721 GP MANAGEMENT PLAN (GPMP) for HCV infection
723 TEAM CARE ARRANGEMENTS (TCA) (if applicable

Date service was provided:		
Patient’s name: 			
Patient’s address:		
Date of Birth:		
Contact Details:		
Medicare No:		
Private health insurance details, if  applicable or health care card details: 	

Details of patient’s usual GP:		Details of patient’s carer (if applicable):	
	
 If the patient has a previous or existing care plan, when was it prepared and what were the outcomes:	
 
Other notes or comments relevant to the patient’s care planning: eg need for translator:	

Current problems:

Medications:

Allergies: 	

Social history: county of birth, ethnicity, languages spoken	

Preparation of a GP Management Plan (Item 721)	
Patient’s health problems / health  needs / relevant conditions	Management goals with which the patient agrees	Treatment and services required, including actions to be taken by the patient	Arrangements for providing treatment/services (when, who, contact details) 	

Chronic hepatitis C: see www.ashm.org.au gesa@gesa.org.au 	
Confirm presence of chronic hepatitis C	Check for active infection	Check hepatitis C RNA (PCR) +ve confirms infection 	GP	
Education about hepatitis C	Good understanding of chronic hepatitis C and treatment with directly-acting antivirals (DAA)
	Patient education  re
•	disease prognosis
•	potential transmission
•	reinfection risk and harm reduction
•	cofactors such as alcohol
•	treatment options with DAAs 
•	adherence to DAAs 
•	avoidance of pregnancy with DAAs 
•	will remain hep C antibody positive for life	GP
Educator	
Determine genotype (optional) / viral load (optional)	Determine treatment regimen and duration	Hepatitis C genotype (optional), RNA quantitative (optional)	GP	
Record previous HCV treatment	Determine treatment regimen and duration	Check previous treatment and response 	GP	
Review possible drug/drug interactions	Avoid potential DDI with current medication 	Optimise current medication to avoid DDI with proposed DAA therapy 	GP	
Detect cirrhosis 
	Detect advanced liver disease or cirrhosis 	Physical examination
Investigations: FBC, INR, LFT
Abdominal ultrasound if advanced fibrosis / cirrhosis is suspected
AST to Platelet Ratio Index (APRI) score ≥1
Refer if cirrhosis, will need to modify DAA therapy
Consider screen for osteoporosis in those with cirrhosis (certainly if decompensated)
FibroScan > 12.4 kPa (if available) or shear wave elastography (if available(	GP 
Specialist	
Detect other causes of liver disease	Need to optimise liver health	Check Hep A, HBsAg, anti-HBc, anti-HBs, HIV Ab, review alcohol intake, weight
Note further investigations if persistently abnormal LFTs post treatment	GP 
Specialist	
Detect and manage conditions that may be contra-indications to DAA therapy  	Need to detect health problems prior to treatment	Check UEC, eGFR –refer if eGFR < 50
Decompensated cirrhosis – refer 
Urine Pregnancy test prior to pre-treatment progression  	GP 
Specialist	
Cirrhosis management 	Optimise management	Specialist referral
Abdominal USS 6 monthly for HCC screening, gastroscopy for varices	GP 
Specialist	
Develop treatment plan	Optimise HCV treatment including monitoring	Prescribe DAA therapy in consultation with gastroenterologist, hepatologist or ID (if GP is not experienced in hepatitis C treatment)
In people who inject drugs, include post treatment yearly PCR test for reinfection surveillance
Monitor response 12 weeks post-treatment: HCV RNA to confirm cure & LFTs  	GP
Specialist	

Lifestyle: see RACGP Red Book www.racgp.org.au/guidelines/redbook/ 	
Smoking
Current:	Complete cessation	Smoking cessation strategy:
- set Quit date, consider medication	Patient 
GP / Nurse	
Weight
Weight:
BMI:
Waist circumference:	Target weight:
Ideal weight:
BMI ≤ 25, Waist <94 cm males, <80 cm females	Monitor
Review 6 monthly
	Patient 
GP / Nurse 
Dietician	
Nutrition	Maintain healthy diet	Patient education	Patient, GP / Nurse, Dietician	
Physical activity
Current:	Target:
Ideal: 30 minutes of moderate activity on most days	Patient exercise routine
	Patient 
GP / Nurse 
Exercise Physiologist	
Alcohol intake
Current  drinks / day:	Target:  drinks / day
Ideal: minimal, 
complete abstinence if cirrhosis	Patient education
	Patient 
GP / Nurse	

Cardiovascular / metabolic:  see RACGP Red Book https://www.racgp.org.au/	
CV risk calculation
Absolute risk:	Minimise risk	Depends on risk	Patient
GP /Nurse	
Blood pressure
Current:	Ideal:  < 120/80 mm Hg	Check every 6-24 months
Non-drug eg weight loss
Medication if elevated	Patient
GP / Nurse	
Lipids
TC:
LDL:
HDL:
TG:	Optimise lipids
TC 
LDL < 2.5
HDL > 1.0
TG < 1.	Check every 1-5 yr
Dietary change
Medication if required	Patient
GP / Nurse
Dietician	
Glucose
Current glucose:	Fasting glucose <5.5 mmol/L 	Check every 1-5 yrs, dietary change
medication as required, 	Patient, GP / Nurse
Dietician	
Renal
eGFR, urinalysis:	eGFR > 90
normal urinalysis	Check every 1-5 yrs
	GP / Nurse

Vaccination:  see RACGP Red Book https://www.racgp.org.au/ 	
Influenza	Prevent	Annual vaccination if at risk 	GP / Nurse	
Hepatitis A	Prevent	Vaccination x 2 	GP / Nurse	
Hepatitis B	Prevent	Vaccination x 3 	GP / Nurse	
Pneumococcal	Prevent	Vaccination every 5 years if at risk 	GP / Nurse	
Tetanus/pertussis	Prevent	Vaccination every 10 years	GP / Nurse	
HPV	Prevent	Vaccination x 3 (not funded for adults)	GP / Nurse	
Meningococcal B 	Prevent	Vaccination X 2	GP / Nurse	
Meningococcal ACWY	Prevent	Vaccination X 1 every 5 years 	GP / Nurse	
Varicella serology 	Prevent 	Vaccination X 2 if needed 	GP / Nurse	
MMR serology 	Prevent 	Vaccination X 2 if needed 	GP / Nurse	
Zoster vaccination	Prevent	Vaccination X 1 at 60, note cautions 	GP / Nurse	

Cancer screening: see RACGP Red Book https://www.racgp.org.au/ 	
Colon	Early detection	FOBT (every 2 years age 50 – 75) or 
colonoscopy (every 5 years  if +ve Fhx)	GP / Nurse	
Skin	Early detection, prevention	Sun avoidance and protection
Consider skin checks (opportunistic, high risk > 40)	GP / Nurse	
Cervical (female)	Early detection	HPV every 5 years 	GP / Nurse	
Breast (female)	Early detection	Mammogram every 2 years (age 50 – 69)	GP / Nurse	
Prostate (male)	Early detection	Consider PSA / DRE from age 50 	GP / Nurse	

Psychosocial  see RACGP Red Book  https://www.racgp.org.au/ ,  ASHM  http://www.ashm.org.au/HCV 	
Depression, mental illness	Early detection, treatment	Opportunistic screening	GP / Nurse	
Drug use	Early detection, treatment	Opportunistic screening, harm reduction, opiate substitution therapy as needed 	GP / Nurse / Specialist addiction/ counselling service 
	
Housing, financial situation, social support	Optimise	Opportunistic screening	GP / Nurse	

Other:  see RACGP Red Book for details  https://www.racgp.org.au/	
Sexual health screen	Early detection 	Screen for Chlamydia if aged 15- 25
Other STI depending on risk group	GP / Nurse	
Dental health	Optimise dental health	Referral for regular dental care	GP / Nurse 
Dentist	
Vision / Glaucoma	Prevent visual loss	Referral to ophthalmologist / optometrist if at high risk (Fhx glaucoma, diabetes, > 60)	GP
Ophthalmologist Optometrist	
Osteoporosis	Optimise bone health	Screen females > 45, males > 50 or younger if risk factors (eg fracture hx, underweight, Fhx, corticosteroid use, endocrine disorder)
Review calcium, vitamin D intake 	GP / Nurse / Dietician	

Other health problems	
Health problems 	Management goals 	Treatment and services required	Arrangements 	

Coordination of Team Care Arrangements (Item 723)	
Treatment and service goals for the patient / changes to be achieved	Treatment and services that collaborating providers will provide to the patient	Actions to be taken by the patient	
Optimise general health	GP	Attend 3 monthly	
Optimise liver health 	Specialist	Attend 6 monthly	
Optimise dental health	Dentist	Attend 6 monthly	
Optimise vaccinations	Practice nurse	Attend as needed 	
Optimise nutritional  health	Dietician	Attend as needed	
Optimise mental health 	Psychologist / counsellor	Attend as needed	

  721	•	I have explained the steps and costs involved, and the patient has agreed to proceed with the GP MANAGEMENT PLAN service	GP’s Signature & Date	
  723
  (if applic)
	•	I have explained the steps and costs involved, and the patient has agreed to proceed with the TEAM CARE ARRANGEMENTS service
•	  The patient also agrees to the involvement of other care providers and to share clinical information without / with restrictions (identify)	GP’s Signature & Date	

I give my permission for my GP to discuss my medical history/diagnosis with other service providers. I understand that referral for service can still go ahead if I do not want information about me made know to the service providers.

I understand the above Management Plan recommendations and agree to the outlined goals.
	Patient/Carer Signature & Date  	
Any information the patient wants withheld:		

Copy offered to patient? 	YES	
Copy added to the patient’s records?	YES 	
Date GPMP completed:		
Date TCA completed:	     /     /	
Copy / relevant parts of GPMP/TCA supplied to other providers?  (Mandatory for 723)	YES / NO / NOT REQUIRED	
Review Date:  (6 months)		     /     /