This requires documentation in the patient�s chart that there

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This requires documentation in the patient�s chart that there Powered By Docstoc
					                               Complex Care Plan
Name: ___________________________                   Emergency Contact: __________________________
PHN: ____________________________                   Chart #: _______                  __________________________
Allergies: _______________________________________                           MD: __________________________
    Diabetes  Ischemic Heart Disease  Chronic Kidney Disease   Asthma  COPD 
    Congestive Heart Disease  Cerebral Vascular Disease   GPSC Dx Code: ____________
Major Care Plan Date: ___________ Option 1: 14030 plus visit                          Option 2: 14033 plus block care visit 
Detailed Chart Review: 
CDM Sheets: DM  IHD  CKD  ASTHMA  CHF  COPD  CVD                                                     HTN 
Other Diagnoses: __________________________________________________________________
Prescription Medications
    Date       Medication name              Dose             How often          Reason for taking                       Notes

 Affordability?         Pharmacare Registered?                         S.A. Forms Done? 
Other Meds: Vitamins, herbals, over-the-counter meds taken on as needed basis
    Date        Medication name       Amount     When taken     Reason for taking                                       Notes

Pneumovax Date: ____________ Influenza Vaccine Date: _____________ TD Date: _____________
Linkages: Dietician  Diabetes Education  Respiratory Education  Heart Rehab  Home Care 
                                                              
          Mental Health  Pharmacy  Stop-Smoking Strategy  Chart Smoker Tagged: 
          Specialist Referrals  ______________________________________________________
Tests:                  Diabetic Protocol           CXR                        K, Cl, Na                  ECG

                         Pulm Function             CT Head                     AST/ALT                  Creat/GFR

                               ACR                  Lipids                     Peak Flow             Depression Scale

Patient Goals:           Stop Smoking
                                             Stop Smoking with a
                                                                         Better Diabetic Control   Conforming with Meds
                            Wt. Loss          Wt. Loss w/ Plan                HgbA1C < 7                 Flu Shot

                            Exercise          Exercise w/ Plan                HgbA1C < 6               Pneumovax
                                                                           BP Control target:
                         Regular Labs           Wt. Tracking

Patient Education Materials:
           Diabetes  Ischemic Heart Disease  COPD  Chronic Kidney Disease 
                Congestive Heart Failure  Cerebral Vascular Disease  Asthma 
Advanced Care Directive: Living Will   Family Aware  Other: ________________

Re-Evaluation Month: J F M A M J J A S O N D                              Signed: ___________________ MD
This requires documentation in the patient’s chart that there has been a detailed review of the case/chart
and of current therapies and a face-to-face visit with the patient or the patient’s medical representative.
Follow up care and changes to the care plan are recorded directly in the chart.

From those two activities a Complex Care Plan for that patient will be developed that:
      specifies a plan for that patient’s care
      incorporates the patient’s values and personal health goals
      outlines expected outcomes
      outlines linkages with other health care professionals that would be involved in the care, and
         their expected roles and an appropriate time frame for re-evaluation of the plan
      is recorded in the patient’s chart
      is communicated verbally or in writing to the patient and/or the patient’s medical
         representative, and to other involved health professionals as indicated
14030 – Complex Care Major Planning fee plus age appropriate visit fee
14031 – Complex Care Minor Planning fee plus age appropriate visit fee
14032 – Complex Care Follow Up fee plus age appropriate visit fee
14033 - Annual Complex Care Practice fee plus the age-related annual care block fees
13135 Annual complex care block fee (age 2-59)
13136 Annual complex care block fee (age 60-69)
13137 Annual complex care block fee (age 70-79)
13138 Annual complex care block fee (age 80+)
Table: GPSC Dx Codes for Complex Care Condition Combinations
                          Condition One                              Condition Two
 A414      Asthma                                      Ischemic Heart Disease
 A428      Asthma                                      Congestive Heart Failure
 A250      Asthma                                      Diabetes
 A430      Asthma                                      Cerebrovascular Disease
 A585      Asthma                                      Chronic Kidney Disease (Renal Failure)
 A491      Asthma                                      COPD (with Emphysema, Chronic Bronchitis)
 I428      Ischemic Heart Disease                      Congestive Heart Failure
 I250      Ischemic Heart Disease                      Diabetes
 I430      Ischemic Heart Disease                      Cerebrovascular Disease
 I585      Ischemic Heart Disease                      Chronic Kidney Disease (Renal Failure)
 I491      Ischemic Heart Disease                      COPD (with Emphysema, Chronic Bronchitis)
 H250      Congestive Heart Failure                    Diabetes
 H430      Congestive Heart Failure                    Cerebrovascular Disease
 H585      Congestive Heart Failure                    Chronic Kidney Disease (Renal Failure)
 H491      Congestive Heart Failure                    COPD (with Emphysema, Chronic Bronchitis)
 D430      Diabetes                                    Cerebrovascular Disease
 D585      Diabetes                                    Chronic Kidney Disease (Renal Failure)
 D491      Diabetes                                    COPD (with Emphysema, Chronic Bronchitis)
 C585      Cerebrovascular Disease                     Chronic Kidney Disease (Renal Failure)
 C491      Cerebrovascular Disease                     COPD (with Emphysema, Chronic Bronchitis)
 R491      Chronic Kidney Disease (Renal Failure)      COPD (with Emphysema, Chronic Bronchitis)

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