Assessment and personal goals
Review of current care, functional ability and the person’s priorities to establish goals and a suitable follow-up plan.
Care services · Accra, Ghana
Care for long-term conditions
We support people living with hypertension, diabetes, the effects of stroke and other ongoing care needs through monitoring, education and coordination with their existing healthcare providers.
Care starts with a conversation and an agreed support plan.
The support we provide
Care shaped around
the person’s needs.
Managing a long-term condition involves care between appointments as well as during them. We help connect professional guidance with everyday life at home, considering the person’s priorities, medicines, mobility and caregiver support.
An initial assessment guides the care plan and review schedule. Monitoring and education are tailored to the individual, with documented follow-up and referral when a change needs attention from the treating clinician.
Appropriate health monitoring
Blood-pressure or glucose monitoring when relevant to the condition and clinical plan, with results recorded for professional review.
Medication reconciliation and adherence
Support with accurate medication information and the existing prescribing plan. Medication changes are handled by the appropriate clinician.
Understanding everyday care
Education about relevant condition-related care, nutrition and lifestyle topics, aligned with the responsible professional’s guidance.
Stroke and frailty support
Review of mobility, home safety and caregiver needs, with coordination of rehabilitation or other professional input.
Caregiver education and follow-up
Practical communication with agreed family contacts, review of the care plan and coordination with treating providers when needs change.
Your care arrangements
How care is arranged
- Step 1
Review the care already in place
We discuss your condition, existing providers, recent hospital care and the support you want at home.
- Step 2
Agree goals and follow-up
An appropriate professional assesses needs and agrees monitoring, visit frequency, family involvement and costs.
- Step 3
Monitor, review and coordinate
We document follow-up, discuss changes and connect you with the relevant clinician or service when further assessment is needed.
Preparing for an assessment
- Have current care instructions, treating-provider details and relevant recent results available for assessment.
- Prepare a medication and allergy list and questions about your ongoing care.
- Consider your care goals, mobility needs and support available between appointments.
Keep medical records and detailed health information out of general email enquiries. If an assessment is arranged, the team explains how to share information appropriately.
Questions about this service
Frequently asked questions
Will GHCS replace my usual clinician?
We coordinate with existing care. Diagnosis, prescribing and treatment decisions remain with appropriately qualified professionals, and we help keep follow-up connected.
How often will follow-up take place?
The schedule is based on assessment, the clinical plan and the support needed. We discuss the frequency and review arrangements with you before care begins.
Can family caregivers be involved?
Yes, with the person’s agreement. Family contacts can participate in planning and education, with health information shared through appropriate confidential arrangements.