CARE PLAN
ITEM: GP Management Plan ____ 721 TCA ____ 723      
PATIENT DETAILS: | GP DETAILS:
[Patient Demographics:Full Details] | [Doctor:Full Details]
DATE CARE PLAN PREPARED: [Miscellaneous:Date]
PROBLEM LIST:
[Clinical Details:History List (Summary)]
ALLERGIES:
[Clinical Details:Allergies]
CURRENT MEDICATIONS:
[Clinical Details:Medication List]
[Clinical Details:Smoking]
[Clinical Details:Measurement BP]
[Clinical Details:Measurements]
CARE PLAN TEAM MEMBERS or if GPMP - SERVICE PROVIDERS:
NAME | TYPE OF CARE | if developing a TCA CONTACTED/ COPY SENT | if developing TCA AGREED?
[Doctor:Name] | GP (details above) | yes | yes
[Addressee:Full Details] | [Addressee:Specialty] | yes | yes
Health Promotion Officer | Health promotion Activities | yes | yes
| pharmacist | yes | yes
PROBLEMS/ NEEDS, GOALS AND PLANNED ACTIONS
Current Health Needs/ Problems | Goal | Planned Actions/ Tasks | Service Provider Responsible
Confirm presence of chronic hepatitis C | Check for active infection | Check hepatitis C PCR | GP

Education about hepatitis C

Good understanding of chronic hepatitis C

Patient education  re
-	disease prognosis
-	potential transmission
-	treatment options
-	avoidance of alcohol

GP
Educator

Determine genotype / viral load

Determine likelihood of response to treatment

Hepatitis C genotype
Hepatitis C genotype

GP

Perform baseline examinations and tests

Detect signs of advanced liver disease or cirrhosis

Physical examination
Investigations: FBC, coagulation, UEC, LFT
Abdominal ultrasound
Specialist referral if symptoms / signs of cirrhosis

GP 
Specialist

Detect other causes of liver disease

Need to optimise liver health

Check Hep A, Hep B, HIV serology
Metabolic liver disease: Iron studies, serum copper 
Exclude autoimmune hepatitis: ANA (antinuclear antibody), SMA (smooth muscle antibody) and LKMA (liver kidney microsomal antibody)
Review alcohol intake, weight

GP 
Specialist

Detect and manage conditions that are contra-indications to interferon / ribavirin

Need to detect health problems prior to treatment

Check for: 
Uncontrolled depression, psychosis
Autoimmune diseases
Pregnant women or couples unwilling to comply with adequate contraception
Severe concurrent medical disease:  epilepsy, cardiovascular, poorly controlled diabetes, renal failure 
Decompensated cirrhosis

GP 
Specialist

Detect and manage conditions that are relative contra-indications to interferon / ribavirin

Need to optimise health prior to treatment

Check for:
Haemoglobin <130 for men <120 for women, neutrophil count  <1500/mm^3
platelet count <90,000/mm^3 
Raised creatinine 
Significant coronary heart disease: consider ECG
Untreated  thyroid diseases: check TSH

GP 
Specialist

Review medication if prescribed

Correct use of medications, minimise side effects, good adherence

Patient education
Review medications

GP to review and provide education, possible shared -care

HCC screening

Early detection of HCC

6 monthly screening if cirrhosis
-	upper abdominal ultrasound
-	alpha-foetoprotein (AFP)

GP 
Specialist

General health monitoring.

Monitoring of general health

Review patient's status.
•	Measure weight, height, BMI, blood pressure.
•	Test total cholesterol profile.

GP
How often?
•	once every 6-12 months.

Medications. | Correct use of medication, with minimal side-effects. | Education about medications. Home medicine review if needed. | Pharmacist

Future complications. Reduce risk of hospitalisation.

•	To prevent/minimise the long-term effects of Chronic Pain on body and everyday life. 
•	To manage medication.

•	Annual complication assessment & review. 
•	Adjustment of medication.

Consultant physician

Smoking | complete cessation | support, educate, counsel | GP, HPO
Need for healthy diet. | To maintain a healthy weight & healthy diet. | Increase understanding of healthy eating, including dietary fat, sugars, glycaemic index. Review diet. | Dietitian / Health Promotion Officer & GP

Need for physical activity.

To exercise for at least 30 minutes, most days of the week.

•	To establish a regular exercise routine. 
•	Reinforce activity.

•	An exercise program of patient's choice.
•	Reinforced by GP.

Alcohol | low risk alcohol consumption | assess medications for potential alcohol interactions - advise patient. Encourage patients to abstain from alcohol or limit intake to 2 or less standard drinks a day. | GP.

Weight

Waist measurment:
Male< 94 cm
Female < 80 cm
BMI <25 kg/m2

assess and monitor BMI and WC, set goals, review, educate

GP

Psychosocial burden of chronic condition | prevent adverse effects of chronic condition on everyday life | assessment, education, support, referral | GP, HPO
PATIENT AGREEMENT TO THE GOALS OF THE CARE PLAN: AGREED
I understand the above Care Plan recommendations and agree to the outlined goals.
Copy of Care Plan given to patient __y___  SUGGESTED REVIEW DATE: ................................................
Copy of Care Plan sent to other team members___y__ (usually 6 months after starting Care Plan)