Planning
Core content
Planning translates diagnosis into an individualized, evidence-based, mutually agreed course of action. A complete plan includes a problem list, measurable goals, guideline-concordant therapy, shared decision making, patient education and self-management support, attention to health literacy and social determinants (cost, transportation, food access, caregiver capacity), preventive care, referrals, and a documented follow-up interval.
Know that guidelines are starting points, not mandates. Glycemic targets, blood pressure goals, and lipid therapy are individualized by comorbidity burden, life expectancy, hypoglycemia risk, and patient preference. Preventive care should be reconciled at every visit - immunizations, cancer screening, bone health, tobacco cessation - even when the visit focus is a chronic problem.
Traps
The most common trap is rigid application of population guidelines to frail older adults. An A1c below 7% may be appropriate for a healthy 65-year-old but harmful in a frail 88-year-old taking insulin. Watch for stems where the correct answer is to deintensify, deprescribe, or address goals of care rather than add another medication. Also watch for plans that ignore cost and insurance coverage, intensify therapy without exploring adherence barriers, or state vague goals ("eat better") instead of measurable ones.
Rule of thumb
Every plan should answer three questions: What is the goal, in numbers and in function? What will this patient realistically do? How and when will we know it is working?
Worked example
An 82-year-old with frailty, A1c 7.4% on glyburide, and two recent falls. Guideline-concordant individualization: relax the target to 7.5–8.0%, stop glyburide because of hypoglycemia risk, consider metformin if kidney function permits, address the falls, and schedule follow-up in three months with A1c and a basic metabolic panel.