GPCCMP

Specialty: General Practitioner Chronic Condition Management Plan (GPCCMP) & Reviews Patient Eligibility & Consent: "Patient has one or more chronic medical conditions present for ≥6 months. Verbal consent obtained to prepare a GPCCM and to share relevant information with members of the care team, where applicable. Patient agrees to the development and reviews of this plan." GP Chronic Condition Management Plan (GPCCMP): Patient Problem or Need or Relevant Condition 1: Type 2 Diabetes Mellitus - Goals - Changes to be Achieved: - Maintain HbA1c below 7.0% - Achieve daily blood glucose readings within target range (4.0-7.0 mmol/L fasting, <10.0 mmol/L post-meal) - Increase physical activity to 30 minutes, 5 times a week - Required Treatments and Services (Including Patient Actions): - Continue Metformin 500mg twice daily - Regular home blood glucose monitoring (before breakfast and 2 hours after main meal) - Adhere to low glycaemic index diet, limiting processed sugars - Attend diabetes education group sessions - Arrangements for Treatment/Services: - Prescription for Metformin renewed at next GP visit. - Patient provided with a blood glucose meter and strips; training provided by practice nurse. - Referral made to local diabetes education programme; first session booked for 15/11/2024. Patient Problem or Need or Relevant Condition 2: Hypertension - Goals - Changes to be Achieved: - Maintain blood pressure below 140/90 mmHg - Reduce dietary sodium intake - Lose 5kg in the next 3 months - Required Treatments and Services (Including Patient Actions): - Continue Ramipril 5mg once daily - Regular home blood pressure monitoring (weekly, morning and evening) - Follow DASH diet principles - Walk for 30 minutes daily - Arrangements for Treatment/Services: - Prescription for Ramipril renewed. - Patient advised on proper home blood pressure monitoring technique. - Provided with resources on DASH diet and local walking groups. Patient Problem or Need or Relevant Condition 3: Chronic Low Back Pain - Goals - Changes to be Achieved: - Reduce pain intensity by 50% (from 7/10 to 3-4/10) - Improve mobility and reduce stiffness - Return to light gardening activities - Required Treatments and Services (Including Patient Actions): - Regular paracetamol 500mg as needed, up to 4 times a day - Daily stretching exercises for the lower back and core - Attend physiotherapy sessions - Avoid prolonged sitting or standing - Arrangements for Treatment/Services: - Referral issued to Physiotherapy department at St. Michael's Hospital. - Patient provided with printouts of recommended exercises. - Discussion about ergonomic adjustments at home. Other Problems: - Elevated cholesterol (managed with diet and exercise) - Occasional anxiety (managed with mindfulness techniques) PATIENT ACTIONS: - Monitor blood glucose and blood pressure daily/weekly and record readings. - Adhere strictly to medication schedules for diabetes and hypertension. - Follow recommended dietary changes (low GI, low sodium, DASH principles). - Engage in physical activity as advised (30 minutes, 5 times a week). - Complete daily stretching exercises for back pain. - Attend scheduled appointments (diabetes education, physiotherapy). - Self-monitor for signs of hypoglycaemia or adverse medication effects. Service Coordination: - Practice Nurse: Provides diabetes education, medication reconciliation, and support for blood glucose monitoring. - Dietitian: Will provide personalised dietary advice for diabetes and hypertension management. - Physiotherapist: Will assess and provide a tailored exercise programme for chronic low back pain. Patient given Plan & a copy saved to patient's medical record. Date Service was Completed: 01/11/2024 Review Date: 01/02/2025