Sample Goals, Treatments & Patient Actions for Management Plans
Condition / Goals / Actions by patient / Treatment and services to achieve goals. / Possible referral to:GENERAL
(for all plans) / -Minimal interference with daily activities.
-Improve understanding of condition and how to best manage it.
-Prevent complications. / -Report to GP any concerns or changes in condition.
-Follow treatment and take any medications as discussed with your GP and specialists.
-Attend GP appointments for monitoring and reviews.
-Keep a healthy diet and good level of physical activity.
-Avoid smoking and even passive smoke. Quitline 131848.
- Limit alcohol consumption to a maximum of 2 standard drinks, Always aim for alcohol free days. / -Ongoing review by GP.
-Ongoing education regarding health problems.
-Eye check every 1-2 years.
-Ongoing review for need of allied health input.
-Dental cleaning/check-up every 6-12 months.
-Yearly vaccination to prevent Influenza. / Exercise Physiologist
Pharmacist for Medicine review
Dietitian
Use goals, actions and treatments from “General” and add the following for the specific illnesses.
Diabetes / -Maintain Blood Pressure below 130/80mmHg
-Maintain Hba1c below 7%.
-Maintain Cholesterol within healthy range: Chol <4.0 mmol/L
- LDL <2.5
- HDL > 1.0
–trig <1.5
-Maintain Blood Glucose Level (BGL/BSL) below 7mmol/L (ideal 4-6 fasting).
-Early detection and prevention of eye complications.
-Prevention of foot complications.
-Prevention of renal complications. / -Regular self-check of feet.
- Follow a low GI diet. / -Annual check of cholesterol.
-Annual check of renal function (microalbuminuria & eGFR)
-Check Blood Pressure every 3-6 months.
-Check Hba1c at least once a year.
-Check condition of feet (by GP, Nurse or Podiatrist) every 6 months.
-Optometry review every 12 months. / Dietitian
Exercise Physiologist
Optometrist
Ophthalmologist
Podiatrist
Dietitian
Diabetes Educator
Use goals, actions and treatments from “General” and add the following for the specific illnesses.
Asthma / -Remain free from asthma symptoms
-Need asthma reliever medication less than 3 times a week / - Avoid known asthma triggers. / -Spirometry every 1-2 years.
- Review asthma plan every 3-6 months. / Dietitian
Exercise physiologist
Physiotherapist
Arthritis/Pain / -Optimal pain management with minimal or no side-effects.
-Optimise and preserve mobility.
-Minimise joint-specific problems. / -Review should be arranged if symptoms of weight loss, severe night pain, marked morning stiffness, pain with fever or progressive worsening of the pain. / -Ongoing review of pain levels and management / Physiotherapist
Osteopath
Pain clinic
Exercise physiologist
CHD (Coronary Heart Disease) / -Maintain Blood Pressure below 130/80mmHg.
-Maintain Cholesterol within healthy range.
-Prevention of kidney complications.
-Remain free from chest pain. / - Chest pain action plan as discussed with GP. / -Annual check of cholesterol.
-Check Blood Pressure every 3-6 months.
-Optometry review every 1-2 years. / Dietitian
Physiotherapist
Optometrist
Podiatrist
Exercise physiologist
Dementia / -Minimise changes to routine.
-Minimise distractions and control noise. / -Have notes around the house as reminders.
-Structure written time tables.
-Place identification in a wallet.
-Post by every phone a list of emergency numbers.
-Have hot water temperatures reduced.
-Consider child-proof latches on cabinets that contain dangerous items.
-Consider timers for stoves. / -Consider Meals on wheels.
-Consider psychologist review for supportive psychotherapy and cognitive behavioral therapy.
-Ongoing review to assess if assistance is needed for lifts or transfers.
Renal/Kidney disease / -Target Hb of 11-12.
-Maintain Blood Pressure below 130/80mmHg
-Maintain Hba1c below 7%.
-Maintain Cholesterol within healthy range. / -Annual check of cholesterol.
-Check Blood Pressure every 3-6 months.
-If plasma Ferritin concentrations below 100 mcg per L. should be given iron supplements.