GP MANAGEMENT PLAN - MBS ITEM No. 721
CHRONIC LIVER DISEASE	

Patient’s Name: <<Patient Demographics:Full Name>>	Date of Birth: <<Patient Demographics:DOB>>	

Contact Details:		Medicare or Private Health Insurance Details:	
<<Patient Demographics:Full Address>>	<<Patient Demographics:Medicare Number>>
<<Patient Demographics:Health Insurance>>	

Details of Patient’s Usual GP:	Details of Patient’s Carer (if applicable):	
<<Doctor:Name>>
<<Doctor:Full Address>>
P: <<Doctor:Phone>>	

	

Date of last Care Plan/GP Management Plan (if done):  <<Date of Last Care Plan / GPMP (if done)?>>

Other notes or comments relevant to the patient’s management plan: 

	

PAST MEDICAL HISTORY

<<Clinical Details:History List>>

FAMILY HISTORY particularly haemochromatosis and hepatocellular carcinoma 

<<Clinical Details:Family History>>

MEDICATIONS 

<<Clinical Details:Medication List>>

ALLERGIES

<<Clinical Details:Allergies>>

SMOKING STATUS

<<Clinical Details:Smoking>>

ALCOHOL INTAKE

<<Clinical Details:Alcohol>>

Patient’s Name: <PtName>
GP MANAGEMENT PLAN - MBS ITEM No. 721
CHRONIC LIVER DISEASE	

Patient problems / needs / relevant conditions	Goals - changes to be achieved	Required treatments and services including patient actions	Arrangements for treatments/services (when, who, contact details)	
1. General				
Patient's understanding of their condition	Patient to have a clear understanding of their condition and patient's role in management.	Patient education/support
Patient resources  	GP / nurse 
Educator / support group	
2. Lifestyle				
Nutrition	Maintain healthy diet	Patient education
	Patient to implement
GP to monitor 
Dietitian	
Weight	Your target: BMI <   
Ideal: BMI ≤ 25 kg/m2	Monitor
Review 6 monthly
	Patient to monitor
GP to review	
Physical activity	Your target:

Ideal:
Exercise at least 30 minutes walking or equivalent 5 or more days per week	Patient exercise routine

OR 
As per Lifescripts action plan	Patient to implement
GP to review
Exercise physiologist	
Smoking	Complete cessation	Smoking cessation strategy:
Consider:
- Quit
- Medication
	Patient to manage
GP to monitor and support
Refer to ATODs	
Alcohol intake	Your target: Complete cessation or if unable < 2  standard drinks per day	Reduce alcohol intake
Patient education
	Patient to manage
GP to monitor and support
Refer to ATODs	
Other drugs

	Abstinence or safe use	Counselling
Medication including OST if appropriate	Patient to manage
GP to monitor and support
Refer to ATODs	
Co-morbidities	New infections HIV, HCV, HBV
New clinical problems	Re-testing for infection, general examination based on history	Pathology referral	
3. Biomedical				
Liver function tests:
ELFTs, FBC, coagulation studies
Where appropriate, Vit D, alpha-foetoprotein	Monitor for early detection of complications or deterioration in liver function, determination of level of risk	Check every 6-12 months	GP
Refer to specialist if significant deterioration	
Liver ultrasound
APRI - Score
+/- FibroScan

	Monitor for development of cirrhosis, portal hypertension, varices and hepatocellular carcinoma	Check every 6-12 months	GP
Refer to specialist if required	
4. Medication				
Medication review	Correct use of medications, minimise side effects especially hepatotoxicity	Patient education
Review medications	GP to review and provide education
Pharmacist	
5. Other				
Vaccination

	Prevent infection with Hepatitis A/B
Prevent influenza- or pneumococcal infection related complications	Immunise against Hep A/B
Annual influenza immunisation
One-off pneumococcal vaccination or two five years apart for ATSI patients	GP
Nurse	
Mental health

	Monitor for depression/anxiety in the context of chronic disease	Psychoeducation
Referral to a psychologist if required
Anti-depressant medication	GP
Psychologist	
Bone density
Vit D levels

	Detect and manage osteoporosis to prevent fractures	BMD every 2-3 years
Prescribe bisphosphonates or other medication as appropriate	GP	

Copy of GP Management Plan offered to patient?  <<Copy of plan offered to patient?>>

Copy / relevant parts of the GP Management Plan supplied to other providers?  <<Copy of GPMP supplied to other providers?>>

GP Management Plan added to the patient’s records?  <<GPMP added to the patient's records?>>

Date service was completed:  <<Date service completed?>>	Proposed Review Date:  <<Proposed review date? (6 months recommended)>>	

I have explained the steps and any costs involved, and the patient has agreed to proceed with the plan.  <<Steps and costs explained to patient?>>

 GP’s Signature:  __________________________________________	Date:___________________