<PracticeLetterhead>

GP MANAGEMENT PLAN / TEAM CARE ARRANGEMENTS - MBS ITEM No. 721 /723 (CHRONIC OBSTRUCTIVE PULMONARY DISEASE - COPD)

Date Prepared: <TodaysDate>		Proposed review date:
Date Reviewed:
Date Reviewed:
Date Reviewed:

Patient Details	GP DETAILS	
Name:<PtFullName>
DOB:<PtDoB>
Address: <PtAddress>
Phone:<PtPhoneMob>
	Name:<DrName>
Address:<DrAddress>
Phone:<DrPhone>
Provider No:<DrProviderNo>	

Current Problems List
<PMHActive>
Resolved Problems List
<PMHInactive>
Current Medications
<CurrentRx>
Allergies
<Reactions>
Immunisations
<Imm>
Smoking status / history 

Social History: 

Date of Confirmed Diagnosis of COPD                 Co-existing asthma  yes / no 
						     
Summary:              
	Date 		
Post bronchodilator Spirometry (at either initial diagnosis or first available spirometry after diagnosis ) 
		FEV1/ FVC =       

FEV1 =         predicted %   
  	
CXR 		Where? 	
Pulmonary Rehab	
	Where?
When? 	
Last Pneumococccal vaccination 		Next due / or now complete 	
Last influenza vaccination 	
	Next due 	
Last BMD T score hip / spine 	
	Next due 	
Home oxygen commenced 		Last review 
Current prescription
	
Last specialist review
		Next review	
Significant co-morbidities 

	
Hospitalisations or ever ICU admission for COPD  			

Biomedical data 	Initial GPMP Date	Review GPMP Date	Review GPMP Date	Review GPMP Date	Review GPMP Date	
BP						
Pulse						
Height						
Weight						
BMI						
Waist Circ.						
Activity levels 
(mins / week )						
Functional Capacity
CAT / mMMR						
Exacerbations in last year						
FEV1/ FVC
(post bd)						
FEV1  (post bd)
						
FEV1 % pred (post bd)						
Severity classification 						
SaO2 (if applicable)
						
Depression score K10/DASS21
/HADS 						
Smoking status 
						
Inhaler technique 						
Action plan rev	
					
AKPS (if indicated) 						

Resources: 
http://lungfoundation.com.au/health-professionals/clinical-resources/copd/general-practice/

http://lungfoundation.com.au/health-professionals/guidelines/copd/copd-x-concise-guide-for-primary-care/

http://lungfoundation.com.au/health-professionals/clinical-resources/copd/primary-care-respiratory-toolkit/

Patient problems / needs / relevant conditions	Goals and Recommendations	Required treatments and services including patient actions	Arrangements for treatments/services (when, who, contact details)	
1. General				
Patient's understanding of their condition of COPD/Chronic Lung Disease	Patient to have a clear understanding of their condition and patient's role in management.	Patient education  

Lung Foundation Australia resources 

COPD On Line Patient Education http://www.cope.lungfoundation.com.au/

Better Living with Your Lung Disease – DVD Series
http://lungfoundation.com.au/patient-support/living-with-a-lung-condition/self-management/

Better living with COPD – a patient guidehttp://lungfoundation.com.au/patient-support/copd/better-living-with-copd-a-patient-guide/

Lung Foundation Patient Information and Support Centre – 1800 654 301

Chronic Disease Self-Management Programs

A Stepwise Management Guide to Stable COPD will guide clinicians in COPD management
http://lungfoundation.com.au/health-professionals/guidelines/copd/stepwise-management-of-stable-copd/

consider referral to Respiratory Physician	GP

Nurse 

Respiratory (nurse) Educator

Lung Foundation Australia 

Respiratory Physician	
2. Lifestyle				
Nutrition	Maintain healthy diet based on nutritional state	Patient education

Assess nutritional state (under or overweight?)

Frequent small meals can reduce dyspnoea	Patient to implement

GP/Nurse to monitor 

Dietitian	
Weight

Your weight

BMI

Waist	Your target: 

Ideal: BMI 25-28 kg/m2

A slightly higher BMI is acceptable in COPD	Monitor
Review 6 monthly

Excessive weight loss is common with advanced COPD

Obesity in patients with COPD is associated with sleep apnoea, CO2 retention, and cor pulmonale.
	Patient to monitor

GP/Nurse to review	
Physical activity

current activity level:	Your target:

General recommendation: Exercise at least 30 minutes walking or equivalent 5 or more days per week
http://www.health.gov.au/internet/main/publishing.nsf/content/health-pubhlth-strateg-phys-act-guidelines
	Patient exercise routine

Pulmonary Rehabilitation for moderate to severe COPD (see below under self-management)
Find the closest one to you: http://lungfoundation.com.au/patient-support/living-with-a-lung-condition/pulmonary-rehabilitation-2/pulmonary-rehabilitation-programs-2/

Referral to Pulmonary Maintenance Exercise Program (post PR) e.g. Lungs In Action
http://lungsinaction.com.au	GP/practice nurse to monitor.

Pulmonary Rehabilitation Programme 

Referral to Chronic Disease Self-Management Programs

Exercise Physiologist

Exercise group	
Smoking

Cigarettes/day:

Pack years: 	Complete cessation	Smoking cessation strategy:
Consider:
- Quitline
- Medication
- Lung Age estimator and pack years calculator http://lungfoundation.com.au/health-professionals/clinical-resources/copd/primary-care-respiratory-toolkit/
Behavioural support/counselling	Patient to manage

GP/Nurse to monitor and support

Quitline referral 

Smoking cessation clinic 

Pharmacist referral / support	
Alcohol intake

current drinks/day

	Your target:

Ideal:
≤ 2 standard drinks per day with at least one alcohol-free day per week
 	Reduce alcohol intake

Patient education
	Patient to manage

GP/Nurse to monitor and support

DASSA – Drug and Alcohol Service of SA	
3. Medication				
Medication review	Pharmacotherapy to optimise function and prevent exacerbations.
Good adherence and device use
Prevent adverse medication  effects 
	Check optimal drug therapy (refer to pharmacotherapy section of Stepwise Management of COPD ahttp://lungfoundation.com.au/health-professionals/guidelines/copd/stepwise-management-of-stable-copd/

Review adherence 

Check and correct device use
LFA videos and inhaler technique fact sheets 
http://lungfoundation.com.au/patient-support/copd/inhaler-technique-fact-sheets

Understanding the use of medications including:
- Inhaled Bronchodilators for symptom relief and to increase exercise capacity

- Maintenance Medications /long acting bronchodilators (LABAs  and/or LAMAs) to improve exercise capacity, reduce breathlessness and reduce risk of exacerbations 

-  Inhaled corticosteroids in patients with severe COPD AND >2 exacerbations in the last 12 months, to reduce risk of exacerbations

- Oral Bronchodilators (low dose Theophylline) to reduce breathlessness (monitor for adverse effects and drug interactions)

Ensure patient has exacerbation medications /emergency pack readily available – details as per Action Plan, including short course oral steroids and antibiotics
	GP

Practice nurse

Respiratory (nurse) Educator 

Pharmacist

Home Medication Review
(Accredited pharmacist) 	
4. Biomedical 				
Spirometry

Your spirometry :
(post bd)
FVC:    litres   
        % predicted

FEV1:    litres 
       % predicted

FEV1/FVC:

Severity assessment when stable: 
Mild 
Mod 
Severe 

http://lungfoundation.com.au/health-professionals/guidelines/copd/stepwise-management-of-stable-copd/

Exacerbations in last 12 months: 
Date:
Hospitalised? Yes / No 
Date: 
Hospitalised? Yes/ No 

	Confirm diagnosis and monitor lung condition

COPD defined as

Post bd FEV1/FVC<0.7
Post bd FEV1<80% predicted)

If the FEV1 response to bronchodilator is:
 • > 400 mL, strongly consider asthma or asthma / COPD overlap.
 • < 400 mL (but ≥ 200 mL and ≥ 12%), consider co-existing asthma with COPD depending on history and pattern of symptoms.

	Record results of spirometric tests at diagnosis (absolute and percentage of predicted)

Perform and record spirometric measurements annually for mild / moderate COPD and twice yearly for severe COPD
(a loss of 500mls over 5 years will identify patients with rapidly progressing disease who may need specialist referral and investigation) 

	GP

Nurse

Respiratory Function Laboratory

Respiratory specialist or physician 	
Pulse Oximetry

Date:

Your Oxygen saturation level (SaO2) today:	Assess tissue oxygen levels	Referral to Respiratory Specialist for further assessment and need for 
long term oxygen therapy (LTOT):
SaO2 < 92% in room air (when stable) 
FEV1<30% predicted
Cyanosis
Polycythaemia 
Peripheral oedema
Raised JVP

Consider referral for assessment:
FEV1 30 – 49% predicted 

Patient education – LFA Home Oxygen resources (e.g. Home Oxygen Booklet; equipment checklists, oxygen prescription and goal setting, power blackout action plan)

http://lungfoundation.com.au/patient-support/living-with-a-lung-condition/oxygen

Assess fitness to fly (if required)   - Patients with advanced or unstable disease might require specialist assessment and high altitude simulation tests (HAST) , particularly if SaO2 is 88% or lower
http://copdx.org.au/copd-x-plan/p-prevent-deterioration/p10-oxygen-therapy/p101-fitness-to-fly/

Patient fact sheet:
http://lungfoundation.com.au/wp-content/uploads/2013/12/Fitness-to-Fly.pdf
	GP

Nurse

Respiratory Physician

Lung Foundation Australia 	
Assess the impact of COPD on the person’s life 

Date:

CAT:      /40
http://www.catestonline.org/

mMRC Dyspnoea scale 
Grade :
 (see Table 2 below)	Monitor long term course of disease, early detection of deterioration, and affect on activities of daily living 

CAT COPD Assessment Tool (Impact on QOL):
5-9 Low
10-20 Medium
>20 High
>30 Very High	Monitor for the impact of COPD  including the degree of breathlessness and affect on activities of daily living 

	GP
Pulmonary Physiotherapist 
Exercise physiologist  Occupational Therapy
Pulmonary Maintenance Exercise Program 

Respiratory Physician	
Blood pressure

Your BP:	Your target:
Ideal: 
< 130/80 mm Hg	Check every 6 months	GP

Nurse	
Osteoporosis

Vitamin D:

BMD date & result:
.	Maintain healthy bones

Patients with COPD are at increased risk of fracture due to the disease itself, the use of high dose corticosteroids  and co-existing risk factors such as immobilisation, reduced muscle mass and other factors	Minimise risk factors for osteoporosis and consider monitoring bone density (two yearly).
Correct any deficiency in vitamin D status 

Advice re adequate calcium intake / sun exposure / exercise http://www.osteoporosis.org.au/resources

Manage osteoporosis according to current guidelines http://www.osteoporosis.org.au/healthcare-professionals

	GP

Nurse

Dietitian 

Pharmacist 

Endocrinologist / Specialist Physician 
	
5. Prevent Deterioration				
Immunisation 

Your current vaccination status:

Influenza – 
Pneumococcal- 
	Maintain immunisation and prevent complications from influenza and pneumococcal disease	Influenza vaccine every year

Pneumococcal vaccine – initial vaccine then booster after 5 years depending on age and ATSI status 
see table 3, page 9

http://lungfoundation.com.au/health-professionals/guidelines/copd/copd-x-concise-guide-for-primary-care/

	GP

Practice nurse	
Home Oxygen	Yes     o   No    o
Date commenced:
	Consider need for home oxygen (see above under pulse oximetry)
Ambulatory oxygen for those on LTOT who want to continue therapy outside the home 
Short burst oxygen only for episodes of severe breathlessness relieved by other treatments 

Patient education – LFA Home Oxygen resources (e.g. Home Oxygen Booklet; equipment checklists, oxygen prescription and goal setting, power blackout action plan)

http://lungfoundation.com.au/patient-support/living-with-a-lung-condition/oxygen

	Respiratory Specialist

Respiratory nurse specialist 

Home oxygen supplier 

Lung Foundation Australia  	
6. Develop self-management plan				
Pulmonary rehab

	Yes     o   No    o
Date referred:

Maintain recommended physical activity levels 	Assess need for pulmonary rehab, particularly in moderate to severe disease
Provide information to patient about PR
http://lungfoundation.com.au/wp-content/uploads/2014/02/Pulmonary-Rehab-Fact-Sheet-Feb-2015.pdf

Refer to suitable PR program 
http://lungfoundation.com.au/patient-support/living-with-a-lung-condition/pulmonary-rehabilitation-2/pulmonary-rehabilitation-programs-2/

Assess need for re- referral 

Assess need for referral to maintenance exercise program (e.g. Lungs In Action http://lungsinaction.com.au)
	GP

Practice nurse 

Respiratory Specialist 

Pulmonary rehab	
Psychosocial and
mental health issues	Prevention and early detection of psychosocial problems, support for patient and extended family	Lung Foundation Australia has a range of educational resources for patients & carers and contacts for local support groups and can be contacted toll-free on 1800 654 301

Regular review with nurse to support patient with health education, advocacy and referral to other health providers as necessary, encourage carers/family to attend appointments if patient is willing
Consider screening for depression/anxiety using assessment tool if appropriate 
-  Kessler Psychological Distress Scale (K10) 
-  Depression Anxiety Stress Scale 21 (DASS 21)
http://www.gppaustralia.org.au/sites/default/files/services/mh/DASS%2021%20with%20Scoring%20Sheet.pdf

-  Hospital anxiety and depression scale (HADS) 
http://www.scalesandmeasures.net/files/files/HADS.pdf
	LungNet National Support Network – 1800 654 301

Nurse

Closing the Gap

Chronic Disease Management Programs

GP

Psychologist / Mental Health Clinician 

	
Family / Carer support	Maintain communication and support for carers and family members if applicable	Encourage carer/family involvement with management if patient willing

Refer to carer’s advocacy/support groups as appropriate

Referral to agencies providing assistance in the home as required/AACAT referral	GP

Nurse

Access 2 home care

Home Assist/local council

Carer support organisations 	
7. Manage exacerbations				
COPD Action Plan 
(Copy attached)	Yes     o   No    o

Early detection and management of  exacerbations 
 
	Develop COPD Action Plan with patient and / or carer http://lungfoundation.com.au/health-professionals/clinical-resources/copd/copd-action-plan/

Review at least annually and after each exacerbation, ED visit or hospitalisation   to review and optimize medication regime, and lung function and consider need for Pulmonary Rehabilitation

Ensure current ambulance subscription 

Have COPD Action Plan (and current list of medicines) readily available to show emergency services  
	Patient / carer 
GP
Nurse
Specialist
Respirator Nurse Practitioner 	
8.  Identify and manage co-morbidities				
Sleep apnoea	Consider sleep apnoea	Assess for symptoms
http://www.sleep.org.au/documents/item/78

Consider using screening tools such as ESS 
http://www.sleepapnoeanz.org.nz/the_epworth_sleepiness_scale.shtml

online form http://www.sleepservices.com.au/patients/epworth-sleepiness-scale

	GP

Specialist referral

Sleep unit	
Management of co-morbidities
These may include
Cardiac disease 
Heart failure 
Sleep-related breathing disorders 
Diabetes 
Anxiety and depression 
Osteoporosis 
	Early detection and management of conditions 	Further review and assessment as required	GP

Specialist	
9. Supportive or palliative care needs 				
	Identify those late in the clinical course of COPD who require supportive or palliative care 
Three triggers that suggest that patients are nearing the end of life are: 
1. The Surprise Question: ‘Would you be surprised if this patient were to die in the next 6 – 12 months? 
2 General indicators of decline - deterioration, increasing need or choice for no further active care. 
3 Indicators of severe COPD (low FEV1, decreased functional capacity)
Australian Karnofsky Performance Status (KPS) scale – decreasing numbers indicate reduced performance
http://ahsri.uow.edu.au/content/groups/public/@web/@chsd/@pcoc/documents/doc/uow129188.pdf
	Discussion of end of life wishes with patient / family / carer  Advance Care Planning 
http://www.advancecaredirectives.sa.gov.au/forms-and-guides
Specialist Palliative Care and Advance Care Planning Advisory Services (Decision Assist) for GPs and aged care staff 1300 668 908 (available 24/7 )  http://www.caresearch.com.au/caresearch/tabid/2583/Default.aspx
Consider referral to palliative care services / specialist 
.

	GP 

Palliative Care Australia 

Local Palliative Care Service 

Palliative Care Physician (private)	

Team Care Arrangements
Provider Name	Treatment/Service	Goals	No. of visits	

				

				

Copy of GP Management Plan offered to patient?  <<Copy of GPMP offered to patient?>>

Copy / relevant parts of the GP Management Plan supplied to other providers?  <<Copy of GPMP supplied to other providers?>>

GP Management Plan added to the patient’s records?  <<GPMP added to patient's records?>>

Date service was completed:  <<Date service completed>>	Proposed Review Date:  <<Proposed review date (recommended 6 months)>>	

I have explained the steps and any costs involved, and the patient has agreed to proceed with the plan.  <<Steps and costs explained, patient agreed>>

 GP’s Signature:  x_______________________________________________	Date: <<Miscellaneous:Date>>
   GP Name:  <<Doctor:Name>>

Table 1: COPD Severity
Based on FEV1%of predicted post-bronchodilator	
Mild	60-80%	
Moderate	40-59%	
Severe	<40%	

Table 2:  Modified Medical Research Council (mMRC) Dyspnoea Scale for grading the severity of breathlessness during daily activities  	
Grade 0	I only get breathless with strenuous exercise	
Grade 1	I get short of breath when hurrying on level ground or walking up a slight hill2On level ground	
Grade 2	I walk slower than people of the same age because of breathlessness, or I have to stop for breath when walking at my own pace on the level 	
Grade 3	I stop for breath after walking about 100 metres or after a few minutes on level ground 	
Grade 4	I am too breathless to leave the house or I am breathless when dressing or undressing 	
_Lung Foundation Australia_GPMP/ TCA Template_ Version 1.0_April 2016_KH_JP