| Client functioning | Client behaviour | Social environment | Physical environment | Health and social care management |
---|---|---|---|---|---|
ABLE | Fall risk | Self-management | Â | Obstacles and hazards in the home | Â |
CAPABLE | Fall risk, functional impairments, depressive symptoms | Self-management | Â | Obstacles and hazards in the home | Polypharmacy, patient-provider communication |
Guided Care | Fall risk, functional impairments | Self-management, dietary intake, substance abuse | Caregiver burden, elder abuse | Â | Care continuity and transitions, access to care |
Restorative Home Care | Functional impairments | Self-management | Caregiver burden | Obstacles and hazards in the home | Polypharmacy, care continuity and transitions |
Carewell | Fall risk, functional impairments, cognitive impairments, depressive symptoms | Dietary intake | Â | Â | Polypharmacy, care continuity and transitions, over- and under treatment |
Embrace | Functional impairments | Self-management | Caregiver burden | Â | Polypharmacy |
FIT | Fall risk, functional impairments, cognitive impairments, depressive symptoms | Medication management, dietary intake, substance abuse | Social isolation, caregiver burden, elder abuse | Obstacles and hazards in the home | Polypharmacy, care continuity and transitions |
U-Profit | Fall risk, functional impairments, cognitive impairments, depressive symptoms | Dietary intake | Social isolation, caregiver burden | Â | Polypharmacy |
Elderly Persons in the Risk Zone | Fall risk, functional impairments | Self-management, medication management, dietary intake | Social isolation | Obstacles and hazards in the home | Â |
Home-Based Case Management | Fall risk, functional impairments | Medication management, dietary intake | Social isolation | Obstacles and hazards in the home | Polypharmacy, care continuity and transitions, access to care |
SpitexPlus | Functional impairments, cognitive impairment | Dietary intake | Social isolation | Â | Care continuity and transitions |