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Clinical guidelines

General practice management of type 2 diabetes 2014–2015

Appendix D: Structured patient-centred care plan/General Practice Management Plan and Patient Care Plan

<Insert practice letterhead>

General Practice Management Plan (MBS Item 721, Diabetes)
Patient name: Date of birth:
<<Full name>> <<DOB>>
Contact: Medicare or private health insurance:
<<Address>> <<Medicare number>>
<<Telephone>> <<Health insurance>>
Date of last GPMP (if done): <<Date>>
This Diabetes Care Plan was developed by staff at the [insert name] Medical Centre. While it specifically relates to management of your diabetes, your other health problems will also be considered. This care plan utilises the skills of many health professionals to help you to have the best of healthcare and for you to manage your diabetes.
This plan focuses on proven therapies that, with support and care, may help prevent complications. Diabetes is best treated early and may be difficult to treat when
complications arise. The management goals in this plan are set by National Diabetes expert bodies. Your diabetes will be monitored against these goals.
This plan encourages you to be actively involved in your care. It is important that you
and your healthcare team monitor your diabetes and report anything that is untoward.
We particularly urge you to report any chest pains, unexplained weakness, foot problems, visual changes, or any symptom that concerns you.
Emergency contact at [insert name] Medical Centre for diabetes – [name] [contact number]
This document should be brought along with you to each visit to the dietitian, diabetes educator, practice nurse, other health professional and to the doctor when your review is due.

Management plan outcomes

Patient needs To become educated regarding diabetes and appropriate preventative activities.
To appropriately manage medication for diabetes and other supportive therapies.
[Insert individual patient needs]
Management goals To lead a happy healthy lifestyle.
To progress toward/achieve recognised goals for diabetes care.
To prevent onset or progression of CVD or its complications.
To remain free of serious side effects from medication.
To minimise the burden of diabetes management and care.
Treatment services To participate in structured care system at the [insert name] Medical Centre.
To involve other health service providers
[Insert individualised patient treatment services]
to assist in provision of services.
Patient actions To undertake appropriate lifestyle measures (e.g. quit smoking, regular exercise, dietary changes).
To participate in this management plan and to self-monitor impact of illness.
To become educated regarding diabetes.
[Insert individualised patient actions]
Monitoring and review The first review will usually be at 1 week to 1 month – to monitor impact of any initial or ongoing therapy medication and other strategies.
Every 3–6 months a major review of the management plan goals will occur.
Thereafter reviews will depend on response to therapy and complexity of all health issues.
A recall will be instituted at least every 3 months to monitor progress.
Review date [Insert review date]

Past medical history
Family history
<<Clinical details of family history>>
Medications
<<Clinical details – medication list>>
Allergies
<<Allergy details>>
Social history

Patient name: <Full name>

GPMP (MBS Item 721, Diabetes)
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. General
Patient’s understanding of diabetes and self-management Patient to have a clear understanding of diabetes and patient’s role in managing the condition Patient education GP/nurse/dabetes educator
  Patient to understand the role of self-monitoring of glucose if this is required Patient education GP/nurse/diabetes educator
2. Lifestyle
Nutrition Normal healthy eating
If concerns regarding cardiovascular risk, advise Mediterranean diet
Patient education
OR
As per Lifescripts action plan
GP to monitor
Dietitian
Weight/BMI Your target:___
Therapeutic goal is 5–10% loss for people overweight and obese with type 2 diabetes
With BMI >35 and comorbidities or BMI >40, greater weight loss measures should be considered
Monitor
Review 6 monthly
OR
As per Lifescripts action plan 
Patient to monitor
GP/nurse to review
Dietitian when appropriate
Physical activity Your target:___
At least 30 minutes of moderate physical activity on most if not all days of the week (total ≥150 minutes/week)
Patient exercise routine
OR
As per Lifescripts action plan
GP/exercise physiologist
Patient to implement
Smoking Complete cessation Smoking cessation strategy:Consider:
- quit
- medication
OR
As per Lifescripts action plan
Patient to manage
GP to monitor
Alcohol intake Your target:
<___ standard drinks/dayHealthy:
≤2 standard drinks/day (adults)
Reduce alcohol intake
Patient education
OR
As per Lifescripts action plan
Patient to manage
GP to monitor
3. Biomedical
Cardiovascular risk calculation      
Cholesterol/lipids Cholesterol level to accepted national target Initiation of pharmacotherapy is dependent on the assessment of absolute cardiovascular risk (Australian absolute CVD risk calculator). This requires using multiple risk factors, which is considered more accurate than the use of individual parameters
Once therapy is initiated the specified targets apply; however, these targets are somewhat arbitrary and should be used as a guide to treatment, and not as a mandatory requirement
Check every 6 months
GP
BP BP to accepted national target GP/nurse
HbA1c Your target: <___
Healthy:
≤53 mmol/mol (range 48–58 mmol/mol)
≤7% (range 6.5–7.5%)
Needs individualisation according to patient circumstances
Check every 3–6 months or as advised by your GP
GP/nurse
Blood glucose level Healthy:<6–8 mmol/L fasting
SMBG on an ongoing basis should be available to those people with diabetes using insulin, with haemoglobinopathies, pregnancy or other conditions where data on glycaemic patterns is required
Routine SMBG in low-risk patients who are using oral glucose-lowering drugs (with the exception of sulphonylureas) is not recommended
Monitoring dependent on individual circumstances Patient
GP/nurse
Diabetes educator when required
4. Medication   
Medication review Targeted and careful use of medications to maximise benefit and minimise side effects Patient education
Review medications
GP to review and provide education
Pharmacist when required
Vaccinations Influenza
Pneumococcal and dTPa vaccine
Annually
At appropriate intervals
GP/nurse
5. Complications of diabetes   
Eye complications Early detection of any problems Eye check every 2 years
Retinal photography or referral by GP
GP/optometrist/ophthalmologist
Foot complications Optimal foot care and avoidance of ulceration and amputation by:
  • patient education on foot care and self-check
  • professional check feet every 6 months
  • early detection and management of complications
Stratify the risk of developing foot complications:
  • low/intermediate/high risk
  • the intensity of monitoring and review increases according to level of risk
GP/podiatrist/nurse
patient
GP
Kidney damage Avoid kidney complications
UACR
<3.5 mg/mmol women
<2.5 mg/mmol men
Test for microalbuminuria annually GP
Sexual dysfunction Maintain sexual function To be discussed with patient where applicable GP
6. Psychosocial
Mood and distress from diabetes Manage distress and depression   GP/nurse
Psychologist when required
Licence assessment Maintain safe driving to Road Authority Standards   GP/nurse/specialist
7. Register with NDSS Provide access to best practice consumer resources to support self-management Provision of self-management information and consumer support and advocacy GP/nurse
Diabetes Australia

Patient monitoring

MeasurementsTargetProgress
HbA1c
(This is a measure of how well your blood glucose has been controlled over the last 3 months)
6.5–7.5% or 48–58 mmol/mol
Individualised, as low as reasonably possible without side effects
         
Cardiovascular risk assessment
This is your risk of having a heart attack or stroke in the next 5 years
           
SBP
The highest reading in BP, is more closely related to poor outcomes.
<130 Initiation of drug therapy depends on the assessment of absolute cardiovascular risk
Targets should be used as a guide to treatment, and not as a mandatory requirement
         
LDL-C
This is the ‘bad’ cholesterol implicated in causing CVD
<2.0          
HDL-C
This is the ‘good’ cholesterol, associated with protection against CVD
>1.0          
Triglycerides <2.0          
Renal function –
eGFR is an indicator of overall kidney function
Microalbuminuria
Microalbuminuria is a sign of kidney stress. Identification at an early stage can prevent kidney problems and/or progression to kidney failure
eGFR
Reduce albuminuria by decreasing BP and blood glucose levels
         
Foot examination
To identify potential and active foot problems (e.g. presence of ulcers, infection, corns, calluses, fissures)
Foot risk = low/intermediate/high
Today’s examination
         
Vision
This is to aid detection of early cataract formation.
Ophthalmology review – to detect small vessel changes in your eyes
Visual care
Full eye review every 2 years
         

Copy of GPMP offered to patient? <<__________________________________________ >>
Copy/relevant parts of the GPMP supplied to other providers?<<  >> <<__________________________________________ >>
GPMP added to the patient’s records?<<  >> <<__________________________________________ >>
Date service completed:<<  >> <<__________________________________________ >>
Proposed review date:<<  >> <<__________________________________________ >>

I have explained the steps and costs involved, and the patient has agreed to proceed with the service.
<<Steps and costs explained, patient agreed>>
GP signature:               Date:
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