<Letterhead>
CHRONIC DISEASE MANAGEMENT
<Type of plan>	

Patient Details:	Contact Details:	
Name: <PtName>
Date of Birth: <PtDoB>
Gender:<PtSex>
IHI: <PtIHI>	Address: <PtDetails>
Phone: (m): <PtPhoneMob>
(H) <PtPhoneH> 
(W) <PtPhoneWk>
Email: <PtEmail>	

Medicare	DVA	Insurance	Pension	
Number: <PtMCNo>
Ref: <PtMCLine>
Expiry: <PtMCExpiry>	Number:<PtDVANo>
Type: <PtDVACard>	Fund: <PtInsFund>
Number: <PtInsNo>	<PtPensionNo>	

Details of Patient’s Usual GP:	Details of Care Plan(s):	
<DrDetails>
Provider No: <DrProviderNo>
HPI-I: <DrHPII>	Date of previous Care Plan (if known/applicable):  <Date of last Care Plan/GPMP> 

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

PROBLEMS NEEDS & RELEVANT CONDITIONS	

<PMHActive>

GOALS FOR OPTIMAL MANAGEMENT	

• Attend <Practice> 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)>kg/m2	
• 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 when care plan created, else if new care plan select today's date).>	<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	o	
Cycle Start	Complete assessments BP/Waist/BMI/Smoking/Alcohol	Practice nurse		o	
<Cycle start (Date when care plan created, else if new care plan select today's date).>	Complete foot examination	Practice nurse		o	
	Confirm goal values and finalise care plan	GP		o	
Interval tasks	Attend pathology collection centre for bloods and urine sampling	Pathology Collection Centre	Within 1 month of cycle start	o	
	Attend optometrist for eye review and obtain copy of report	Optometrist	Prior to review 1 visit	o	
Review 1	Review allied health attendance and care plan progression	Practice nurse		o	
<Review 1 date (4 months)>	Complete medication review	GP		o	
	Review goal values and complete care plan review	GP		o	
Interval tasks	Attend pathology collection centre  for bloods and urine sampling	Pathology Collection Centre	1 month prior to review visit 2	o	
Review 2	Complete assessments BP/Waist/BMI/Smoking/Alcohol 	Practice nurse		o	
<Review 2 date (8 months)>	Complete foot examination 	Practice nurse		o	
	Review goal values and complete care plan review with GP 	GP		o	
Interval tasks	 				
Review 3	Review care plan completion (cycle of care) and progression towards goals 	Practice nurse		o	
<Review 3 date (1 year)>	Review goal achievments and complete cycle of care 	GP		o