Chronic Disease Management (CDM) Plan Notes

Reporting Month/Year: November 2024 Patient Information Full Name: John Smith Date of Birth (DOB): 01/11/1950 Medical Record (MR) #: 123456 Primary Address: 123 Health St, Wellness City, WC1 2AB Contact Number: 01234 567890 Emergency Contact: Jane Smith, Wife, 01234 098765 Usual Medical Practitioner: Dr. Thomas Kelly, MD Practice Name: Wellness Clinic Practice Contact: 01234 567891 Eligibility Criteria - The patient’s chronic or terminal condition: Type 2 Diabetes, confirmed eligible for CDM services. - Expected duration of condition(s): Expected to last at least six months or longer. - Verification of CDM service eligibility: Eligibility confirmed through HPOS/MBS. - Usual medical practitioner’s role: Dr. Thomas Kelly has provided most care in the last 12 months and will continue to do so for the next 12 months. Chronic Medical Conditions - Type 2 Diabetes (ICD-10: E11) - Diagnosed in 2010, moderate severity, with elevated HbA1c levels. - Management plan includes Metformin, dietary changes, and regular blood glucose monitoring. - Referred to endocrinologist, ongoing monitoring of HbA1c, and quarterly lab tests required. - Hypertension (ICD-10: I10) - Diagnosed in 2015, controlled with medication. - Management plan includes Lisinopril, low-sodium diet, and regular blood pressure checks. - No specialist referrals needed at this time, bi-annual monitoring required. Other Medical Conditions - Hyperlipidemia – Managed with Atorvastatin, impacts cardiovascular health, requires lifestyle modifications and annual lipid profile tests. - Osteoarthritis – Affects mobility, managed with physical therapy and NSAIDs, referral to physiotherapist for exercise plan. Patient Assessment and Needs Identification - Functional Status: Limited mobility due to osteoarthritis, impacts daily activities. - Cognitive Status: No significant cognitive impairments, independent in daily tasks. - Psychosocial Needs: Strong family support, occasional anxiety related to health. - Nutritional Needs: Requires low-sugar, low-sodium diet, referred to dietitian. - Medication Management: Adherent to medication, pharmacist review scheduled. - Lifestyle Factors: Non-smoker, moderate alcohol intake, advised to increase physical activity. CDM Plan Development Planned Interventions and Services - Medical Management: Quarterly assessments, HbA1c and blood pressure monitoring. - Preventive Care Needs: Up-to-date on vaccinations, annual screenings scheduled. - Patient Education: Educated on diabetes self-management and symptom monitoring. - Referrals to Allied Health Services: - Physiotherapy: Referred for osteoarthritis management, expected to improve mobility. - Dietetics: Referred for dietary management of diabetes and hyperlipidemia. - Podiatry: Referred for foot care due to diabetes. - Pharmacy Medication Review: Scheduled to address polypharmacy risks. Health Goals (Short and Long-Term) - Short-Term Goal 1: Reduce HbA1c to below 7% within three months. - Short-Term Goal 2: Increase physical activity to 30 minutes daily. - Long-Term Goal 1: Maintain blood pressure below 130/80 mmHg. - Long-Term Goal 2: Improve overall quality of life and reduce anxiety. Monitoring and Support Services Date: 01/11/2024 - Service Provided: Medication review - Duration: 30 minutes - Provider Name & Credentials: Nurse Jane Doe, RN Date: 15/11/2024 - Service Provided: Symptom management - Duration: 45 minutes - Provider Name & Credentials: Nurse John Doe, RN Date: 30/11/2024 - Service Provided: Health education - Duration: 60 minutes - Provider Name & Credentials: Nurse Mary Smith, RN Referrals to Allied Health Professionals - GPMP and Team Care Arrangements (TCAs) Status: Completed - Referral Letter Status: Sent to allied health provider - Allied Health Practitioners Engaged: - Dietitian: Appointment scheduled for 05/12/2024 - Physiotherapist: Appointment scheduled for 10/12/2024 - Podiatrist: Appointment scheduled for 15/12/2024 Review and Reassessment - Planned Review Date: 01/02/2025 - Changes in Patient Condition: No significant changes noted. - Plan Modifications: No modifications needed at this time. Billing and Medicare Compliance - CDM Plan Development: Claim under MBS Item 721 confirmed. - Monitoring and Support Services: Claim under MBS Item 10997 (Enter number of units: 3). - Allied Health Referrals: Claim under MBS Item 723 confirmed. - Review Services: Claim under MBS Item 732 confirmed. Signatures Usual Medical Practitioner: Dr. Thomas Kelly, MD Date: 01/11/2024 Practice Nurse/Support Staff Signature: Nurse Jane Doe, RN Date: 01/11/2024