Chronic Disease Management Plan

Reporting Month/Year: 10/2023

Patient Information

Full Name: Robert John Evans

Date of Birth (DOB): 14/05/1952

Medical Record (MR) #: 482-910-3B

Primary Address: 42Jacaranda Street, Chermside QLD 4032

Contact Number: 0412 345 678

Emergency Contact: Margaret Evans (Wife), 0412 876 543

Usual Medical Practitioner: Dr Andrew Chen, MBBS, FRACGP

Practice Name: Northside Family Medical Centre

Practice Contact: (07) 3214 5678, admin@northsidefmc.com.au

Eligibility Criteria

• The patient’s chronic or terminal condition: Type 2 Diabetes Mellitus (T2DM) and Moderate Chronic Obstructive Pulmonary Disease (COPD); verified eligible for CDM services.
• Expected duration of condition(s): Both conditions are permanent and will continue for > 6 months.
• Verification of CDM service eligibility: Checked and confirmed via HPOS/MBS online on 10/10/2023.
• Usual medical practitioner’s role: Confirmed; practice has provided majority of care over the past 12 months and will continue for the next 12 months.

Chronic Medical Conditions

• Type 2 Diabetes Mellitus (ICD-10: E11.9)
  • Diagnosed 2015, moderate severity. Latest HbA1c 7.8 %, eGFR 68 mL/min/1.73m², BMI 31 kg/m². Mild peripheral neuropathy noted bilaterally.
  • Managed with metformin (Diabex®) 1,000 mg PO BID and empagliflozin (Jardiance®) 10 mg PO daily. Low-GI diet, daily BGL monitoring.
  • Referred to podiatry and dietetics. Require 3-monthly HbA1c, annual microalbuminuria/U&E, and annual optometry review.
• Chronic Obstructive Pulmonary Disease (ICD-10: J44.9)
  • Diagnosed 2018, GOLD Stage II (FEV1 62 % predicted). Experiences exertional dyspnoea (mMRC Grade 2) and occasional winter exacerbations.
  • Managed with umeclidinium/vilanterol (Anoro Ellipta®) 62.5/25 mcg INH daily and salbutamol (Ventolin®) 100 mcg INH PRN. Pulmonary rehabilitation advised.
  • Annual spirometry and ongoing review with respiratory clinic at Prince Charles Hospital as required.

Other Medical Conditions

• Essential Hypertension – Diagnosed 2012, well controlled on perindopril (Coversyl®) 5 mg PO daily. Latest BP 132/78 mmHg. Annual cardiovascular risk assessment and routine home BP monitoring.
• Bilateral Knee Osteoarthritis – Causes chronic joint pain and limits walking distance. Managed with paracetamol (Panadol Osteo®) 1,330 mg PO TID PRN and physiotherapy exercises.

Patient Assessment and Needs Identification

• Functional Status: Independent with ADLs. Walking limited to 200 m due to knee pain and SOB.
• Cognitive Status: Alert and oriented. Intact memory and comprehension; manages own appointments without prompts.
• Psychosocial Needs: Lives with supportive wife. Mild anxiety regarding dyspnoea episodes; no clinical depression (K10 score: 14).
• Nutritional Needs: Overweight (BMI 31 kg/m²). Struggles with carbohydrate portion control; referred to dietitian.
• Medication Management: Adherent to regimen, uses Webster-pak. Inhaler technique requires regular reinforcement; HMR planned to assess polypharmacy.
• Lifestyle Factors: Ex-smoker (ceased 2018, 40 pack-year hx). Alcohol: 2 standard drinks/week. Sedentary lifestyle; needs graded exercise program.

CDM Plan Development

Planned Interventions and Services

• Medical Management: 3-monthly clinical review for BP, weight, foot check, and HbA1c. Annual renal panel, lipids, and spirometry. Adjust hypoglycaemic agents if HbA1c remains > 7.5 %.
• Preventive Care Needs: Annual influenza vaccine (completed 04/2023), COVID-19 booster (completed 05/2023), Pneumococcal vaccine (Prevenar 13® due today). Bowel cancer screening up to date.
• Patient Education: Educated on COPD action plan, spacer/inhaler technique, hypoglycaemia recognition, and daily foot care.
• Referrals to Allied Health Services:
  • Physiotherapy: Referred for knee OA strengthening and pulmonary rehabilitation to improve exercise tolerance.
  • Dietetics: Referred for caloric restriction and diabetic diet education to achieve weight loss and lower HbA1c.
  • Podiatry: Referred for diabetic neuropathy screening and routine nail/foot care to prevent ulceration.
  • Pharmacy Medication Review: Home Medicines Review (HMR) requested to assess inhaler technique and optimise regimen.

Health Goals (Short and Long-Term)

• Short-Term Goal 1: Reduce HbA1c from 7.8 % to < 7.2 % within 3 months.
• Short-Term Goal 2: Walk for 15 minutes continuously 4 times/week within 3 months.
• Long-Term Goal 1: Achieve and maintain a 5 kg weight loss over 12 months.
• Long-Term Goal 2: Prevent COPD exacerbations and hospital admissions over the next 12 months.

Monitoring and Support Services

Date: 10/10/2023

• Service Provided: Baseline observations, inhaler technique assessment, and COPD Action Plan education.
• Duration: 30 minutes
• Provider Name & Credentials: Sarah Jenkins, NP

Date: 15/11/2023

• Service Provided: Foot examination, neuropathy screening, and BGL log review.
• Duration: 20 minutes
• Provider Name & Credentials: Sarah Jenkins, NP

Date: 12/12/2023

• Service Provided: Dietary adherence check, weight check, and medication compliance review.
• Duration: 20 minutes
• Provider Name & Credentials: Sarah Jenkins, NP

Referrals to Allied Health Professionals

• GPMP and Team Care Arrangements (TCAs) Status: GPMP and TCAs completed and signed by patient on 10/10/2023.
• Referral Letter Status: EPC referral forms sent via secure message to allied health providers on 10/10/2023.
• Allied Health Practitioners Engaged:
  • Dietitian: Appointment scheduled for 24/10/2023
  • Physiotherapist: Appointment scheduled for 26/10/2023
  • Podiatrist: Appointment scheduled for 02/11/2023

Review and Reassessment

• Planned Review Date: 10/01/2024
• Changes in Patient Condition: Baseline plan; no acute changes at present.
• Plan Modifications: No modifications required at this stage; review in 3 months.

Billing and Medicare Compliance

• CDM Plan Development: Claimed under MBS Item 721.
• Monitoring and Support Services: Claimed under MBS Item 10997 (Enter the number of units: 3).
• Allied Health Referrals: Claimed under MBS Item 723.
• Review Services: Scheduled to be claimed under MBS Item 732 at 3-month mark.

Signatures

Usual Medical Practitioner: Dr Andrew Chen, MBBS, FRACGP

Date: 10/10/2023

Practice Nurse/Support Staff Signature: Sarah Jenkins, NP

Date: 10/10/2023