General TCA Review Template - Item 732

TEAM CARE ARRANGEMENTS REVIEW (ITEM 732) Patient Name: John Smith Date: 01/11/2024 Doctor Coordinating Team Care Arrangement Review: Dr. Thomas Kelly Informed consent has been obtained to prepare this review. Date of Original Team Care Arrangement: 01/05/2024 Review of Team Care Arrangement goals in collaboration with the participating providers and with verbal informed consent from the patient: Goal 1: Improve blood sugar control to maintain HbA1c below 7%. - Have goals been met? Partially - Further actions required: Continue current medication regimen and increase physical activity. Referral to a dietitian for nutritional guidance. Goal 2: Reduce blood pressure to below 130/80 mmHg. - Have goals been met? No - Further actions required: Adjust antihypertensive medication and monitor blood pressure weekly. Schedule follow-up with cardiologist. Goal 3: Increase physical activity to 150 minutes per week. - Have goals been met? Yes - Further actions required: Maintain current exercise routine and consider joining a community walking group for additional support. Is a revised (new) Team Care Arrangement (Item 723) required?: Yes, due to the need for medication adjustments and additional referrals. Review of Team Care Arrangement discussed with patient?: Yes Copies of Team Care Arrangement Review given to patient and relevant providers?: Yes Next Review Date: 01/05/2025