GP Management Plan (Item 721), Team Care Arrangement  (Item 723) & Review (Item 732) - COPD

Patients Details: <<Patient Demographics:Full Name>>
Date of Birth: <<Patient Demographics:DOB>>

Medicare No: <<Patient Demographics:Medicare Number>>
Does Patient identify as Aboriginal or Torres Strait Islander: <<Patient Demographics:Ethnicity>>

Address: <<Patient Demographics:Full Address>>

Pt Home Ph: <<Patient Demographics:Phone (Home)>>
Pt Mobile: <<Patient Demographics:Phone (Mobile)>>

Date GPMP/TCA completed: <<Miscellaneous:Date (short)>>

Date of previous GPMP (if applicable):
<<Date of previous GPMP (if applicable)>>

Details of Patient's Usual GP: <<Doctor:Name>> <<Doctor:Qualifications>>
Dr's Address: <<Doctor:Full Address>>

Dr's Ph: <<Doctor:Phone>>
Dr's Fax: <<Doctor:Fax>>

Assessment of patient | Patient Identified Problems / Health Care Needs | GP/Nurse identified Problems / Health Care Needs

Diagnosis: <<Diagnosis:>>
Date of Diagnosis <<Date of Diabetes Diagnosis>>

Medical / Surgical History:
<<Clinical Details:History List>>

Medications:
<<Clinical Details:Medication List>>

Allergies:
<<Clinical Details:Allergies/Adverse Reactions>>

Immunisation History:
<<Clinical Details:Immunisation List>>

Smoking History:
<<Clinical Details:Smoking>> Quitting Stage <<Clinical Details:Smoking Quitting Stage>>

Social History:
<<Clinical Details:Social History>>

Planned Review Date: (Recommendation: not less then 6 months after initial Management Plan)  <<Planned Review Date?>>

GPMP added to the patients records:  <<GPMP added to the patients records: >>
Copy of GPMP offered to patient: <<Copy of GPMP offered to patient:>>

I understand this Management Plan recommendations & agree to the outlined goals.
Patient Signature:	Date: <<Miscellaneous:Date (short)>>

I have explained the steps and costs involved, and the patient has agreed to proceed with the service.
GP Signature: 	Date: <<Miscellaneous:Date (short)>>

Current health need/problem

Goal
(delete inappropriate and add goals as required)

Agreed action by health professionals and patient

Review 1 
-6 months
(Add date here)

Review 2 
12 months
(Add date here)

Review 3 
18 months
(Add date here)

1. General | | | | |

Patient's understanding of COPD

To have a clear understanding of COPD

Patient education
Resources available from https://lungfoundation.com.au/patients-carers/living-with-a-lung-disease/copd/overview/

COPD Self- Management Plan

To self-manage COPD and symptoms of COPD 
To reduce COPD flare-ups and avoid hospital admission

Provide education and written plan to guide patient on management of condition and symptoms.  
Review regularly.

Resources available from:
https://lungfoundation.com.au/news/how-to-use-a-copd-action-plan/
.

2. Lifestyle | | | | |

Quality of Life

To measure impact of COPD on health status and current quality of life

Complete COPD Assessment Test (CAT):
Available from:
https://www.catestonline.org/

Nutrition

To eat a balanced diet and maintain a healthy weight

Patient education:
Discuss importance of adequate nutrition 
Appropriate position for eating
Reliever use prior to meals
Small meals often

Refer to dietitian
 
Resources available from https://copdx.org.au/copd-x-plan/o-optimise-function/o6-non-pharmacological-interventions/o610-nutrition/
https://lungfoundation.com.au/wp-content/uploads/2018/09/Book-Better-Living-with-COPD-Dec2016.pdf

Weight

Your target:
Weight: <Weight (kg) >  Kg
BMI:  <BMI:>	
Ideal: BMI  - 25

Patient education on maintaining ideal BMI and prevention of weight loss/weight gain
If BMI abnormal (low or high) refer to dietitian

Resources available from:
https://lungfoundation.com.au/wp-content/uploads/2018/09/Book-Better-Living-with-COPD-Dec2016.pdf

Physical activity

To increase physical exercise and keep as active as possible
To maintain and improve ability to carry out activities of daily living
Your target: 

Set suitable exercise regime/locate suitable exercise programs

Patient education
Encourage daily activity: exercise for 30 mins most days of the weeks eg. Walk for 10 mins 3 times a day

Refer to Pulmonary Rehabilitation
Refer to Exercise Physio

Join Patient Support Groups - Queensland
For contact details of all groups and Pulmonary Rehabilitation, please call The Australian Lung Foundation toll-free on 1800 654 301

Energy Conservation

To conserve as much energy as possible

Patient education on ways to conserve energy when carrying out activities of daily living.

Refer Pulmonary Rehabilitation
Refer exercise physio

Resources available from:
https://lungfoundation.com.au/wp-content/uploads/2018/09/Book-Better-Living-with-COPD-Dec2016.pdf

Smoking

To be a non smoker

Current Smoking status: <<Clinical Details:Smoking>>
Quitting Stage: <<Clinical Details:Smoking Quitting Stage>>

Smoking cessation strategy:
Consider: 
- Quitline (13QUIT)
- Medication
- Behavioural and psychological support.

Alcohol intake
NHMRC Alcohol Guidelines
https://www.nhmrc.gov.au/health-advice/alcohol

Low risk alcohol consumption.
Your target:
___standard drinks per day

To reduce the risk of harm from alcohol-related disease or injury for healthy men and women, drink no more than 10 standard drinks per week and no more than 4 standard drinks on any one day.
The less you choose to drink, the lower your risk of alcohol-related harm. For some people not drinking at all is the safest option (NHMRC).

Reduce alcohol intake
Patient education
Assess patient medications for potential interactions with alcohol.

3. Biomedical | | | | |

Spirometry

To assess lung function

Your spirometry :
FEV1/FVC.  
FEV1%.    
Severity:.................
Date Spiromerty performed:......................
COPD defined as post bronchodilator
FEV1/FVC  <0.7
FEV1% -  Mild 60-80%,  Moderate 40-59%,  Severe <40%  (and not fully reversible)

Check 6 monthly or annually depending on COPD stage of severity

Symptom Control

Improve ability to manage and reduce severity of symptoms eg. Breathlessness, cough, sputum, chest tightness

Patient education on use of medications to relieve breathlessness
Discuss pursed lip breathing, relaxed breathing, recovery positions, pacing, improving fitness, active cycle of breathing

Assess for home oxygen - (specialist referral needed), order ABGs
Assess for sleep apnoea

Refer to pulmonary rehabilitation
Refer to exercise physio

Resources available from:
https://lungfoundation.com.au/wp-content/uploads/2018/09/Book-Better-Living-with-COPD-Dec2016.pdf

4. Medication | | | | |

Medication review

To understand and use medications effectively
To minimise side effects of medications

Review medications ( Consider DMMR/Home Medication Review – Item 900)

Patient education:
Check & correct inhaler device technique and provide device handouts; use spacer with puffer; rinsing to prevent oral thrush; effects of oral steroid use

Immunisation

Your current vaccination status
Annual Influenza vaccination current: <Annual Influenza vaccination current   >
Pneumococcal vaccination current  <Pneumococcal vaccination current>
Pneumococcal  vaccination next due: <Pneumococcal  vaccination next due:>
(Pneumococcal - initial then booster after 5yrs.)

Check annually

Long Term Home Oxygen

To Improve use of oxygen therapy

Patient education: 
Check patient’s understanding of oxygen prescription, how to use oxygen equipment, nasal care, benefits of oxygen therapy, safety etc.

Resources available from:
https://lungfoundation.com.au/news/home-oxygen-how-it-helps-and-how-much-is-right-for-you/

5. Complications | | | | |

Osteoporosis

Maintain  bone density 
Date last bone density test: <<Date last bone density test: >>

Minimise risk factors for osteoporosis and  monitor  bone density/vitamin D status

Check bone density annually

Others to consider:
Heart failure, CAD, Obstructive sleep apnoea, GORD, reflux, aspiration, hypertension, lipidaemia

6. Mental Health and Wellbeing | | | | |

Depression, anxiety and stress

Manage depression, anxiety and stress 
Assessment. K10 Score......
Consider Mental Health Treatment Plan (Item 2710 or 2702)
Medication or cognitive behaviour therapy

Monitor for depression, anxiety and stress
Refer to psychologist Patient Support Groups - Queensland
For contact details of all groups, please call The Australian Lung Foundation toll-free on 1800 654 301

Social isolation

To prevent social isolation and improve social support

Referral to support group 
Patient Support Groups - Queensland
For contact details of all groups, please call The Australian Lung Foundation toll-free on 1800 654 301

Team Care Arrangements
Provider Name | Treatment/ Service/ Goals | Address | Phone Number | Has agreed to TCA | Number of visits

Investigations:
<<Summary:Investigation Results (Selected)>>

GP Management Plan & TCA for <<Patient Demographics:Full Name>>  DOB <<Patient Demographics:DOB>> Reviewed February 2020