GP Management Plan (Item 721), Team Care Arrangement  (Item 723) & Review (Item 732) - Diabetes Type 2
Patients Details:  <PtName>
Date of Birth:  <PtDoB>	Medicare No: <PtMCNo>
Does Patient identify as Aboriginal or Torres Strait Islander:  <Does Patient identify as Aboriginal or Torres Strait Is>	
Address: <PtAddress>	Pt Home Ph:  <PtPhoneH>
Pt Mobile:  <PtPhoneMob>	
Date GPMP/TCA completed:  <TodaysDate>	Date of previous GPMP (if applicable): <Date of previous GPMP: >	
Details of Patient's Usual GP: <DrName>  <DrQualifications>
Dr's Address: <DrAddress>	Dr's Ph: <DrPhone>
Dr's Fax:  <DrFax>	

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:
<PMHAll>
Medications:
<CurrentRx>
Allergies:
<Reactions>
Smoking History:
<Smoking>  Quitting Stage <Smoking Quitting Stage>
Social History:
<SocialHx> 
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: <TodaysDate>	I have explained the steps and costs involved, and the patient has agreed to proceed with the service.
GP Signature: 	Date: <TodaysDate>	

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 diabetes	Patient to have a clear understanding of diabetes and patient's role in managing the condition	Patient education  				

2. Lifestyle	
Nutrition	Maintain healthy diet	Patient education
Referral to dietician.
Lifescripts action plan	 			
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 level of disease control and comorbidities..
Discuss and provide written guidelines e.g. Lifescripts.
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
Lifescripts action plan
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  	<2.0 mmol/L
HDL-C  	> 1.0 mmol/L	Annual check
Patient education – dietary
Cholesterol lowering medications where appropriate				
Blood pressure	Your target: < __
Ideal: 
< 130/80 mm Hg	Check every 6 months
Refer to dietician
Patient education 				
HbA1c	Your target: < __
Ideal: 
≤ 7%	Check every 3 months (6 months depending on previous levels and clinical risk)				
Blood glucose level	Your target: < __
Ideal: 
< 7 mmols/L (4-6 fasting)	Based on new NDSS criteria for obtaining test strips e.g., unstable diabetes, change medication				

4. Medication	
Medication review	Correct use of medications, minimise side effects	Patient education
Review medications
Consider DMMR (Item 900)				

5. Complications of diabetes	
Eye complications	Early detection of any problems	Eye check every 2 years (yearly if diabetic retinopathy)
Referral by GP to eye specialist				
Foot complications	Prevent foot complications	Patient education on foot care
Patient to check feet regularly
Check feet every 6 months
Consider referral to podiatrist				
Kidney damage	Avoid renal complications
Your targets:
< __ µg/min timed overnight collection
< __ mg mg/L spot collection
< __ mg/mmol women
< __ mg/mmol men albumin creatinine ratio
Ideal:
< 20 µg/min timed overnight collection
< 20 mg mg/L spot collection
< 3.5 mg/mmol women
< 2.5 mg/mmol men albumin creatinine ratio	Test for microalbuminuria annually
If renal impairment, record stage 1-5				
Mental Health	Prevention and early detection of psychosocial problems  - depression
Your K10 score:  	GP/practice nurse to advise on support services and group self help measures
Consider Mental Health Treatment Plan (Item 2702 or 2710) to access Mental Health Services
				
Sexual dysfunction	Maintain sexual function	To be discussed with patient where applicable				

Team Care Arrangements
Provider Name	Treatment/ Service/ Goals	Address	Phone Number	Has agreed to TCA	 Number of visits	
1.						
2.						
3.						

Investigations
<Ix>