable and, for them, comprehensive care has a substantial role in helping to prevent harm. Consider the groups of vulnerable patients that use the organisation’s services and ensure that systems for comprehensive care meet the needs of these groups.

For example, 40% of patients in hospitals are aged 65 years or over.1 Hospitalised older patients often suffer from multiple chronic conditions that may require input from many different clinicians, and are known to be at higher risk of potentially preventable adverse events such as falls, delirium, pressure injury and malnutrition.2

The population served by the health service organisation and the nature of the services provided will determine the approach to screening and assessment.


Planning for comprehensive care

Screening of risk

Clinical assessment

Developing the comprehensive care plan


  1. Thistlethwaite J. Values-based interprofessional collaborative practice. New York: Cambridge University Press; 2012.
  2. Australian Institute of Health and Welfare. Australia’s hospitals 2013–14: at a glance. Canberra: AIHW; 2015.
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