This case study focuses on an Indigenous patient. It shows how health professionals use GPCCMP services to coordinate care for a patient with chronic conditions.
Case study
A 52-year-old Indigenous patient presents with an infected foot that requires wound management and antibiotics.
Their medical history includes all of the following:
- hypertension and high cholesterol.
- mild renal condition.
- myocardial infarction.
- type 2 diabetes.
- increasing circulation concerns with associated foot issues.
As well as this, they:
- have a family history of heart disease
- smoke
- have nutrition-related risk factors
- have had limited access to health services
- usually attend the clinic every 6 months to renew prescriptions
- may need additional support to manage their chronic conditions.
Actions to develop the care plan
There are steps to develop the GPCCMP.
First visit
In this visit, you do all the following:
- Discuss your patient’s health issues.
- Outline the potential benefits of a care plan.
- Outline the process of putting a structured plan in place to better manage your patient’s chronic conditions.
- Decide to develop a GPCCMP.
- Collaborate with and coordinate treatment by a multidisciplinary team of health and care providers.
- Tell your patient you’ll start developing the plan.
- Discuss it further with the patient when they come back in a few days for wound review.
- Ask your patient if they would like support from an Aboriginal and Torres Strait Islander health practitioner.
- Explain to your patient what is involved.
Your patient agrees to the plan.
Follow-up visit
In the next visit, you do all the following:
- Go through the draft plan and discuss goals and actions with your patient and the health care team.
- Discuss arrangements for health services with allied health professionals and Aboriginal and Torres Strait Islander primary health care professionals.
- Make arrangements for specialist services at the local public hospital with a cardiologist, endocrinologist, renal physician and ophthalmologist.
- Offer a copy of the plan to your patient.
- Ask if you can distribute relevant information from the plan to other health and care professionals.
- Explain that you can refer your patient for some Medicare-subsidised allied health and Aboriginal and Torres Strait Islander health and wellbeing services.
You and your patient agree on the care plan.
Referrals
You decide to refer your patient for allied health and Aboriginal and Torres Strait Islander health and wellbeing services, including all the following:
- 3 individual services with a podiatrist
- 2 individual services with an Aboriginal and Torres Strait Islander health worker
- one assessment for suitability for group education services with a diabetes educator.
Learn more about chronic condition allied health and other primary health care items.
Monitoring and support services
As well as these services, you ask your patient to attend services with the Aboriginal and Torres Strait Islander health practitioner.
You do all of the following:
- Check on your patient’s clinical progress.
- Support your patient to manage their medicines.
- Provide self-management advice.
- Collect information to support future reviews of care plans.