Extramural gerontology management devising an integrating record for a geriatric care service, an experience report.

Unlabelled: The Gerontological Care Plan is idealized through case management that includes in its aspect engaging the elderly, self-care and the acquisition and maintenance of health-promoting behaviors.

Objective: To evaluate the importance of a gerontological care plan, in a geriatric service of a referral hospital in the city of São Paulo.

Methods: Fifteen older adult patients were interviewed and the Gerontological Care Plan (PAGe) was applied.

Results: Most respondents were classified as independent for instrumental activities of daily living, 42% of whom lived alone. Data from 277 yellow sheets were analyzed, that is, referral forms, in which it was found that the most affected areas were: social work and psychology. For the social worker, the most recurring requests were: verification of the social support network, namely lack of companion and caregiver, with 53%; family problems, with 20%; lack of adherence to treatment, 12%, and problems related to medication, 10%. In the area of psychology, 82% of referrals were due to the need for psychological support, psychotherapy, and help with family problems, depression and grief.

Conclusions: A gerontological management proposal was developed within the Geriatric Services of Hospital das Clínicas. The management plan was intended to integrate the actions carried out by the interprofessional team, through the creation of an Integrating Form that allowed the gerontologist to propose, execute and implement a plan of care, follow-up, and monitoring of cases, including the extra context-hospital.