Thinking Holistically About Your Patient
Care Plan Library
Introduction
This page is part of the Care Plan Building Library used by GeneralPracticeTraining.com.au.
It is designed to support clinicians and practice teams in applying a holistic, patient-centred approach when developing care plans in general practice.
Problem or Condition Overview
This snippet focuses on holistic patient assessment, recognising that health outcomes are shaped not only by medical conditions, but also by social, psychological, environmental, and cultural determinants of health.
Patients experiencing disadvantage often have complex needs and may face barriers to accessing care. Understanding these factors allows GPs to tailor advice, improve engagement, and deliver equitable, effective care. Subject_ October 2024 Update_ N…
Care Plan Snippet – Holistic Patient Assessment (Table Format)
Care Plan Details
Item: GP Chronic Condition Management Plan (Medicare item 965)
Date of care plan: [Insert date]
Patient Details
Patient: [Patient name], [DOB], [Address], [Phone]
GP Details
GP: [Doctor name], [Provider number], [Clinic name], [Clinic address]
GP Management Plan – Problems / Goals / Treatments / Arrangements
| Holistic domain | Key considerations | GP actions | Arrangements and supports |
|---|---|---|---|
| Social determinants of health | Socioeconomic disadvantage, housing, employment, financial stress, access to transport and food | Discuss social situation sensitively. Identify barriers to care and adherence. | Referral to local community services, social work, financial or housing support services. |
| Cultural and community context | Aboriginal and Torres Strait Islander background, CALD background, language barriers, cultural beliefs | Provide culturally safe care. Use interpreters where required. Tailor advice to cultural context. | Aboriginal Health Services, interpreter services, culturally appropriate community programs. |
| Psychological and mental health | Mental illness, trauma history, stress, stigma, fear of discrimination | Screen for mental health concerns. Provide supportive, non-judgemental care. | Mental health services, counselling, psychology, community supports. |
| LGBTIQA+ considerations | Gender identity, sexual orientation, prior negative healthcare experiences | Use correct names and pronouns. Provide respectful, gender-affirming care. Avoid assumptions. | Referral to inclusive services. Ongoing GP support and follow-up. |
| Physical and functional health | Disability, obesity, chronic disease burden, mobility limitations | Assess functional capacity and physical limitations. Adapt management plans accordingly. | Allied health referrals. NDIS-linked services where appropriate. |
| Health literacy and engagement | Understanding of health information, confidence navigating the health system | Assess health literacy. Use plain language and written materials. | Education resources. Nurse follow-up and reinforcement. |
Special Population Considerations
Some population groups may delay or avoid healthcare due to stigma, discrimination, or previous negative experiences.
Groups more likely to experience disadvantage include:
- Socioeconomically disadvantaged people
- Aboriginal and Torres Strait Islander peoples
- People from culturally and linguistically diverse backgrounds
- People with serious mental illness
- LGBTIQA+ people
- People who are overweight or obese
- People with disability
A holistic approach requires awareness of these factors and proactive support to reduce barriers to care. Subject_ October 2024 Update_ N…
Preventive Care and Lifecycle Considerations
For patients with differing levels of risk, preventive care should be aligned with lifecycle stage and individual circumstances.
Clinicians should refer to lifecycle-based preventive recommendations and tailor care accordingly.
Review and Follow-up
Holistic needs should be reviewed regularly, particularly when social circumstances, mental health, or functional status change.
Care plans may require more frequent review and coordination
(Medicare item 967, where applicable).
Closing and Links
You can use our Care Plan Building Tool to incorporate holistic considerations into individualised care plans.
You can also explore our online courses, completed by thousands of health professionals worldwide, covering cultural safety, preventive care, and patient-centred practice.
Optional Note on Updates
This page is periodically updated.
Please check back for the latest version aligned with preventive care and equity-focused guidelines.