CHRONIC DISEASE MANAGEMENT	
COMBINED GP MANAGEMENT PLAN AND TEAM CARE ARRANGEMENTS (MBS ITEMS 721 AND 723)	

GP Management Plan (721) Component	

Patient’s Name	Date of Birth	Contact Details	Medicare or Private Health Insurance Details	
<<Patient.Full Name>>	 <<Patient.Date Of Birth>>	 <<Patient.Address>><<Patient.Phone>>	 <<Patient.Medicare No>>	

Details of Patient’s Usual GP	Details of Patient’s Carer (if applicable)	
 DR Christine Ellison (Provider Number: 16809H)
 DR Nadine CDMPlus (Provider Number: 18954J)
<<Health Service.Clinic Details>>	<<Patient.Emergency Contact Details>>	

MEDICATIONS	
<<Clinical Record.Current/Regular Medication>>	

ALLERGIES	
<<Clinical Record.Alerts and Other Information>>
<<Clinical Record.Adverse Reactions (Drug)>>
<<Clinical Record.Adverse Reactions (Non-Drug)>>	

PAST HISTORY	
<<Clinical Record.Clinical Items Summary (Details)>>	

IMMUNISATIONS	
<<Clinical Record.Immunisations>>	

FAMILY HISTORY	
<<Clinical Record.Latest Qualifier (Name and Value)=RELEVANT FAMILY HISTORY>>	

SOCIAL HISTORY	
<<Clinical Record.Latest Qualifier=SOCIAL HISTORY>> 	

PROGRESS NOTES	
<<Current Service.Progress Note>>	

INVESTIGATIONS/RESULTS	
<<Clinical Record.Investigation Results>>	

QUALIFIERS	
<<Clinical Record.Qualifier Summary>>	

Patient’s Name: 	<<Patient.Full Name>>	

I have explained the steps and costs involved, and the patient has agreed to proceed with the service.	
GP’s Signature:  			                     	Date: <<Miscellaneous.Today's Date (dd/mm/yyyy)>>	

GP MANAGEMENT PLAN	
Patient problems, needs, and relevant conditions	Goals – changes to be achieved	Required treatments and services including patient actions.	Arrangements for treatment or services (when, who, contact details)	GPMP/ TCA Review
Date: 	GPMP/ TCA Review
Date:	GPMP/ TCA Review
Date:	
Diabetes	Blood Glucose Level: 6-8 mmol (FASTING) and 8-10 mmol (NON-FASTING)
BP Target: < 130/80
HbA1c: 6.5 -7.5%
Total Cholesterol: < 4.0 mmol/L
Urine ACR: < 3.5 mg/mmol (WOMEN) and < 2.5mg/mmol (MEN)
2-3 session of resistance exercise.
Correct Device Use.
Identify and reduce impact of diabetes as a risk factor for chronic conditions.
Identify barriers to self-management.
Minimise medication side effects.
Reduce sedentary behaviours.	Education about  Diabetes
Review goals, individual targets and risk factors.
Review cycle of care requirements
Optometrist - eye examination
Referral to Podiatrist
Review by Endocrinologist
At least 6 monthly: review weight, height, BMI, BP and assess feet.
Annual ECG	GP
Nurse
Diabetes Educator
Podiatrist
Endocrinologist				
Heart Disease	Blood Pressure target: < 130/80
Lipids: LDL-C <1.8mmol/L
 HDL-C >1.0mmol/L
 TG <2.0mmol/L
Improve knowledge of condition
Identify and modify CV risk factors
Psychosocial Wellbeing	Annual ECG
Assess albuminuria (uACR)
Assess for comorbid depression
Provide education about CVD
Referral to Cardiac Rehab
Review Absolute CR every 6-12 months
Review by Cardiologist
Review pharmacological management	GP
Nurse
Cardiologist				
Chronic Kidney Disease	Early detection and management of complications
Reduce Progression Of Chronic Kidney Disease (CKD)	Education
Consider nephrologist review
Bloods 3-6monthly	GP
Nurse/AHW				
COPD	Correct inhaler or device technique
Improve knowledge of condition and the role of self-management
Maintain COPD Action Plan
Maintain lung function
Reduce exacerbations	Annual COPD Action Plan
Annual Spirometry
Referral for Pulmonary Rehab
Review by Respiratory Physician
Engage patient with respiratory care nurse
Observe correct inhaler/medication technique
Provide education about COPD	GP
Nurse
Respiratory Physician
Respiratory Nurse				
Asthma	Access to written asthma action plan
Be able to detect deterioration in asthma and respond appropriately
Best lung function or PEFR on spirometry
Confirm Diagnosis
Correct Inhaler Technique
Improve knowledge of condition and role of self-management
Minimise medication side effects and support adherence
Optimise asthma control
Reduce the frequency and severity of asthma attacks	Annual Spirometry
Appropriately manage flare-ups when they occur
Current Asthma Action Plan
Education about Asthma
Observe inhaler technique
Patient to avoid known triggers
Peak flow (if recommended) 	GP
Nurse				
Dementia/ Alzheimers	Providing a safe environment	ACAT
Home help
Support services & networks
Carer
Respite	GP
Nurse/AHW				
Osteoporosis	Adequate protein intake
Exercise
Maintain health weight and BMI
Optimal calcium and vitamin D levels
Reduce the risk of falls
Patient access to education and psychosocial support	Encourage exercise participation
3-6 month review after commencing pharmacological interventions
Follow-up BMD testing
Provide education and psychosocial support
Falls prevention Program	GP
Nurse/AHW				
Social Emotional Wellbeing

	Maintaining health and wellness	Mindfulness
Counselling
Screening
Education 
Programs	GP
Nurse/AHW				
LIFESTYLE							
Smoking	Complete cessation	Smoking cessation strategy:
Consider:
- Quit
- Medication	Patient to manage
GP to monitor and support				
Alcohol intake	Limit alcohol intake
Target:No safe level of drinking

Reduce harm by:
 no more than 10 standard drinks per week AND
 no more than 4 standards drinks on any one day
Women who are pregnant or breastfeeding should not drink alcohol
	Reduce alcohol intake
Patient education - including dangers of driving after drinking	Patient to manage
GP to monitor and support				
Diet	Diet rich in fruit and vegetables, low in salt and saturated trans fats	Recommend Diet rich in fruit and vegetables
Low in salt and saturated trans fats
Decrease take away to once a week	Patient to implement
GP to monitor 
Dietitian				
Physical Activity	At least 30 minutes of moderate intensity physical activity on most or preferably every day of the week	Patient exercise routine	Patient to implement
GP to review
Exercise Physiologist
Personal Trainer				
Vaccine preventable disease	Up to date immunisations	Annual Influenza
Pneumococcal
Zostavax	GP
Nurse/AHW				
Cancer Screening- WOMEN	Screening & Early detection of cancers	Bowel Screening
Cervical Screening
Mammogram
Skin Check	GP
Nurse/AHW				
Cancer Screening-MEN	Screening & Early detection of cancers	Bowel Screening
Skin Check	GP
Nurse/AHW				
Medication 	Correct use of medications, minimise side effects	Patient education
Review medications
HMR Referral	GP
Pharmacy				

Copy of GPMP offered to patient? YES	Copy/relevant parts of GPMP supplied to other providers? YES	GPMP added to patient’s record? YES	

Date service was completed: <<Miscellaneous.Today's Date (dd/mm/yyyy)>>	Review Date: 3 MONTHS	

Does the patient require and qualify for a Team Care Arrangement service? YES	

Patient’s Name: <<Patient.Full Name>>

Team Care Arrangements (723) Component	

I have explained the steps and costs involved, and the patient has agreed to proceed with the service. The patient also agrees to the involvement of other health providers and to share clinical information without/with restrictions (identify)	
GP’s Signature:  	                   	Date: <<Miscellaneous.Today's Date (dd/mm/yyyy)>>	

TEAM CARE ARRANGEMENTS	
Specialist	Allied Health	Other/Programs	
 Cardiologist
 Respiratory Physician
 Nephrologist
 Neurologist
 Ophthalmologist
 Pain Specialist
 Endocrinologist 
 Rheumatologist 
 Gastroenterologist  
 Skin Specialist 
 Haematologist 
 Geriatrician 
 Psychiatrist

	Podiatrist
Dietitian
Exercise Physiologist
Aboriginal Health Worker
Optometrist
Speech Pathologist
Occupational Therapist
Psychologist
Mental Health Worker
Pharmacist	ITC
Pulmonary Rehab
Another GP 
Falls Prevention Program 
Drug & Alcohol Services	

Copy of TCA offered to patient? YES	Copy/relevant parts of the TCA supplied to other providers? YES	
TCA added to the patient’s records? YES
	Referral forms for Medicare allied health and dental care services completed? YES	

Date service was completed: <<Miscellaneous.Today's Date (dd/mm/yyyy)>>	Review Date: 3 MONTHS