Community Dwelling Elders

The purpose of the Evidence-based Standardized Care Plans for Community Dwelling Elders is to provide a shared care plan for elders and providers in order for elders to remain at optimal health and wellbeing, and live safely in their homes/communities. Problems included in this guideline were identified by international stakeholders, including home care providers and scholars. Interventions were synthesized from the literature and validated by providers, scholars, and consumers. The interventions are intended to be non-overlapping across problems, and to build a comprehensive, holistic plan of care for those problems deemed applicable by the consumers and members of the health care team. For more information, see Metadata for Community Dwelling Elders.


Monsen, K.A., Foster, D. J., Gomez, T., Poulsen, J. K., Mast, J., Westra, B. L., Fishman, E. (2011). Evidence-based standardized care plans for use internationally to improve home care practice and population health. Applied Clinical Informatics, 2, 373-384. doi:10.4338/ACI-2011-03-RA-0023

*Monsen, K.A., Westra, B.L., Paitich, N., Ekstrom, D., Mehle, S.C., Kaeding, M., Abdo, S., Natarajan, G., & Ruddarraju, U. (2012). Developing a shared personal health record for elders and providers: Technology and content. Journal of Gerontological Nursing,38(7), 21-5.

*Westra, B. L., Paitich, N., Ekstrom, D., Mehle, S.C., Kaeding, M., Abdo, S., Monsen, K.A. (2013). Getting on with living life: Experiences of older adults after home care. Home Healthcare Nurse, 31, 9 1-9.

*This publication was supported by an unrestricted educational grant, Grant Number 1UL1RR033183 from the National Center for Research Resources (NCRR) of the National Institutes of Health (NIH) to the University of Minnesota Clinical and Translational Science Institute (CTSI). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CTSI or the NIH. The University of Minnesota CTSI is part of a national clinical and translational science award (CTSA) consortium created to accelerate laboratory discoveries into treatments for patients.