GP chronic condition management plan

Conditions: * Type 2 Diabetes Mellitus * Hypertension * Osteoarthritis SMART Goals: * Diabetes: Patient will reduce HbA1c to below 7.0% within 6 months through diet and exercise, monitored at 3-monthly reviews. (Specific, Measurable, Achievable, Relevant, Time-bound) * Hypertension: Patient will achieve a blood pressure reading of less than 130/80 mmHg within 3 months through medication and lifestyle changes, reviewed monthly. (Specific, Measurable, Achievable, Relevant, Time-bound) * Osteoarthritis: Patient will increase mobility and reduce pain levels to a score of less than 4/10 on the visual analogue scale (VAS) within 6 weeks through physiotherapy and pain management, reviewed at 6-weekly intervals. (Specific, Measurable, Achievable, Relevant, Time-bound) Tasks – Patient: * Diabetes: Follow a structured meal plan, engage in 30 minutes of moderate-intensity exercise most days of the week, and monitor blood glucose levels daily. * Hypertension: Take prescribed medication as directed, monitor blood pressure at home twice weekly, and reduce sodium intake. * Osteoarthritis: Attend physiotherapy sessions twice a week, perform prescribed exercises daily, and take paracetamol as needed for pain relief. Tasks – GP: * Diabetes: Review blood glucose control, medication adherence, and adjust medications as needed. Order HbA1c and renal function tests every 3 months. * Hypertension: Review blood pressure readings, medication efficacy, and adjust medications as needed. Order blood tests to monitor kidney function and electrolytes every 6 months. * Osteoarthritis: Review pain levels, mobility, and medication effectiveness. Consider referral to an orthopaedic specialist if symptoms worsen. Tasks – Practice Nurse: * Diabetes: Provide education on diabetes self-management, including diet, exercise, and medication. Administer annual flu and pneumococcal vaccinations. * Hypertension: Monitor blood pressure and provide lifestyle advice. Review medication side effects and adherence. * Osteoarthritis: Provide education on pain management strategies and exercise. Offer advice on assistive devices. Tasks – Multidisciplinary Team Members: * Dietitian: * Provide a structured meal plan tailored to the patient's diabetes and hypertension. * Educate the patient on carbohydrate counting and portion control. * Review dietary intake and provide feedback every 3 months. * Clinical rationale: Optimise blood glucose control and blood pressure management through dietary modifications. * Frequency of reviews: Every 3 months. * Reporting outcomes: Report HbA1c, blood pressure, and dietary adherence to the GP. * Physiotherapist: * Assess the patient's mobility and pain levels. * Develop an exercise program to improve joint function and reduce pain. * Provide education on proper posture and body mechanics. * Clinical rationale: Improve mobility and reduce pain associated with osteoarthritis. * Frequency of reviews: Every 6 weeks. * Reporting outcomes: Report pain scores, mobility improvements, and exercise adherence to the GP. Review Plan: * Review every 3 months by Dr. Thomas Kelly. Activities include medication review, blood test review, and goal setting. "Patient verbally consented to audio transcription and is aware that: - Audio recording would be completed during the consultation - Recording is for the purpose of creating notes"