Comprehensive Chronic Care Management Notes

Reporting Month/Year: 03/2025

Patient Information

Full Name: Arthur Pendelton

Date of Birth (DOB): 14/05/1948

Medical Record (MR) #: MRN-849-204-QLD

Type of Residence: Home (lives with spouse in single-storey dwelling)

Chronic Conditions (2 or more required for eligibility)

• Type 2 diabetes mellitus with diabetic nephropathy (ICD-10: E11.21) – Moderate severity, complicated by stage 3a CKD (eGFR 52 mL/min/1.73m², uACR 14.2 mg/mmol). Recent HbA1c 7.8 %.
  • Continue metformin (Diabex®) 1,000 mg PO BID and empagliflozin (Jardiance®) 10 mg PO daily. Low-GI diet, daily foot checks, home BGL monitoring. Repeat HbA1c and renal panel in 3 months.
• Essential hypertension (ICD-10: I10) – Benign, suboptimally controlled. Home BP averaging 142/84 mmHg; clinic BP 146/86 mmHg.
  • Perindopril (Coversyl®) 5 mg PO daily and amlodipine (Norvasc®) 5 mg PO daily. Sodium restriction (< 2 g/day), twice-daily home BP log. Review log in 4 weeks for potential perindopril up-titration.
• Chronic obstructive pulmonary disease, unspecified (ICD-10: J44.9) – GOLD Stage 2 (moderate), baseline FEV1 64 % predicted. Stable; 1 mild exacerbation in past 12 months, mMRC dyspnoea scale 1.
  • Umeclidinium/vilanterol (Anoro Ellipta®) 62.5/25 mcg INH 1 puff daily; salbutamol (Ventolin®) 100 mcg INH 2 puffs PRN SOB. Annual influenza vaccine, pulmonary rehabilitation exercises, smoking cessation maintained (ex-smoker 10 yrs).

Other Medical Conditions

• Bilateral knee osteoarthritis – Causes chronic weight-bearing joint pain and morning stiffness (< 30 mins), limiting ambulation distance and exercise tolerance.
  • Paracetamol (Panadol Osteo®) 1,330 mg PO TID PRN pain. Low-impact hydrotherapy twice weekly, weight management.
• Gastro-oesophageal reflux disease (GORD) – Well controlled, occasional nocturnal symptoms if eating late; minimal impact on general health.
  • Esomeprazole (Nexium®) 20 mg PO daily. Elevate head of bed, avoid meals 3 hours prior to sleep.

Other Needs (Social and Access to Care)

• Transportation Needs: No longer drives due to reduced peripheral sensation; relies on spouse for local transport and community transport services for specialist appointments.
• Social Support System: Lives with wife (primary support, mildly frail). Daughter lives 20 minutes away and assists with weekly grocery shopping and heavy housework.
• Nutritional Needs: Requires diabetic and low-sodium diet. Struggles with meal prep when wife is unwell. Referral to Accredited Practising Dietitian (APD) initiated for simplified meal planning.
• Psychosocial and Mental Health Needs: Cognition intact (MMSE 29/30). Mild diabetes-related distress and frustration regarding declining mobility; PHQ-9 score 4 (minimal depression).
• Functional Limitations: Independent with basic ADLs. Uses single-point cane for community ambulation. Requires assistance with IADLs including heavy housework, gardening, and transport.

Physician or Qualified Health Professional (QHP) Responsible for CCM

Primary Physician/QHP: Sarah Jenkins, NP

Date Initial Plan of Care Developed: 03/03/2025

Date Plan of Care Provided to Patient/Caregiver: 04/03/2025

Consent Documentation

• Verbal or Written Consent Obtained: Yes
• Date of Consent: 03/03/2025
• Consent Notes: Verbal consent obtained. Explained CCM services, 24/7 access to care team for urgent needs, care plan sharing, and applicable monthly co-payments/billing structure. Patient expressed understanding and agreed to enrol; aware he may revoke consent at any time.

Care Plan Components

• Assessment of Patient’s Medical, Functional, and Psychosocial Needs: 76yo male with T2DM, Stage 3a CKD, HTN, COPD, and knee OA. High cardiovascular risk profile requiring tight BP and glycaemic control to halt nephropathy progression. Functionally independent at home with spouse, though mobility limited by OA and mild exertional dyspnoea. Low psychosocial risk, good health literacy.
• Preventive Care Needs Addressed: Administered seasonal influenza vaccine (03/03/2025). Pneumococcal conjugate vaccine (Prevenar 13®) up to date. Annual diabetic retinal screening and podiatry neurovascular assessment scheduled for 04/2025.
• Medication Reconciliation and Self-Management Plan: Reconciled active regimen: metformin 1,000 mg PO BID, empagliflozin 10 mg PO daily, perindopril 5 mg PO daily, amlodipine 5 mg PO daily, umeclidinium/vilanterol 62.5/25 mcg INH daily, salbutamol 100 mcg INH PRN, esomeprazole 20 mg PO daily, paracetamol 1,330 mg PO TID PRN. Ceased over-the-counter ibuprofen 200 mg PO PRN (counselled on NSAID nephrotoxicity in CKD). Webster-pak® arranged via local pharmacy to support adherence. Sick-day management plan (SADMANS rules) reviewed and written copy provided.
• Care Coordination and Communication:
  • Coordination with Dr. David Vance (Nephrologist) for co-management of diabetic nephropathy and SGLT2i therapy.
  • Referral to My Aged Care for domestic assistance and community transport assessment.

Care Transition Management

• Hospital or Facility Discharges in the Past 30 Days: No
• Recent Emergency Department Visits: Yes
• Follow-up Actions Required: Attended Redcliffe Hospital ED on 26/02/2025 for acute exacerbation of knee pain following a minor trip (no fracture on X-ray, discharged on short-course analgesia). Follow-up completed: ceased acute NSAID prescribed in ED, transitioned to regular paracetamol, and requested home occupational therapy falls-risk assessment.
• Continuity of Care Documents Shared: Yes

Chronic Care Management Activities and Time Documentation

Date: 04/03/2025

• Activity: Telehealth call with patient and spouse. Completed post-ED medication reconciliation, identified and ceased OTC ibuprofen, educated on renal sick-day rules (withholding metformin, empagliflozin, perindopril during dehydrating illness), and finalised CCM care plan.
• Time Start and Stop: 10:15 - 10:40
• Total Time: 25 minutes
• Documentation Reference: EHR Telehealth Encounter #40921
• Signature: Sarah Jenkins, NP

Date: 14/03/2025

• Activity: Care coordination: reviewed recent pathology (eGFR, uACR, HbA1c), prepared and sent clinical summary and referral letter to Nephrology (Dr. Vance) and APD. Submitted My Aged Care online referral for domestic/transport support.
• Time Start and Stop: 14:10 - 14:30
• Total Time: 20 minutes
• Documentation Reference: EHR Care Coordination Note #41883
• Signature: Sarah Jenkins, NP

Date: 26/03/2025

• Activity: Follow-up phone call with patient. Reviewed 3-week home BP and BGL logs (BP averaging 136/80 mmHg, fasting BGLs 6.2–7.4 mmol/L). Assessed inhaler technique understanding and confirmed Webster-pak® commencement with community pharmacist.
• Time Start and Stop: 16:00 - 16:15
• Total Time: 15 minutes
• Documentation Reference: EHR Call Log #43012
• Signature: Sarah Jenkins, NP

Total CCM Time for Month: 60 minutes

Billing Codes and Documentation

• 99487 – Complex Chronic Care Management (CCCM), requiring at least 60 minutes of clinical staff time
• 99489 – Each additional 30 minutes of CCCM (Enter number of units: 0)
• 99490 – Standard Chronic Care Management (CCM), requiring at least 20 minutes of clinical staff time
• 99439 – Each additional 20 minutes of CCM (Up to 2 units)
• 99491 – CCM, requiring at least 30 minutes of physician time
• 99X21 – Each additional 30 minutes of physician time
• 99X22 – Principal Care Management (PCM), requiring at least 30 minutes of physician time

Supervising Physician or QHP Signature

Sarah Jenkins, NP

Date: 31/03/2025