<Letterhead>

GP MANAGEMENT PLAN - MBS ITEM 721 (Cancer Supportive Care) 	

Patient’s Name: <PtName>	Date of Birth: <PtDoB>	

Patient's Contact Details:	Medicare / Private Health Insurance Details:	
Phone: <PtPhoneH>
Address: <PtAddress>
ATSI Status: <PtEthnicity>
ATSI Status: <ATSI Status>
Cultural Identity / Ethnicity: <Cultural Identity / Ethnicity:>
Interpreter Required: <Interpreter Required>
Language: <Language>
My Health Record: <My Health Record>
Advanced Care Directive: <Advanced Care Directive>	Medicare: <PtMCNo>
Health Insurance: <PtHealthIns>	

Details of Patient’s Usual GP:	Details of Patient’s Carer (if applicable):	
<DrName>
<DrAddress>	<Name of Patient's Carer>

	

Treating Cancer Specialist: <Name of Treating Cancer Specialist>

Date of last Care Plan/GP Management Plan (if done):  <Date of last Care Plan/GPMP>

Details of My Aged Care/NDIS Package (if done): <Details of My Aged Care/NDIS Package>

NDIS recipient: <NDIS recipient>

Patient's main concerns and goals: 
<What are the patient's main concerns and goals?>

		
PAST MEDICAL HISTORY

<PMHAll>

FAMILY HISTORY

<FamilyHx>

MEDICATIONS

Domiciliary Medication Management Review <Domiciliary Medication Management Review>
<CurrentRx>

ALLERGIES

<Reactions>

NATIONAL CANCER SCREENING PROGRAMS

	Bowel	Breast	Cervical	
Eligibility	For men and women aged between 50 and 74.	For women aged between 50 and 74.	For women aged between 25 and 74.	
Eligible	<Bowel cancer eligibility: Patient aged 50 -74? >	<Breast cancer eligibility: Patient female aged 50-74?>	<Cervical screening eligibility: Female aged 25-74?>	
Frequency	Every 2 years.	Every 2 years.	Every 5 years.	
Date of last test	<Date of last bowel screen>	<Date of last breast screen (if eligible)>	<Date of last Cervical Screening Test (CST)>	
If overdue	Phone 1800 627 701 to order a new kit.
(Provide demonstration if required).	Phone 13 20 50 to book an appointment.	Book CST with GP/Nurse. If more information required phone 1800 627 701	

Patient’s Name: <PtName>

GP MANAGEMENT PLAN – Cancer Supportive Care (MBS ITEM 721)	

Patient health problems/
health needs/relevant conditions	Goals - changes to be achieved	Required treatments and services including patient actions	Arrangements for treatments/services (when, who, and contact details)	
MAIN DIAGNOSIS 	
DIAGNOSIS

	Optimal management of the cancer. 

Maintain quality of life. 

	May Require:
- Surgery
- Chemotherapy
- Radiotherapy

Treatment to reduce recurrence.

Patient to avoid risk factors for recurrence e.g. stop smoking/alcohol.

Annual general health assessment e.g. cholesterol, diabetes, other cancer screening, exercise programs.	GP
Practice Nurse 
Patient 
Specialist team
Cancer Nurse Practitioner
Cancer Resource Nurse

RESOURCES
1. Cancer Council - Optimal Care Pathways guidance
2. Refer to HealthPathways

Cancer Treatment and Management Decision Making 	Patient and/family actively participate in treatment decisions.
	Open communication between patient, family, GP and other healthcare professionals. 

Please refer to Specialist Treatment Plan (if available)	Patient
Family
GP
Practice Nurse
Specialist team
Cancer Nurse Practitioner
Cancer Resource Nurse
Cancer Support Groups	
SYMPTOMS OF CANCER or CANCER TREATMENT to consider 	
Pain Management	Optimal pain management to minimise pain.

Reduce side effects of medication management.

	Diagnose and treat the cause of the pain. Seek advice from Specialist/Cancer Nurse Practitioner before prescribing.

Medication management.

Non Medication management  e.g. massage, exercise, heat packs.	GP
Specialist
Cancer Nurse Practitioner
Cancer Resource Nurse
Allied Health Professionals
Practice Nurse 
Community Nurse
Patient/family

(Refer to HealthPathways)	
Nausea Related Problems
 
Dehydration
Weight loss
Dry mouth
Loss of appetite
	Improve quality of life by reducing common side effects of cancer or it's treatment.

	- Identify cause of symptom.
- Treat cause where possible.
- Educate patient and family.
- Diet and fluids as per patient and family wishes.
- Diligent mouth care.
- Ice to suck.
- Medication management.
- Non Medication management.	GP
Practice Nurse
Patient
Family
Cancer Nurse Practitioner
Cancer Resource Nurse
Community Nurse
Dietitian
Specialist 

(Refer to HealthPathways)	
Fatigue	Reduce fatigue.

Maintain ability for independent mobilisation, self-care and active engagement with others for as long as possible.

Maintain muscle strength.

Maintain cognitive function and social interaction.	- Ensure good nutrition.
- Nutrition supplements.
- Home help.
- Help with day to day care.
- Conserving energy
- Exercise programs that will improve fitness, flexibility and strength.
- Self awareness of signs of exhaustion.	GP
Practice Nurse
Patient /family
Carers
Cancer Nurse Practitioner
Cancer Resource Nurse
Counselling
Exercise Physiologist (consider referral to Wellness, Cancer & Exercise program)
My Aged Care

(Refer to HealthPathways) 	
Skin Care 

Dryness

Rashes 

Radiotherapy burns

Pressure sores

	Prevent discomfort due to damage to skin through treatment or pressure sores.

Recognise and treat skin conditions early.
	Regular moisturising of skin.
Early attention and treatment of ulcers /sores.
Mobilisation, change position to reduce pressure sores.
Topical medications.

Care of high risk patient:
- change position frequently.
- keep skin clean and dry.
- lotions as needed.
- treat any bed sores.
- exercise arms/legs as tolerated.	GP
Practice Nurse
Patient/family
Cancer Nurse Practitioner
Cancer Resource Nurse
Community Nurse	
Lymphoedema
(for patients who have had lymph node clearance, primarily breast, melanoma, prostate)	Reduce risk of lymphoedema.

Early treatment to reduce effect of lymphoedema.	Educate patient and carers on factors that increase risk of lymphoedema.
Patient to remind health care professionals when having procedure.
Referral to lymphoedema clinics as needed.	Patient
Carers
GP
Practice Nurse
Specialist Clinic
Allied health 

(Refer to HealthPathways)	
Constipation	Avoid development of constipation.
Reduce risk factors for constipation.
Early treatment.	Review diet and fluids.
Aperients as needed.
Prophylaxis if on opioid medication.
Review current medication.

	GP
Patient / family
Community Nurse
Dietitian
Pharmacist

(Refer to HealthPathways)	
Incontinence

	Avoid or minimise incontinence. 
Ensure appropriate hygiene.
Avoid skin irritation due to incontinence.	Educate patient and family if risk of incontinence with treatment,
Discuss treatment options with patient,

	GP
Patient / family
Community Nurse
Dietitian
Urologist
Continence Nurse

(Refer to HealthPathways)
	
OTHER 				
Medication Management	Optimise medication management.
Minimise side effects from medication.
Reduce risk of drug interaction.

	Patient/carers to keep up to date list of current medication from all providers.
GP – regular review and maintain up to date list.
Compliance with prescribed medication.   
Consider Webster pack	GP
Practice Nurse 
Pharmacist
Specialist
Cancer Nurse Practitioner
Community nurse
Patient / Carers	
Organisational/Legal	Ensure own wishes and directives are known. 

	Make arrangements for:
- Advance Care Planning.
- Medical Treatment Decision Maker.
- Financial Power of Attorney.
- Will up to date.	Patient
Family
GP
Practice Nurse
Solicitor

(Refer to HealthPathways)	
Cultural Considerations	Culturally responsive care delivery	Patient may require interpreter/resources in their language/plain English or support to ensure understanding of treatment and follow up.

Patient may require gender specific care worker, or other e.g. Aboriginal Health worker	Interpreter Services
Culturally and Linguistically Diverse Services
Integrated Team Care Services (ITC) for Aboritinal and Torres Strait islanders
(Refers to HealthPathways)	
PSYCHOSOCIAL CONSIDERATIONS
Cancer Council Victoria nurses can provide information and support to people affected by cancer and provide feedback to GP’s. Online referral form available on Cancer Council Victoria website.	
Mental Health 
Anxiety
Depression
Stress
Grief
	Minimise psychological stress to patient.

Minimise psychological stress to family.

Good sleep hygiene.	Education of patient and family.
Screening for mental health issues.
Counselling - GP to consider mental health care plan.
Relaxation techniques.
Medication.
Genetic counselling. 	GP 
Counsellor
Social Worker
Psychologist
Nurse
Community Support

(Refer to HealthPathways)	
First Nations cultural identification
Connection to country and community
Cultural responsibilities
Men’s/Women’s business
	Maintain connection to country and community
Culturally responsive care delivery
Cultural safety

	Cultural support
Return to country	Aboriginal Health Service
Aboriginal Liaison Officer

Practice Incentive Program-Indigenous Health Incentive (PIP-IHI)

Integrated Team Care Program (ITC)

Health Ax for Aboriginal and Torres Strait Islander People (MBS Item 715)

(Refer to HealthPathways)
	
Religious / Spiritual support	Religious and spiritual needs are attended to.	Patient/family to contact and engage with relevant people. 	Religious advisor	
Social Support	Maintain best possible quality of life.
Daily care needs are attended to.
Reduce risk of carer fatigue.

	Home help.
Shopping.
Respite.
Well-being and complementary therapies. 
	GP
Practice Nurse
Cancer Resource Nurse
Community Nurse
My Aged Care
Local Council
Other community services	
Sexual Health	Maintain sexual wellbeing.
Maintain intimacy and sexual relations with partner. 

	Patient to contact and engage with relevant people. 
Counselling.
	GP
Social Worker
Psychologist
Cancer Resource Nurse
Community Nurse
Cancer Council Victoria	

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

Copy 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 3-6 months)>	

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

 GP’s Signature:  _________________________________________	Date:___________________

 Patient’s Signature:  ______________________________________	Date:___________________