GP MANAGEMENT PLAN - MBS ITEM No 721 (Palliative Care) 	

Patient’s Name
	<<Patient Demographics:Full Name>>	
Date of Birth
	<<Patient Demographics:DOB>>	
Contact Details	
	<<Patient Demographics:Phone (Mobile)>>
<<Patient Demographics:Phone (Home)>>
<<Patient Demographics:E-mail>>	
Medicare or Private Health Insurance Details:	<<Patient Demographics:Medicare Number>>
<<Patient Demographics:Health Insurance>>	
Details of Patient’s Usual GP:
	<<Doctor:Name>>	
Details of Patient’s Carer (if applicable):
	<<Patient Demographics:Next of Kin>>
	
Date of last Care Plan/GP Management Plan (if done):  

Other notes or comments relevant to the patient’s management plan:
		
PAST MEDICAL HISTORY

	<<Clinical Details:History List>>	
MEDICATIONS 

	<<Clinical Details:Medication List>>	
ALLERGIES

	<<Clinical Details:Allergies/Adverse Reactions>>	

Patient’s Name: 

GP MANAGEMENT PLAN – PALLIATIVE CARE (MBS ITEM 721)	

Problems / needs / relevant conditions	Goals - to be achieved

(SAS scores 0 – 10)	Treatments, process, services including patient actions	Arrangements for treatments/services (when, who, and contact details)	
Goals of care discussion	Patient goals of care discussed and clarified
	Advance care planning
ACD completed and returned by patient
Uploaded into patients My Health Record
	Review with GP
ACPA Referral service	
After hours support	Patient and carer feel confident in accessing after hours support if needed	Out of hours support contact details provided	Practice after hours contact
Ambulance	
Medication Management	Future medicine needs anticipated and prescribed.
Simplified medication regime. 
	Medication review
Deprescribing	Review with GP
Pharmacist medication review	
Appetite / weight management	Maintain and / or improve appetite 
Maintain adequate fluid intake maintenance
Enjoy favourite foods
Decrease fluid retention	Snack strategies
Appetite stimulants
Medication timing before meals
Dietary supplements
Diuretics	Review with GP
Specialist palliative care service
Dietician	
Bowels	Maintain regular bowel functioning
Reduce bowel discomfort
Prevent constipation	Medications / laxatives
Diet / fluids management
Preventative strategies 
Non-pharmacological strategies	Review with GP
Specialist palliative care service	
Breathing / breathlessness /cough	Reduce and / or manage breathlessness episodes
Reduce anxiety	Medication
Non-pharmacological management techniques
Oxygen therapy	Review with GP
Respiratory service
Ambulance
	
Fatigue	Patient able to undertake activities important to them.
	Energy conservation strategies
Review for reversible causes 
Home assistance	OT
Physiotherapist
Review with GP
Community nursing	
Nausea / vomiting	Well controlled or reduced	Prevention strategies
Pharmacological strategies	Review with GP
Specialist palliative care service	
Pain	Pain adequately managed, including break through pain
Pain control versus lucidity balance preference clarified. 	Ongoing pain assessment and monitoring, including type and causes.
Medications
Non-pharmacological management techniques	Review with GP
Specialist palliative care service	
Sleeping	Reduce daytime impairment, so patient can undertake activities important to them	Medications 
Breathless management
Sleep hygiene strategies
Emotional / psychological support	Review with GP
Referral specialist palliative care service
Counsellor 	
Spiritual needs / existential suffering
	Reduce spiritual distress
Reduce fear	Ongoing discussions around meaning making, values and beliefs
Monitor for demoralisation disorder	Pastoral care
Counsellor 
Bereavement service
Specialist palliative care service
Religious advisor	
Psychological / emotional needs	Reduce psychological / emotional distress	Counselling
Medication
Support groups	Pastoral care
Counsellor 
Bereavement service
Specialist palliative care service	
Carer / family needs	Reduce carer distress
Increase carer capacity to manage role
Meet information needs	Patient and carer websites and resources.	Social work 
Bereavement worker
Resources
	
Other 				

Copy of GP Management Plan offered to patient?  Yes/No

Copy / relevant parts of the GP Management Plan supplied to other providers?  Yes/No

GP Management Plan added to the patient’s records?  Yes/No

Date service was completed:  	Proposed Review Date:  	

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

 GP’s Signature:  ________________________________________________	Date:__<<Miscellaneous:Date>>_

Palliative Care Phase
Abbreviated Definition
Clinician rated assessment 
1.	Stable Symptoms and problems are adequately controlled by established management. Monitor, review, anticipate & respond.
2.	Unstable An urgent change in the plan of care or emergency treatment is required due to development of a new problem &/or a rapid increase in the severity of existing problems &/or family/carer problems. Urgent response required.
3.	Deteriorating The plan of care is addressing anticipated needs but requires periodic review due to gradual functional decline &/or worsening of existing symptoms &/or the development of new but expected problems &/or family/carer problems. Review & change care plan
4.	Terminal Death likely in a matter of days. Monitor, review & respond
Complete Phase Definitions available on the PCOC website www.pcoc.org.au

Australia-modified Karnofsky Performance Status (AKPS) Scale
The AKPS is a single score measure between 10 & 100 assigned by a clinician based on observations of a patients ability to perform common tasks relating to activity, work, and self care.
A score of 100 signifies normal physical abilities with no evidence of disease. 
A score of 50  or below consider MDT
Australia-modified Karnofsky Performance Status 
Complete Definition
Clinician rated assessment of performance relating to work, activity and self-care over a 24hr period
100.	Normal, no complaints or evidence of disease
90.	Able to carry on normal activity, minor signs or symptoms of disease
80.	Normal activity with effort, some signs or symptoms of disease
70.	Care for self, unable to carry on normal activity or to do active work
60.	Occasional assistance but is able to care for most needs
50.	Requires considerable assistance and frequent medical care
40.	In bed more that 50% of the time
30.	Almost completely bedfast
20.	Totally bedfast & requiring nursing care by professionals and/or family
10. Comatose or barely rousable
Examples of Questions:
“Have there been any changes today with the patient’s ability to attend to activities of daily living?” 
“Is the patient requiring more physical care today?” 
“How much time is the patient actually spending in bed?”
For a patient with COPD it is vital to be able to monitor a patients functional capacity and physical status, the AKPS is an appropriate assessment tool Research link here

How to assess AKPS 

1.  Use the AKPS definitions to determine the initial rating on admission or commencement of an episode of care. 
2.  Assess routinely. A minimum of daily in an inpatient setting, at each visit in a community setting or each consult.
3.  Assess whenever there is a phase change and at episode end when the patient is discharged. 
4.  Assessment may be conducted face to face or over the phone. 
5.  Record the rating as assessed (scores in increments of 10). In between scores such as 45, 55 or scores such as 50-60 are invalid.

AKPS score of 50 or below consider MDT

AKPS Rating	Clinical Response	
70 - 90	Commence advance care planning and goals of care discussions with the patient
Schedule follow up appointments for regular reviews and monitoring
	
60	Consider referral to allied health if appropriate
Continue goals of care discussions
Consider referral to community nursing and specialist palliative care nursing if required	
50	Consider discussion at multidisciplinary team meeting, review care plan, complete a NSW Ambulance Palliative Care Plan, if patient at home. Liaise with RACF staff regarding goals of care and care needs.
Complete a caregiver assessment	
30 - 40 	Review care plan at multidisciplinary team meeting, taking into consideration patients preferred place of death.
Liaise with community and specialist palliative care nursing as patient deteriorates
Ensure family has afterhours support information
Assess and address carer distress 	
10 - 20 	End of life care planning, anticipatory prescribing needs / syringe driver drugs
Liaise with community and specialist palliative care nursing
Provide carer with information regarding imminent death of patient, including after hours support	

COPD GPMP

Risk factors include smokers, non-smokers who have: asthma, passive smoking, indoor and outdoor air pollution, and occupational exposures, with women at increased risk

Management of a chronic illness such as COPD must include both anticipatory proactive care in addition to acute reactive care, and should address four components: 
• optimising function • preventing deterioration • developing support networks and self management skills, and • managing exacerbations.

Phase	Sign/symptom	plan/action 	
Stable
Start – 
Patient problems and symptoms are adequately controlled by established plan of care and 
 Further interventions to maintain symptom control and quality of life have been planned and 
 Family/carer situation is relatively stable and no new issues are apparent
End
The needs of the patient and / or family/carer increase, requiring changes to the existing plan of care.	•	Usual amount of cough/Phlegm
•	Can perform usual activities	Monitor
*SAS Assessment
*AKPS (score 60-100)- Schedule follow up appointments for regular reviews and monitoring
Medication plan
Patient education to prevent or lower ED and presentations & hospital admissions:
-	Check & correct inhaler device technique
-	Review & reinforce the use of the COPD Action Plan
Commence ACP conversations.
Identify current supports & services.
Identify carer and engage early conversations.

	
Unstable 
Start-
An urgent change in the plan of care or emergency treatment is required because  Patient experiences a new problem that was not anticipated in the existing plan of care, and/or  Patient experiences a rapid increase in the severity of a current problem; and/or  Family/ carers circumstances change suddenly impacting on patient care.
End
The new plan of care is in place, it has been reviewed and no further changes to the care plan are required. This does not necessarily mean that the symptom/crisis has fully resolved but there is a clear diagnosis and plan of care (i.e. patient is stable or deteriorating) and/or  Death is likely within days (i.e. patient is now terminal)

	I am getting worse despite the extra medications(including increased reliever, prednisolone &/or antibiotics)     
	Urgent action required
*SAS assessment
*AKPS (50 and under)
Review care plan at MDT meeting, taking into consideration patients preferred place of death.
Liaise with community and specialist palliative care nursing as patient deteriorates.
Ensure family has afterhours support information
Assess and address carer distress

Review of GPMP and update
Review MDT (TCA) update
MDT case conference
(HMMR) Medication review-
Assess for home oxygen suitability (Blood Gases)
Carer assessment SAS &/or NATCC
Refer to Specialist Palliative care for holistic review & assessment.
ACP/ACD review currency & update as per patient wishes 
OR
ACP/ACD to be completed and uploaded as per the ACP processes.
TCA review - OT assessment (equipment & functional/mobility assessment
Referral for Out of Hospital Package
Caring@Home training
	
Deteriorating
Start
The care plan is addressing anticipated needs but requires periodic review because 
 Patients overall functional status is declining and/or
 Patient experiences a gradual worsening of existing problem and/or 
 Patient experiences a new but anticipated problem and/or 
 Family/carers experience gradual worsening distress that impacts on the patient care
End
 Patient condition plateaus (i.e. patient is now stable) or
 An urgent change in the care plan or emergency treatment and/or 
 Family/ carers experience a sudden change in their situation that impacts on patient care, and urgent intervention is required (ie patient is now unstable) or
 Death is likely within days (i.e. patient is now terminal)
	•	Coughing more than usual
•	More Breathless
•	Needing reliever medication more often
•	More tired/lethargic
•	Having difficulty with usual activities
	Review plan of care
*SAS assessment
*AKPS (score 30-40)  Review care plan at MDT meeting, taking into consideration patients preferred place of death.
Liaise with community and specialist palliative care nursing as patient deteriorates
Ensure family has afterhours support information
Assess and address carer distress
ACP review
Review COPD Action Plan
Review &/or assess carer needs and action as per outcome
Palliative care referral – Equipment, community nurse (home visits), 
TCA review - OT assessment (equipment, functional and mobility assessment)
Referral for End-of-Life Package
Caring@Home training

Terminal
Start
Death is likely within days.
End
 Patient dies or 
 Patient condition changes and death is no longer likely within days (i.e.patient is now stable or deteriorating).

		Provide EOL care
SAS (Carer)
AKPS (score 10-20)
End of life care planning, anticipatory prescribing needs / syringe driver drugs
Liaise with community and specialist palliative care nursing
Provide carer with information regarding imminent death of patient, including after hours support
Referral for End-of-Life Package
Carer supports.
Oxygen availability 24/7
Medication review- Anticipatory medications

Bereavement- post death
Start
The patient has died 
 Bereavement support provided to family/carers is documented in the deceased patient’s clinical record.
End
Case closure Note: If counselling is provided to a family member or carer, they become a client in their own right.

		GP – After Death Audit
Carer -Refer to G& B counselling