GP Management Plan (Item 721), Team Care Arrangement  (Item 723) & Review (Item 732) - Cardiac
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 coronary heart disease	Patient to have a clear understanding of coronary heart disease and the patient's role in managing the condition	Patient education				
Chest pain action plan	Develop action plan	Action plan on use of anti-anginals, informing someone nearby of symptoms, and dial 000 if symptoms are severe or worsening.				

2. Lifestyle						
Nutrition	Establishing and maintaining a healthy eating pattern, low fat diet	Patient education, referral to Dietician, Heart Foundation Healthy Eating Guidelines
				
Weight	Your target:
BMI:	
Waist	cm
Ideal: BMI  - 25
Men waist 94 cm
Women waist  80 cm	Monitor and assess BMI and waist circumference 
Set immediate and achievable goals
Encourage healthy eating and regular physical activity.
Review 6 monthly				
Physical activity	Your target: 

Ideal: Progress to at least 30 minutes moderate intensity physical activity 5 or more days per week (min 150 minutes per week)	Patient exercise routine
Asses physical activity together with severity of disease.
Discuss and provide written guidelines e.g. Lifescripts.
Refer to Cardiac rehab where appropriate.
Monitor progress in consultation with patient.				
Smoking	Complete cessation
Avoidance of second-hand smoke.	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						
Cholesterol/Lipids	Your target:
Cholesterol	mmols/L
Triglycerides	mmol/L
LDL-C 	mmol/L
HDL-C	mmol/L
Ideal:
Cholesterol  	4.0 mmols/L
Triglycerides  	<1.5 mmol/L
LDL-C  	<1.8 mmol/L
HDL-C  	> 1.0 mmol/L	Annual check
Patient education – dietary
Cholesterol lowering medications where appropriate				

4. Medication						
Medication review	Correct use of medications, minimise side effects	Patient education 
Review medications ( Consider Home Medication Review – Item 900)				
	Use of antiplatelet agents	Low dose aspirin or other anti-platelet medications ((unless contraindicated)				
	Use of ACE inhibitors	Consider in all patients (angiotension II receptor antagonists if develop side effects)				
	Use of Beta-blockers	Consider in all post-acute coronary syndromes unless contraindicated				
	Use of Statins	In patients with CHD unless contraindicated				
	Use of Anticoagulants	Warfarin or NOAC if high risk of thromboembolism post-myocardial infarction ( monitor closely consider risks vs benefits)				
	Anti-anginal medications	Short acting or long acting - oral or sublingual				

5. Mental Health and Wellbeing						
Depression	Manage depression	Assessment. 
Consider Mental Health Treatment Plan (Item 2710 or 2702)
Medication or cognitive behaviour therapy
Patient education
				
Social isolation	Reduce social isolation	Improve social support e.g. referral to support group (Heart Foundation 1300 362 787)
Assess level of social support and provide follow-up through referral to cardiac rehabilitation or social worker/psychologist				

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

						

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