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]

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] | | yes | yes
Health Promotion Officer | Health promotion Activities | yes | yes
Patient’s Name: 

GP MANAGEMENT PLAN

Patient problems / needs / relevant conditions | Goals - changes to be achieved (if possible) | Required treatments and services including patient actions | Arrangements for treatments/services (when, who, and contact details)
1. General | | |
Patient's understanding of cerebrovascular disease including peripheral vascular disease, coronary heart disease and cerebrovascular disease | Patient to have a clear understanding of cardiovascular disease and the patient's role in managing the condition | Patient education | GP

Emergency action plans as relevant

Chest pain action plan if relevant 
stroke action plan if relevant

peripheral arterial disease action plan if relevant

Understand cardiac chest pain e.g pain associated with exercise, relieved by rest crushing retrosternal pain radiation to neck chin or left arm.

understanding associated symptoms of cardiac chest pain or angina e.g. acute nausea, vomiting, sweating , diarrhoea

Understand the symptoms of the onset of stroke.

Understand the FAST test 

understand the symptoms of chronic limb ischaemia and acute limb ischaemia.

Develop action plan

GP and patient agree on written action plan on use of anti-anginals and when to ring the ambulance – especially when chest pain persists > 10 minutes after use of anti-anginal medication.

GP and patient agree on FAST test use and action plan including the use of emergency ambulance service

GP and patient to agree on management plan for both acute and chronic limnb ischaemia including appropriate use of emergency ambulance service

GP
Patient 
pharmacist

2. Lifestyle | | |

Nutrition

Healthy eating pattern, low fat diet

Patient education

GP
Patient to implement
Dietitian

Weight

Your target:
BMI  25
Men waist 94 cm
Women waist  80 cm

Monitor
Review 6 monthly

Patient to monitor
GP
Dietician

Physical Activity

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

Patient exercise routine

Patient to implement
GP
Physiotherapist

Smoking

Complete cessation

Smoking cessation strategy:
Consider:
- Quit
- Medication

Patient to manage
GP
smoking cessation advisor

Alcohol

Your target:
     standard drinks per day
Ideal:
2 standard drinks per day (men)
1 standard drinks per day (women)

Reduce alcohol intake
Patient education

Patient to manage
GP to monitor

2. Biomedical | | |

Cholesterol / Lipids

Your target:
Cholesterol  4.0 mmols/L
Triglycerides  2.0 mmol/L
LDL-C  2.5 mmol/L
HDL-C  1.0 mmol/L

Annual check

GP

Blood pressure

Your target:
< 140/90
if diabetic target may be lower

Check every 6 months
discuss with GP

GP

Diabetes screen | Exclude diabetes as a risk factor in cardiovascular disease | Annual check | Gp

If diabetic

Ensure HBA1C < 7.5

Check every 6 months 
Consider medication to achieve this glycaemic target

Gp

3. Medication | | |

Medication review

Correct use of medications, minimise side effects

Patient education
Review medications

GP and pharmacist to review and provide education

Anti-hypertensive medication

Understand the role that antihypertensive medications play in reducing blood pressure and understand the need for optimal blood pressure control in cardiovascular disease.

Understand the indications, contra-indications and side effects of these medications.

Monitor compliance, indications, contraindications and side effects of these medications

Patient education and monitoring

Gp to reveiew at 6 monthly intervals or more frequently if indicated

pharmacist to reveiew opportunistically at each dispensing.

Pharmacist to refer back to prescribing clinican (or GP) as appropriate in the event of any issues arising.

Anti-anginal medications

Understand the role that anti-anginal medications play in coronary heart disease.

Understand the indications, contra-indications and side effects of these medications.

Monitor compliance, indications, contraindications and side effects of these medications

Patient education and monitoring

Gp to reveiew at 6 monthly intervals or more frequently if indicated

pharmacist to reveiew opportunistically at each dispensing.

Pharmacist to refer back to prescribing clinican (or GP) as appropriate in the event of any issues arising.

Anti-platelet medication

Understand the role that anti-platelet medications play in preventing cardiovascular disease

Understand the indications, contra-indications and side effects of these medications.

Monitor compliance, indications, contraindications and side effects of these medications

Patient education and monitoring

Gp to reveiew at 6 monthly intervals or more frequently if indicated

pharmacist to reveiew opportunistically at each dispensing.

Pharmacist to refer back to prescribing clinican (or GP) as appropriate in the event of any issues arising.

Cholesterol lowering agents

Understand the role that cholesterol lowering medications play in preventing cardiovascular disease

Understand the indications, contra-indications and side effects of these medications.

Monitor compliance, indications, contraindications and side effects of these medications

Patient education and monitoring

Gp to reveiew at 6 monthly intervals or more frequently if indicated

pharmacist to reveiew opportunistically at each dispensing.

Pharmacist to refer back to prescribing clinican (or GP) as appropriate in the event of any issues arising.

Beta blcokade

Understand the role that beta blockers play in preventing coronary heart disease

Understand the indications, contra-indications and side effects of these medications.

Monitor compliance, indications, contraindications and side effects of these medications

Patient education and monitoring

Gp to reveiew at 6 monthly intervals or more frequently if indicated

pharmacist to reveiew opportunistically at each dispensing.

Pharmacist to refer back to prescribing clinican (or GP) as appropriate in the event of any issues arising.

ACE inhibition

Understand the role that ACE-inhibitors play in preventing cardiovascular disease

Understand the indications, contra-indications and side effects of these medications.

Monitor compliance, indications, contraindications and side effects of these medications

Patient education and monitoring

Gp to reveiew at 6 monthly intervals or more frequently if indicated

pharmacist to reveiew opportunistically at each dispensing.

Pharmacist to refer back to prescribing clinican (or GP) as appropriate in the event of any issues arising.

4. Psychosocial | | |

Depression

Understand the risk of developing depression and or anxiety disorders in any chronic disease in general and in cardiovascular disease in particular 

understand the role of screening for mood disorder and anxiety disorder

assess and provide management for any mood or anxiety disorder: management may include talking therapies and or medications.

Assessment.
Medication or cognitive behaviour therapy

referral to psychologist / psychiatrist as appropriate

GP to assess and initiate management

psychologist / psychiatrist

Social isolation

Reduce social isolation

Improve social support 
eg referral to support group

GP to advise and monitor

Copy of GP Management Plan offered to patient?  y

Copy / relevant parts of the GP Management Plan supplied to other providers?  y

GP Management Plan added to the patient’s records?  y

Date service was completed: | Proposed Review Date:

I have explained the steps and any costs involved, and the patient has agreed to proceed with the plan. YES