GP Chronic Condition Management Plan

GP Chronic Condition Management Plan (GPCCMP) And Reviews

Patient Eligibility And Consent

"The patient has had one or more chronic medical conditions for at least 6 months." "The patient gave verbal consent for a GPCCM to be prepared and, where relevant, for pertinent information to be shared with members of the care team." "The patient consents to creating and reviewing this plan."

GP Chronic Condition Management Plan (GPCCMP)

Patient Problem Or Need Or Relevant Condition 1

• Goals — Changes To Be Achieved:
  • Achieve HbA1c < 7.0% within 6 months.
  • Prevent microvascular and macrovascular diabetic complications.
• Required Treatments And Services (Including Patient Actions):
  • Continue metformin (Diabex®) 1,000 mg PO BD.
  • Adhere to low-GI diet and regular aerobic exercise.
  • Annual diabetic foot check and retinal screening.
• Arrangements For Treatment/Services:
  • GP to provide pathology request for 3-monthly HbA1c, fasting lipids, UEC, and urine ACR.
  • EPC referral provided for Podiatry (3 visits) and Dietitian (2 visits).
  • Patient to book annual optometry review independently.

Patient Problem Or Need Or Relevant Condition 2

• Goals — Changes To Be Achieved:
  • Maintain clinic BP < 130/80 mmHg and home BP < 125/75 mmHg.
• Required Treatments And Services (Including Patient Actions):
  • Continue perindopril (Coversyl®) 5 mg PO daily.
  • Restrict dietary sodium intake to < 2 g/day.
  • Monitor home BP twice weekly and maintain log.
• Arrangements For Treatment/Services:
  • Patient to bring home BP log to 3-monthly GP reviews.
  • Practice nurse to check BP and weight at each visit.

Patient Problem Or Need Or Relevant Condition 3

• Goals — Changes To Be Achieved:
  • Reduce bilateral knee pain to ≤ 3/10 on VAS.
  • Improve mobility and achieve 5 kg weight loss over 6 months.
• Required Treatments And Services (Including Patient Actions):
  • Paracetamol (Panadol Osteo®) 1,330 mg PO TID PRN for pain.
  • Engage in quadriceps strengthening and low-impact hydrotherapy.
• Arrangements For Treatment/Services:
  • EPC referral provided for Physiotherapy (3 visits) for tailored exercise programme.

Other Problems

• Dyslipidaemia: Stable on atorvastatin (Lipitor®) 20 mg PO nocte; monitor fasting lipids in 6 months.
• gastro-oesophageal reflux disease (GORD): Well controlled on esomeprazole (Nexium®) 20 mg PO PRN.

Patient Actions

• Take all prescribed medications daily as directed.
• Walk for 30 minutes at least 5 days per week and attend weekly hydrotherapy.
• Record home blood pressure readings twice weekly.
• Book and attend appointments with podiatrist, dietitian, physiotherapist, and optometrist.
• Complete fasting blood and urine tests 1 week prior to next GP review.

Service Coordination

• Ms Sarah Jenkins (Accredited Practising Dietitian): Medical nutrition therapy for glycaemic control and weight reduction.
• Mr David Tran (Podiatrist): Comprehensive diabetic foot assessment, neurovascular screening, and footwear advice.
• Mr Mark Webber (Physiotherapist): Supervised joint mobilisation and lower-limb strengthening programme for knee OA.
• Local Optometrist: Annual dilated fundus examination for diabetic retinopathy screening.

"The patient received the plan, and a copy was stored in the patient's medical record."

Date Service Was Completed: 24/05/2024

Review Date: 24/08/2024