One Older Person, One Coordinated Care Plan: Why Shared Care Planning and Care Coordination Matter Across Viet Nam’s Care Continuum

One Older Person, One Coordinated Care Plan: Why Shared Care Planning and Care Coordination Matter Across Viet Nam’s Care Continuum

INTEGRATED CARE, CARE TRANSITIONS

Last reviewed: October 2026

An older person may see a cardiologist for heart failure, a rehabilitation team after a fall, a primary-care clinician for chronic disease follow-up and a community health worker at home. A family member may organize medications and appointments. After hospitalization, another team may provide discharge instructions, while care at home focuses on mobility, nutrition, daily activities or cognitive changes.

Each part of that care may be appropriate. The problem is what happens between them. Does everyone know what matters most to the older person? Are important changes visible to the next provider? Is there a clear understanding of who is responsible for follow-up? If the person deteriorates at home, does the family know whom to contact? When priorities or circumstances change, who makes sure the plan changes too?

For older people with multiple health, functional and social needs, quality depends on more than receiving good care from individual services. It also depends on whether those services work together around the same person. That is why shared care planning and care coordination matter.

One older person can have many providers, but care still needs one direction

Health systems are usually organized around organizations, specialties and episodes of care. Older people do not experience their lives that way. A person does not experience “cardiology,” “rehabilitation,” “community care” and “home care” as separate administrative systems. They experience one life in which health conditions, functional ability, medications, family relationships, living circumstances and personal goals interact every day.

This becomes especially important when several professionals are involved. One clinician may be trying to improve disease control, while another is concerned about dizziness and falls. Rehabilitation may focus on walking independently. The family may be most worried about confusion at night. The older person may care most about remaining at home or being able to attend a weekly community activity without assistance.

None of these priorities is necessarily wrong. The problem arises when they are managed separately. Individually reasonable decisions can become contradictory, burdensome or unrealistic when nobody brings them together. A coordinated care plan helps create a common direction by asking not only, “What treatment does this condition require?” but also, “What are we collectively trying to achieve for this person, and who is responsible for what?”

What a coordinated care plan is, and what it is not

A discharge summary, prescription, referral letter and appointment schedule can all contain important information, but none is automatically a coordinated care plan. A coordinated plan connects the older person’s goals with the health, functional and social issues that need to remain coherent across different parts of the care journey.

In practice, this may include the person’s priorities and goals, important health conditions and risks, functional and cognitive needs, current medications and significant recent changes, nutrition and mobility needs, relevant social and environmental circumstances, agreed interventions, responsibilities of different professionals and caregivers, follow-up arrangements, warning signs and escalation pathways, and when the plan should be reviewed.

The purpose is not to reproduce an entire medical record. Clinical records document care within organizations and encounters. A coordinated plan has a different purpose: to help the people involved understand what matters now, what needs to happen next and how their responsibilities connect.

Nor should “one plan” mean one permanent document. Older-person care changes. Function can decline after hospitalization and improve during rehabilitation. A caregiver may become unavailable. A new medication can cause an adverse effect. Cognition can fluctuate, and a fall, infection or new diagnosis can change priorities quickly. The goal is not one static file, but one coherent and current direction of care.

“Shared” also matters in two ways. The plan should be developed with the older person, not simply written for them, and the information needed for care should be available to appropriate people through lawful and properly governed processes. Neither should be assumed automatically.

WHO is placing personalized care planning at the center of integrated older-person care

WHO’s current Integrated Care for Older People, or ICOPE, guidance provides an important international reference point. The second edition of the ICOPE handbook, published in September 2025, describes four steps in the primary-care pathway: basic assessment, in-depth assessment, development of a personalized care plan, and implementation and monitoring. The handbook is designed for adaptation to local contexts and gives greater attention to community-level care, social support and the involvement of community health workers and other stakeholders.

This matters because personalized care planning is not treated as an administrative endpoint. The plan follows assessment and is followed by implementation and monitoring. Identifying needs is useful only if those findings are translated into agreed priorities and actions that can subsequently be followed, reviewed and adapted.

The broader direction of WHO’s work is also significant. In 2026, WHO convened a Technical Working Group to develop Global Standards for Quality Health Care Services for Older People. The standards are intended to define quality health care for older people and provide standards, indicators and implementation guidance for person-centered, integrated and responsive care. WHO has identified fragmented services, weak coordination across health and social care, limited workforce capacity and inadequate support for carers among the continuing gaps in older-person care.

For Viet Nam, the relevance is clear. The question is increasingly not only whether individual services exist, but whether they can work together around the needs and goals of an older person.

Viet Nam now has a stronger foundation, but not yet one shared plan across the continuum

Viet Nam’s policy environment for older-person care changed substantially in 2026. The Law on Population No. 113/2025/QH15, effective from 1 July 2026, recognizes self-care, care at home, care in the community, and care in older-person care facilities or medical examination and treatment facilities. It also calls for diversified forms of care that respond to older people’s level of autonomy and needs.

Decree No. 168/2026/NĐ-CP, also effective from 1 July 2026, provides more detail on home and community care. It recognizes community older-person care clubs and establishes community day-care points as a specific model under commune health stations. These day-care points do not provide medical examination and treatment services; their functions include health and self-care guidance, physical activities and support with activities of daily living. The Decree also gives commune health stations roles in training and assigning certain people involved in community-based care.

Decision No. 1116/QĐ-TTg of 22 June 2026 further updates the Older People Health Care Program to 2030. From 2026, older people are to receive a free periodic health examination or screening at least once a year and have health-monitoring and management records established. The Decision also sets 2030 targets for community care clubs, volunteer teams, day-care models and geriatric services.

Most directly relevant to care planning, Ministry of Health Decision No. 1976/QĐ-BYT of 1 July 2026 issues professional guidance for older-person care at home and in the community. It brings important elements of the ICOPE approach into this guidance, including screening of intrinsic capacity and an individual care-planning process. The workflow involves reviewing assessment information, setting person-centered goals according to the wishes of the older person, and discussing and agreeing on proposed care. The application can then generate the individual care plan as a PDF for storage or sharing, including submission to the commune health station.

Circular No. 34/2026/TT-BYT, effective from 8 September 2026, provides further implementation mechanisms through the National Target Program on Health Care, Population and Development. For community-based older-person health care, it assigns responsibilities to the Department of Population, provincial health authorities and commune health stations for training, guidance and implementation, with activities explicitly linked to the professional guidance in Decision 1976.

These are important developments. Together, they create a stronger foundation for assessment, individual care planning, community support and health management than existed previously. But an important distinction should remain clear: the 2026 national instruments reviewed for this article do not establish a single shared care plan that is required to follow an older person across hospital, specialist care, primary care, home, community and long-term care settings. Nor do they establish a universal care-coordinator role responsible for every older person across that entire continuum.

“One Older Person, One Coordinated Care Plan” should therefore be understood as a quality and implementation principle, not as a description of a national legal requirement that already exists. The opportunity is to build on the foundations now being created.

What good coordination should look like in practice

A useful plan should begin with the older person rather than with a list of diagnoses. For one person, the priority may be walking safely to a nearby market. For another, it may be staying at home despite increasing dependence. Someone else may value avoiding repeated hospital visits, controlling pain, maintaining cognition or continuing an important family or community role.

Those priorities can affect clinical decisions. More intensive treatment for one disease may have limited value if it worsens dizziness or falls. A medication may improve one symptom but reduce appetite or worsen cognition. A rehabilitation plan may be clinically sound but difficult to follow in the person’s home. A care plan may assume that a family member can provide support when that person is working full time, lives elsewhere or is physically unable to perform the expected tasks.

Good coordination therefore connects what matters to the older person with what professionals consider clinically necessary, safe and realistically achievable. It should also make responsibilities visible. If a referral is needed, who arranges it? If a medication changes, who makes sure the current list is understood? If function deteriorates, who reassesses the plan? If an agreed follow-up does not happen, who notices?

The intensity of coordination should reflect complexity. A healthy and independent older person with stable needs may require relatively little formal coordination, while a person living with multimorbidity, frailty, cognitive impairment, complex medications, repeated admissions and substantial social-care needs may require much more active support.

Recent evidence supports this direction without suggesting that one model fits every health system. A 2026 systematic scoping review of 181 studies across 26 countries found that multidisciplinary delivery was common and that care coordination or personalized care planning featured in about two-thirds of integrated-care interventions for older adults in primary health care. The authors also found that implementation outcomes such as feasibility, acceptability and fidelity were assessed much less consistently, while evidence remained concentrated in higher-income settings.

A separate 2026 review of care coordination for older adults with long-term-care needs found that coordination was commonly undertaken by a designated health or social-care professional who assessed needs and helped develop and monitor a care plan with a multidisciplinary team. However, most of the evidence came from North American community programs, with relatively little information from lower- and middle-income countries or institutional long-term-care settings. Limited time, inadequate training and fragmented communication were recurring implementation challenges.

For Viet Nam, the lesson is not that every older person needs a new professional called a “care coordinator.” Depending on the setting and level of complexity, coordination might be undertaken by an appropriately trained primary-care professional, nurse, geriatric-team member, case manager or another clearly designated professional within an agreed model. The title is less important than knowing who is responsible.

Transitions are where coordination is tested

Care fragmentation often becomes most visible when an older person crosses a boundary: hospital to home, hospital to rehabilitation, rehabilitation to community care, home to a long-term-care facility, or community care back to hospital.

At these moments, information and responsibility can easily be lost. A medication may have been stopped in hospital but remain on an old list at home. Rehabilitation recommendations may not reach the people supporting the person day to day. Follow-up may be recommended without clarity about who arranges it. A receiving provider may know the diagnoses but not understand what changed during the previous episode of care or what the older person is now trying to achieve.

A 2026 systematic umbrella review of care transitions involving older adults identified recurring organizational risks related to communication, discharge documentation and coordination. Frequently studied interventions included discharge planning, medication management, patient education, interdisciplinary collaboration and home-based interventions. The review also emphasized that transitional-care interventions are usually multifaceted and need to be adapted to context rather than treated as one universal package.

A coordinated plan therefore provides a simple test of transition quality: does the next person responsible for care know what changed, what matters now and what needs to happen next?

Family caregivers are often central to this process in Viet Nam, but they should not become the default coordinators of a fragmented system. Families may organize appointments, help with medications, observe changes and communicate with professionals, yet they should not have to reconstruct the clinical story independently for every provider or decide which of several conflicting instructions is current. Their involvement should also reflect the older person’s wishes, autonomy and confidentiality. The family can be an essential partner in coordination, but it should not be the mechanism that compensates for the absence of coordination.

Information needs to follow the person, with appropriate governance

Shared planning requires information continuity, but better coordination does not mean unrestricted information sharing. Viet Nam’s Law on Personal Data Protection No. 91/2025/QH15 has been effective since 1 January 2026. Article 26 contains specific provisions governing personal data related to health information, including consent requirements subject to statutory exceptions and restrictions on providing such data to third-party health-care or insurance providers.

Any cross-organizational shared-care model therefore needs to be designed within Viet Nam’s applicable personal-data, confidentiality and health-information requirements. The objective should be appropriate information continuity: ensuring that authorized people have the information genuinely needed to provide safe, coordinated care while maintaining privacy, security, confidentiality and the older person’s rights.

Digital technology may make this easier, but technology does not create coordination on its own. A shared electronic record cannot decide who follows up when responsibility is unclear. Interoperability cannot reconcile conflicting goals between providers. A digital care plan that is never updated can preserve outdated information more efficiently without improving care.

Technology should therefore follow the care model. Before choosing software, organizations need to understand what information should move across settings, who creates and verifies it, who updates it, who needs access, what happens when the person’s circumstances change and what action should occur when an agreed step is missed. Only then does digitization become an enabler of coordination rather than another layer of documentation.

Where could coordination be anchored in Viet Nam?

Viet Nam’s 2026 framework gives commune health stations an increasingly important role in home- and community-based older-person care. Under Decision 1976, screening information and individual care plans can be sent to the commune health station, which also has roles in identifying impairments and care needs and advising on referral where appropriate. Circular 34 reinforces commune-level responsibilities for training volunteers and providing older people and family caregivers with guidance on self-care and care at home and in community day-care settings.

This creates an opportunity for commune health services to become an important local point of continuity, particularly after hospital treatment and between specialist encounters. A local team may be well placed to understand the person’s home environment, observe changes in function, support families and reconnect the person with higher-level services when needed.

That does not mean commune health stations currently hold responsibility for coordinating the entire hospital-to-long-term-care continuum. Complex older-person care may also require coordination from hospitals, geriatric services, rehabilitation teams, primary-care providers, long-term-care organizations or other services depending on the person’s needs and the local model. The implementation challenge is therefore not simply to decide which organization “owns” older-person care, but to establish reliable interfaces between them.

Can relevant hospital information reach the local team in a timely and usable form? Can community teams contact hospital or specialist services when clarification is needed? Are important medication changes visible? Is there a clear pathway for deterioration or reassessment? Can changes identified at home flow back to the professionals responsible for clinical decisions? Effective coordination requires communication in both directions.

Measure whether care is actually coordinated, then start small and learn

If coordinated care planning is introduced, the easiest indicator may be the percentage of eligible older people with a completed care plan. That can be useful for measuring coverage, but it does not show whether coordination actually occurred.

A plan may exist while being outdated, inaccessible to the next provider or disconnected from the older person’s priorities. Measurement should therefore look beyond the presence of a document. Useful questions might include whether person-centered goals were recorded, responsibility for key actions was clear, relevant information reached the next provider, planned follow-up occurred, the older person and caregiver understood what should happen next, and the plan was reviewed after an important change.

These are illustrative quality questions, not a proposed national indicator set for Viet Nam. The objective is not to create another large dashboard. It is to determine whether the plan actually helped different parts of care work together.

Viet Nam also does not need to wait for a nationwide interoperable system before learning what works. Practical pilots could begin around clearly defined populations and transitions. A hospital and selected commune health stations could test a common care-plan and follow-up process for older people with frailty after discharge. A geriatric service could test more active coordination for people with repeated admissions and complex needs. A home- and community-care program could examine whether individual care plans remain current and useful several months after assessment.

The most valuable pilot questions would not be simply, “Can we complete the form?” They would be: Who should maintain the plan? What information is genuinely useful? Which transitions create the greatest risk? Can existing staff realistically sustain the process? Does the older person understand and value the plan? Does the receiving provider actually use it? What governance is needed for information sharing? What measures show that care became more coordinated rather than simply more documented?

This local learning matters because much of the international evidence on integrated care and care coordination still comes from higher-income health systems. Viet Nam needs models that fit its own workforce, financing arrangements, primary health-care infrastructure, family-care context and developing long-term-care system.

One coordinated plan is ultimately about one coherent care journey

Older-person care will always involve multiple professionals and organizations. Hospitals, specialist services, rehabilitation, primary care, community programs, home care and long-term-care providers perform different functions, and specialization remains necessary. Integration does not require making those services the same. It requires making their work coherent from the perspective of the person receiving care.

Viet Nam now has stronger foundations for doing this. The Population Law recognizes a broader continuum of older-person care. Decree 168 develops home and community models. Decision 1116 strengthens health monitoring and national older-person health objectives. Decision 1976 introduces a practical pathway for assessment and individual care planning in home and community care, while Circular 34 supports wider implementation. The next challenge is connecting these pieces.

For health and care organizations, the most useful question is therefore not simply, “Does this older person have a care plan?” It is: “Do the older person, the family where appropriate, and the professionals involved understand the same priorities, know what each person is responsible for, and have a reliable way to keep care coordinated when needs change or the person moves from one setting to another?”

When the answer is yes, a care plan becomes more than documentation. It becomes part of the infrastructure for continuity, safety and person-centered care. That is why shared care planning and care coordination are not merely administrative issues. They are quality, safety and implementation issues across the entire older-person care continuum.

References

1. World Health Organization. Integrated care for older people (ICOPE): guidance for person-centred assessment and pathways in primary care. 2nd ed. 2025.

2. World Health Organization. WHO Global Standards for Quality Health Care Services for Older People — Technical Working Group Members. 23 August 2026.

3. National Assembly of Viet Nam. Law on Population No. 113/2025/QH15. 10 December 2025; effective 1 July 2026.

4. Government of Viet Nam. Decree No. 168/2026/NĐ-CP detailing provisions and implementation measures of the Law on Population. 15 May 2026; effective 1 July 2026.

5. Prime Minister of Viet Nam. Decision No. 1116/QĐ-TTg amending Decision No. 1579/QĐ-TTg approving the Older People Health Care Program to 2030. 22 June 2026.

6. Ministry of Health of Viet Nam. Decision No. 1976/QĐ-BYT issuing professional guidance on care for older people at home and in the community. 1 July 2026.

7. Ministry of Health of Viet Nam. Circular No. 34/2026/TT-BYT guiding selected components of Phase I (2026–2030) of the National Target Program on Health Care, Population and Development 2026–2035. 8 September 2026.

8. National Assembly of Viet Nam. Law on Personal Data Protection No. 91/2025/QH15. 26 June 2025; effective 1 January 2026.

9. Sun M, Liu J, Yi M, et al. Implementing integrated care for older adults in primary health care: A systematic scoping review. International Journal of Nursing Studies. 2026;176:105342. doi:10.1016/j.ijnurstu.2026.105342.

10. Grande de França N, de Souto Barreto P, Jang H, Cesari M, Rolland Y. An overview of care coordination elements for older adults with long-term care needs: A narrative review. Archives of Gerontology and Geriatrics. 2026;141:106077. doi:10.1016/j.archger.2025.106077.

11. Wagenaar B, Schouten B, Ket JCF, Wagner C, Merten H. Addressing organizational risk factors and interventions during transitions of care for older patients: a systematic umbrella review. BMC Health Services Research. 2026;26:530. doi:10.1186/s12913-026-14222-w.