HSMC.GPCCMP Review

GP Chronic Condition Management Plan (GPCCMP) Review Details: 1. Review of Overall Progress and Goals: - Patient's Progress Towards Goals: Patient reports good adherence to prescribed medications and regular attendance at physiotherapy sessions. Blood pressure and blood glucose levels have shown moderate improvement since the last review. Mobility remains limited due to osteoarthritis in knees, but patient is compliant with recommended exercise regimen. - Updates to GPCCMP (Goals, Actions, Services): Goal relating to weight reduction updated to reflect recent achievements; new target set collaboratively with patient. Plan amended to include home podiatry services due to recent concerns about foot care. 2. Updated Multidisciplinary Care Assessment & Referrals: - Consideration of Multidisciplinary Team Information (if any): Recent podiatry report reviewed and noted ongoing issues with foot sensation. Physiotherapy notes confirm continued improvement in joint mobility. - New/Updated Referrals and Consent to Share: Referral made to local diabetes educator for updated diet counselling. Patient consented to sharing updated plan details with involved allied health professionals. - Provision of Updated Plan to MDT: Relevant parts of the updated plan to be provided to physiotherapist, podiatrist, and diabetes educator. 3. Updated Preventative Health & Lifestyle: - Immunisations Action: Patient reports having received recent influenza and COVID-19 boosters; no further action required at this time. - Smoking Status & Action: Patient is a non-smoker. - Alcohol Use & Action: Occasional alcohol use discussed; patient advised to limit to no more than two standard drinks on any occasion. - Exercise Habits & Action: Patient continues walking program 3x weekly as per physiotherapist recommendation. - Diet Habits & Action: Patient reports improved dietary choices with reduced processed sugar intake. - Screening Tests (CST, FOBT, Mammogram, Pathology): Next HbA1c scheduled in 3 months; last CST up to date. - Advanced Care Directive: Discussed and confirmed no current directive in place; patient not ready to proceed at this stage. - Home Medicine Review (HMR): Not indicated at this time. 4. Arrangements to Review the Plan: - Updated Review Arrangements: Next review scheduled with practice nurse in 3 months. GPCCMP Review Process Documentation: - Patient Consent and Agreement to Updates: Patient verbally consented to the plan updates and revised goals. - Offer of Updated Plan Copy to Patient/Carer: Copy of updated plan offered to patient and accepted. - Updated Plan Added to Medical Records: Updated plan to be uploaded to patient's medical records. Medicare Item Number & Recall: - Medicare Item Number: 93667 - 3/12 Recall: 3-month recall entered into system for follow-up. - Follow-up Appointment with Nurse: Follow-up with practice nurse booked for 13/11/2025.