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| Name | Input | Activity | Output | Required knowledgebase |
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| 1: assess the person's ability | 1-1 | 1-1: evaluate person's condition | Attribute of the person | Evaluate person's condition | Results of assessment of the person | Ability assessment sheet |
| | 1-2 | 1-2: determine actual abilities | Results of assessment | Determine actual ability of the person on the basis of the results of 1-1 | Actual abilities | (Logic for determining actual abilities: included in ability assessment sheet) |
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| 2: assess home/facility condition | 2-1 | 2-1: evaluate home/facility condition | Attribute of the home/facility | Evaluate environmental condition of the home/facility, where the person will live | Results of assessment of the home/facility | Home/facility assessment sheet |
| | 2-2 | 2-2: reflect home/facility condition | Results of assessment of the home/facility | Limit selectable realization pattern and care option on the basis of the results of 2-1 | (i) Limited selectable realization patterns
(ii) Limited selectable care options | (Table of limitation to realization pattern and care option: included in the home/facility assessment sheet) |
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| 3: assume a hypothetical way of daily living | 3–1 | 3–1: create a hypothetical mode of life | (i) Limited selectable realization patterns
(ii) Hopes of the person/families | Set (multiple) realization patterns for the person on the basis of the results of 2-2, considering the hopes of the person/families | Realization patterns to be achieved | (List of Realization Pattern: included in the table of required ability for element action) |
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| 4: identify care needs | 4–1 | 4–1: identify care needs | (i) Realization patterns to be achieved
(ii) Actual abilities | Identify person's care needs as gaps between required ability for (multiple) realization patterns set in 3–1 and actual abilities determined in 1-2 | Care needs | Table of required ability for element action |
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| 5: design care program (preliminary) | 5–1 | 5–1: evaluate care options | (i) Care needs
(ii) Limited selectable care options
(iii) Actual abilities | Evaluate practicability of care options to meet the person's care needs identified in 4–1 and actual abilities determined in 1-2 | Practicable care options | Table of required ability for care |
| | 5–2 | 5–2: design care program | (i) practicable care options
(ii) hopes of the person/families | Determine care to be provided and design care program from the care options found practicable in 5–1, considering the hopes of the person/families | (i) Care to be provided
(ii) Care program | — |
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| 6: design long-term care service plan | 6–1 | 6–1: evaluate care service options | Care to be provided | Determine care services to implement elderly care selected in 5–2 | Care services to be included | Table of care service option |
| | 6–2 | 6–2: design care service plan | (i) care services to be included
(ii) hopes of the person/families
(iii) social factors | Design a long-term care service plan on the basis of the results of 6–1, considering the hopes of the person/families | Long-term care program | (Design item (PIC, Timeline, etc.)) |
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