721 GP MANAGEMENT PLAN (GPMP) for HEPATITIS B
723 TEAM CARE ARRANGEMENTS (TCA) (if applicable)

Patient eligibility
•	721 - patients with a chronic or terminal medical condition (existing or likely to exist for 6 months)
•	723 - patients must also have complex needs that require ongoing care from a multidisciplinary team (GP + at least 2 care providers)
•	Patients in the community and private in-patients being discharged from hospital
•	Patients NOT available to public in-patients being discharged from hospital NOR residents living in an aged care facility	

Date service was provided:		

Patient’s name and 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: 	

Ethnicity, languages spoken: 	

Other team members (optional)	Address / phone	

		

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 treatments/services 
721 - as needed
723 - mandatory to obtain agreement & collaborate with 2 care providers 	

Chronic hepatitis B: see www.ashm.org.au   www.gesa.org.au  www.hepbhelp.org.au 	
Confirm patient is 
HB sAg +ve for > 6 months	Confirm chronic hepatitis B  	Check anti-HBs, anti-HBc, HBsAg, HBeAg, anti-HBe, HBV viral load (DNA), LFT 	GP	
Notify health department	Appropriate notification as required by regulations	Notify all patients diagnosed with chronic hepatitis B if required in your jurisdiction	GP	
Determine likely time / mode of infection	More information about  source of infection 	Obtain history of jaundice or other indications of likely date of infection, family history of hepatitis B / chronic liver disease/ liver cancer 	GP	
Testing +/- vaccination of family and sexual or household contacts	Detection of chronic HBV in family/contacts
Vaccination to protect susceptible contacts 	Testing all first degree family and sexual/household contacts – HBsAg,  anti-HBs, anti-HBc
Vaccination of susceptible contacts	GP / Viral Hepatitis Nurse	
Education about hepatitis B	Good understanding of chronic hepatitis B
	Patient education re
-	disease progression
-	need for life-long monitoring, treatment
-	potential transmission
-	screening / vaccinations of family, household, sexual contacts
-	co-factors such as  alcohol	GP / Viral Hepatitis Nurse 	
Review medication if prescribed 	Correct use of medications, minimise side effects, good adherence	Patient education
Review medications	GP 	
Perform baseline examinations and tests	Detect signs of advanced liver disease or cirrhosis
	Physical examination
Investigations: FBC, coagulation, UEC, LFT, alpha-fetoprotein (AFP)
Abdominal ultrasound
Specialist referral if symptoms / signs of cirrhosis	GP 
Specialist	
Detect other causes of liver disease	Need to optimise liver health	Check Hep A, Hep D, Hep C, HIV serology, 
iron studies, auto-immune screen, caeruloplasmin, alpha-1 antitrypsin
Review alcohol intake, weight
Vaccinate if hepatitis A Ab -ve	GP	

Determining phase of infection, monitoring and referral:  based on HB eAg, LFT, HBV viral load (DNA) 	
Immune tolerant phase HBeAg +ve
ALT normal
HBV DNA > 20000 IU	Check every 6-12 months to monitor for change in phase 	If young annual check or more frequently if any concerns.
Consider specialist review if over 40 years. 	GP 	
Immune clearance phase
HBeAg +ve
ALT elevated
HBV DNA variable but may be > 20000	Need for more detailed assessment and possible treatment	Referral for specialist review and possible treatment. 

	GP 
Specialist	
Immune control phase
HBeAg -ve
ALT normal
HBV DNA < 2000 IU	Check every 12 months to monitor for change in phase	Annual check or more frequently if any concerns 	GP	
Immune escape phase
HBeAg -ve
ALT elevated
HBV DNA > 2000 IU	Need for more detailed assessment and possible treatment	Referral for specialist review and possible treatment	GP 
Specialist 	
Hepatocellular carcinoma (HCC)  screening 
Abdominal ultrasound
alpha-fetoprotein (AFP) 
	Early detection of HCC 	6 monthly screening if
-	cirrhosis
-	Asian male > 40
-	Asian female > 50
-	African > 20
-	Fhx HCC	GP 
Specialist	

Lifestyle: see RACGP Red Book for details   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 
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 for details   	
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 < 1.5	Check every 1-5 yr
Dietary change
Medication if required	Patient
GP / Nurse
Dietician	
Type 2 diabetes
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 for details  	
Influenza	Prevent	Annual vaccination if at risk 	GP / Nurse	
Hepatitis A	Prevent	Vaccination x 2 if a risk 	GP / Nurse	
Human papilloma virus	Prevent	Vaccination x 3 – females 	GP / Nurse	
Pneumococcal	Prevent	Vaccination every 5 years if at risk 	GP / Nurse	
Tetanus/pertussis	Prevent	Vaccination every 10 years	GP / Nurse	

Cancer screening: see RACGP Red Book for details  	
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
Regular skin checks (opportunistic, high risk > 40)	GP / Nurse	

Breast (female)	Early detection	Mammogram every 2 years (age 50 – 69)	GP / Nurse	
Cervical (female)	Early detection	PAP every 2 years 	GP / Nurse	

Prostate (male)	Early detection	Consider PSA / DRE from age 50 	GP / Nurse	

Other: see RACGP Red Book for details  	
Sexual health screen	Early detection 	Screen for Chlamydia if aged 15- 25
Other STI depending on risk group	GP / Nurse	
Depression	Early detection, treatment	Opportunistic screening	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 	

				

  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 applicable)
	•	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)	

Copy offered to patient? 	YES / NO 	
Copy added to the patient’s records?	YES / NO	
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)		     /     /