The role of care professionals who are in regular and frequent contact with the older person with frailty has a vital role in supporting the review and follow-up of the supported self-care plan.

Even if the professional has not been directly involved with the goal setting, integrate assessment or action planning, they can still influence the success of the plan by providing encouragement, checking on progress and exploring solutions to any barriers that have been encountered.

“How am I getting on?”

Evidence shows that unless goals are followed up within a fortnight, providing encouragement and support for people, they are less likely to progress towards and achieve their goals. This could be as simple as getting the person to reflect on “How am I getting on?”

Some individuals will be most comfortable with providing a description of the progress for others, or for particular actions, using some sort of scale may be helpful (for example, “On scale of one to ten, where one is no progress and ten is complete progress, how much progress would you say you’ve made?”).  Keeping it simple, person-centred and focused on the positives are important considerations whatever approach is adopted.

To reinforce the sense of empowerment, it is important that the focus is on developing the individual’s problem solving skills, whilst ensuring that expectations remain realistic.

Engaging partners, close family members and informal carers in supporting the follow-up, reinforcing positive messages and maintaining motivation will be easier if they have been involved during the action planning stage.

Technology also provides an increasing range of ways to support follow up and review including:

  • E-mails or texts can be set up to send automatically every couple of weeks if this is an effective mode of communication with the individual;
  • Digital approaches to helping people monitor their own health, such as apps, or something as simple as a pedometer;
  • Skype or FaceTime can provide virtual face-to-face check-ins.

“How do I feel now?”

Finally, given the unpredictable and non-linear nature of frailty, it is important to also ask the person to consider “how do I feel now”as part of the follow-up and, depending on the answer, whether this has changed “What is really important to me?

Enabling Zone templates:
How am I getting on?
How do I feel now?