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

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 asthma	Patient to have a clear understanding of asthma and the patient's role in self- management.	Patient education 
Ongoing asthma education by GP/Nurse during regular reviews

Resources available from:
National Asthma Council: https://www.nationalasthma.org.au/ 

Asthma Australia: 
https://asthma.org.au/ 

Minimise symptoms	Absent or minimal symptoms
No nocturnal or early morning symptoms.
Minimal exertional cough or wheeze.
Absent or minimal reliever medication use (less than 3 times a week except with exercise).
	GP/Nurse to assess asthma severity when patient is stable (use https://www.asthmahandbook.org.au/resources/tools/control-questionnaires  ) and individualise treatment.
Patient to keep symptom diary or PEFR diary.
Patient to adhere to preventer medication routine.
Patient to take continuing responsibility for their asthma and attend for regular review.				
Self-management skills	Patient in control of their asthma.

Patient is able to recognise early signs of deterioration in asthma and respond appropriately.

Patient knows when to and how to obtain prompt medical attention	GP/Nurse to provide a written asthma action plan and rehearse with patient.
Patient to use asthma action plan and have it reviewed regularly
Patient given written phone number for the GP surgery and out of hours number.

Action plans available from:
https://www.nationalasthma.org.au/living-with-asthma/asthma-action-plans

2. Lifestyle						
Physical Activity
	Your target:____

Ideal: At least 30 minutes walking or equivalent 5 or more days per week

If exercise induced asthma, patient to take reliever medication 5-10 minutes before exercise	Patient to implement exercise routine

Resources available from: 
https://www1.health.gov.au/internet/main/publishing.nsf/content/health-pubhlth-strateg-phys-act-guidelines 

Smoking	Complete cessation (if applicable)	Patient education and support for quitting:
-5As Brief Intervention 
-Nicotine Replacement Therapy
-Smoking Cessation Medication
-Combination Therapy
-Quitline 137848  
-Local Pharmacy

Resources available from:
RACGP: 
https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/supporting-smoking-cessation 

Quitline:

https://www.health.gov.au/contacts/quitline 

Quit HQ:

https://quithq.initiatives.qld.gov.au/ 
				
Nutrition	To eat a balanced diet and maintain a healthy weight	Patient education
Refer to dietician if BMI low or high

Resources available from:

https://www.nhmrc.gov.au/about-us/news-centre/reducing-health-risks-drinking-alcohol 
				
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
Lifescripts action plan
Assess patient medications for potential interactions with alcohol.				

3. Biomedical						
Achieve best lung function	To improve quality of life

Optimal lung function on spirometry

Peak Flows:  Best PEFR __________	GP – intensive asthma therapy until optimal lung function achieved

Patient to continue with intensive asthma therapy until optimal lung function achieved

Patient to have regular spirometry to monitor lung function

Patient self-monitoring using peak flow meter. Resource 

https://www.brisbanenorthphn.org.au/page/news-and-events/latest-news/changes-to-spirometry-medicare-benefits-schedule-item-numbers/ 
				
Maintain best lung function
	Reduce the frequency and severity of asthma attacks

Prevent the permanent development of abnormal lung function
	GP/Nurse help patient identify trigger factors

Patient to avoid trigger factors if possible

Patient to use preventers regularly, as per written asthma action plan				

4. Medication						
Optimise medication program
	Optimise medication to give lowest possible dose that controls asthma and symptoms.

No side effects or minimum side effects from medications

Optimise lung deposition of asthma medications	GP to supervise step down of medication after effective control in place for 6-12 weeks
GP/Nurse to organise regular spirometry 
Patient agree to return for planned review even when feeling ‘well’

Use of spacer to give optimal inhaled medication if applicable				
Immunisation	Yearly influenza vaccination  recommended
Pneumococcal vaccine if eligible	Check annually				

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

Team Care Arrangement
Date TCA completed: 	Planned Review Date: 	
TCA added to the patients records:  

Copy of TCA offered to patient:	Copy of relevant parts of the TCA supplied to other providers?

Referral form for allied health services completed?
	
I have explained the steps and costs involved, and the patient has agreed to proceed with the service. The patient also agrees to the involvement of other health providers and to share their clinical information without / with restrictions.

GP signature:  x_________________________________ Date: <<Miscellaneous:Date (short)>>

GP name: <<Doctor:Name>>	I give permission for my GP to discuss my medical history/diagnosis with other service providers. I understand that referral for service can still go ahead if I do not want information about me made know to the service providers.

Patient/Carer Signature:  x_______________________________________
Date: <<Miscellaneous:Date (short)>>
I understand the above Team Care Arrangement recommendations and agree to the outlined goals.	

Any information the patient wants withheld:

	

Treatment and service goals	Treatment services that collaborating health professionals will provide	Arrangements for treatments and services (when, who, how often)	Actions to be taken by patient	1st Review- 6 mths (add date here)	2nd review- 12 mths (add date here)