<<Miscellaneous:Practice Letterhead>>

CHRONIC DISEASE MANAGEMENT
<<Type of plan>>	

Patient Details:
Name: <<Patient Demographics:Full Name>>
Date of Birth: <<<Patient Demographics:DOB>>
Gender: <<Patient Demographics:Gender>> <<Patient Demographics:Transgender>>
IHI: <<Patient Demographics:IHI>>	Contact Details:
Address: <<Patient Demographics:Full Address>>
Phone: (m): <<Patient Demographics:Phone (Mobile)>>
(H) <<Patient Demographics:Phone (Home)>>
(W) <<Patient Demographics:Phone (Work)>>
Email: <<Patient Demographics:E-mail>>	

Medicare	DVA	Insurance	Pension	
Number: <<Patient Demographics:Medicare Number>>
Exp: <<Patient Demographics:Medicare Expiry Date>>	Number: <<Patient Demographics:DVA Number>>	Fund: <<Patient Demographics:Health Insurance>>	Number: <<Patient Demographics:Pension Number>>	

Details of Patient’s Usual GP:	Details of Care Plan(s):	
<<Doctor:Full Details>>
Provider Number: <<Doctor:Provider Number>>
HPI-I: <<Doctor:HPI-I>>	Date of previous Care Plan (if known/applicable):
<<Date of last Care Plan/GPMP>>

Date of today's <<Type of plan>>: 
<<Miscellaneous:Date>>	

PROBLEMS NEEDS & RELEVANT CONDITIONS	

<<Clinical Details:History List>>

PROBLEMS NEEDS & RELEVANT CONDITIONS	

• Attend <<Practice:Name>> every 4 months for the management of condition and prevention of complications.
• Monitor the effectiveness of medications and therapies.
• Immunise against vaccine-preventable diseases
• Target BMI range <<Target BMI (provide range or single value)>>
• Target HbA1c <<Target HBA1c (mmol/mol)>> mmol/mol
• Target HDL <<Target HDL (mmol/L)>>mmol/L
• Target Cholesterol <<Target Total Cholesterol (mmol/L)>>mmol/L
• Target eGFR <<Target eGFR>>
• Target Urine ACR <<Target UACR>>
• Target BP <<Target BP (mm/Hg)>>mm/Hg

COMMENTS	

<<Comments>>

CARE PLAN PROGRESS REVIEW INTERVALS
(appointment with Nurse and GP)	

Cycle Start	Review 1	Review 2	Review 3	
<<Cycle start (Date care plan was created, else today)>>	<<Review 1 date (4 months)>>	<<Review 2 date (8 months)>>	<<Review 3 date (1 year)>>	

CARE PLAN TASKS	

INTERVAL	TASK	PROVIDER INVOLVED	DUE	COMPLETED	
Any	Obtain influenza and/or pneumococcal vaccinations	Practice nurse	Before review visit 3		
Cycle Start	Complete assessments BP/Waist/BMI/Smoking/Alcohol	Practice nurse			
<<Cycle start (Date care plan was created, else today)>>	Complete foot examination	Practice nurse			
	Confirm goal values and finalise care plan	GP			
Interval tasks	Attend pathology collection centre for bloods and urine sampling	Pathology Collection Centre	Within 1 month of cycle start		
	Attend optometrist for eye review and obtain copy of report	Optometrist	Prior to review 1 visit		
Review 1	Review allied health attendance and care plan progression	Practice nurse			
<<Review 1 date (4 months)>>	Complete medication review	GP			
	Review goal values and complete care plan review	GP			
Interval tasks	Attend pathology collection centre  for bloods and urine sampling	Pathology Collection Centre	1 month prior to review visit 2		
Review 2	Complete assessments BP/Waist/BMI/Smoking/Alcohol	Practice nurse			
<<Review 2 date (8 months)>>	Complete foot examination	Practice nurse			
	Review goal values and complete care plan review with GP 	GP			
Interval tasks					
Review 3	Review care plan completion (cycle of care) and progression towards goals 	Practice nurse			
<<Review 3 date (1 year)>>	Review goal achievments and complete cycle of care 	GP		