<<Miscellaneous:Practice Letterhead>>
  
GP MANAGEMENT PLAN/TEAM CARE ARRANGEMENTS	

Patient’s Name: <<Patient Demographics:Full Name>>
Date of Birth: <<Patient Demographics:DOB (long)>>
Medicare No: <<Patient Demographics:Medicare Number>>
Address: <<Patient Demographics:Full Address>>
Patient's Carer: <<Name of Patient’s Carer (if applicable):>>
Relationship to Patient: <<Relationship of Carer to Patient>>
Tel: <<Contact Telephone or Mobile No of Carer >>	 Details of Patient’s Usual GP:
Name: <<Doctor:Name>>
Practice Address: <<Doctor:Address Line 1>><<Doctor:Address Line 2>><<Doctor:City>><<Doctor:Postcode>>
Phone: <<Doctor:Phone>>
Fax:<<Doctor:Fax>>
Provider No: <<Doctor:Provider Number>>	

PAST MEDICAL HISTORY:
<<Clinical Details:History List>>

FAMILY HISTORY:
<<Clinical Details:Family History>>

SOCIAL HISTORY:
<<Clinical Details:Social History>>

MEDICATIONS:
<<Clinical Details:Medication List>>

ALLERGIES/ADVERSE REACTIONS:
<<Clinical Details:Allergies>>

IMMUNISATIONS:
<<Clinical Details:Immunisation List>>

SMOKING:
<<Clinical Details:Smoking>>
<<Clinical Details:Smoking Quitting Stage>>

ALCOHOL:
<<Clinical Details:Alcohol>>

PROGRESS NOTES:
<<Summary:Progress Notes (Selected)>>
Patient’s Name: <<Patient Demographics:Full Name>>

GP MANAGEMENT PLAN/TEAM CARE ARRANGMENT	

Patient problems / needs / relevant conditions	Goals - changes to be achieved	Required treatments and services including patient actions	Arrangements for treatments/services (when, who, contact details)	
1. Lifestyle				
Nutrition	Diet rich in fruit and vegetables, low in salt and saturated trans fats	Patient education

	Patient to implement
GP to monitor 
Dietitian	
Weight	Your target: BMI <   
Ideal: BMI ≤ 25 kg/m2
Wait Circumference: Men <94cm and
Women <80cm	Monitor
Review 6 monthly
	Patient to monitor
GP to review	
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	
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

	Patient to manage
GP to monitor and support	
2. Biomedical				
Blood pressure	Your target: < 
Ideal:  < 130/80 mm Hg	Check every 6 months	GP 
Nurse	
3. Immunisations				
Influenza	Prevent Infuenza	Annual Immunisation	GP/Nurse	
Pneumococcal	Prevent meningitis, pneumonia and bacteraemia		GP/Nurse	
4. Medication				
Medication review	Correct use of medications, minimise side effects	Patient education
Review medications
HMR Referral	GP to review and provide education
Pharmacy	
5. Conditions				
Cardiovascular 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	
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.	GP
Nurse
Diabetes Educator
Podiatrist
Endocrinologist	
Chronic Kidney Disease (CKD)	Early detection and management of complications
Reduce Progression Of Chronic Kidney Disease (CKD)	Education about Chronic Kidney Disease (CKD)
Review by Nephrologist	GP
Nurse
Nephrologist
	
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 adeherence
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	
COPD

	Correct inhaler or device technique
Imrpove 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	
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 reivew after commencing pharmacological interventions
Follow-up BMD testing
Provide education and psychosocial support
Falls prevention 	GP
Nurse
	
6. Cancer Screening				
Cancer Screening-MEN	Early detection of cancers
Identify and reduce cancer risk factors	Bowel Screening (IFOBT every 2 years).
Skin Check - regular self check and 6/12 clinical exam if high risk	GP 
Nurse	
Cancer Screening- WOMEN	Early detection of cancers
Identify and reduce cancer risk factors	Bowel Screening - IFOBT every 2 years
Cervical Screening - HPV test every 5 years (25-74)
Mammogram (second yearly mammogram (ages 50-74)
Skin Check - regular self check and 6/12 clinical exam if high risk	GP
Nurse	

Copy of GP Management Plan offered to patient?  YES

Copy / relevant parts of the GP Management Plan supplied to other providers?  YES

GP Management Plan added to the patient’s records?  YES

Date service was completed:  <<Miscellaneous:Date (long)>>	Proposed Review Date:  3 months	

I have explained the steps and any costs involved, and the patient has agreed to proceed with the plan YES
 GP’s Signature:  x_______________________________________________	Date: <<Miscellaneous:Date>>
   GP Name:  <<Doctor:Name>>

INVESTIGATIONS:
<<Summary:Investigation Results (Selected)>>