Management plan

General principles

  • The main focus of a management plan is to
    • Provide health information
    • Assist person to identify realistic and achievable goals so that they can manage their condition with support as needed
    • Individualise plan to person's goals, needs and circumstances
    • Coordinate persons care, support a self-management approach, link person to internal (community) and external (town) services 

Management plans include

  • Adult health assessment and care plans — Medicare item 715 — see Adult health check
    • Based on primary prevention strategies — engage with person, screen for risk factors, provide health promotion messages and Brief interventions
  • Chronic conditions care plans — Medicare item 721
    • Based on secondary and tertiary prevention strategies to manage conditions and prevent or delay complications 
  • Team care arrangements — Medicare item 723
    • Coordinate persons care with other health professionals — diabetes educator, OT, physio, speech therapist, social worker, psychologist, rehabilitation services, disability liaison officer, paediatrician, dietitian, mental health team, alcohol and other drugs 
  • Consider access to non-government and Aboriginal organisations — disability services, respite services, childcare, domestic or family violence support service 

Look in file notes 

  • Previous management plan
  • Specialist letters
  • Past medical history 
  • Pathology 
  • Medications

Ask

  • Does the person believe they have a problem 
  • What person thinks might help
  • Are they able to identify goals, what are their priorities 
  • About person's own resources — family, community, clinic, other services (eg mental health, drug and alcohol)
  • About triggers for distress, dysfunction (eg relationship, money problems)

Consider: Are they ready to discuss risk factors, new diagnosis or health care needs — see Stages of change 

Do

  • Develop management plan considering
    • Physical, psychological, social and environmental health 
    • Carer support
    • Legal considerations
  • Provide education about condition
  • Set achievable goals, provide brief interventions
  • Give relapse prevention strategies
    • Identify early warning signs and plan for what to do
    • Help person and family reduce relapse triggers — smoking, cannabis, volatile substance misuse, stress and worries — see Brief interventions
  • Record who (person/service) is responsible for follow-up care and when this should happen 

Physical health

Psychological health

  • Supportive therapy
    • Develop supportive caring relationship with person
    • Allow them to talk about their worries/distress
  • Problem solving and goal setting
    • Work toward some resolution of their immediate concern
    • Break down the pressures the person is feeling — address each one, start with ones that are easily resolved
    • Listen to what person has to say — take them seriously, respect them
    • Give them power over their situation — focus on their strengths
    • Encourage them to find things to do, people who can help
    • Talk about the future
  • Consider involving traditional healers. Family will advise and arrange
  • Self-help strategies — use family/friends for support and rest, cultural activities (eg hunting, painting, spending time on country, bush medicines)
  • Mental status assessment as needed
  • Psychotherapy (eg CBT, narrative, interpersonal) — psychologist if needed
  • Consider specialised programs if available — anger management, alcohol/drug rehabilitation, problem gambling

Social and environmental health

  • Centrelink for benefits
  • Employment opportunities — TAFE, school, further training 
  • Community programs — art centre, school, sport and recreation 
  • Safe place to sleep, enough food
    • Community services — housing, meals, laundry, personal care 
  • Does the person need ACAT (Aged Care Assessment Team) or NDIS referral 
  • Access to transport 
  • Identify family support — partner, significant others 
  • If carer needed 
    • Make sure enough carers to keep person safe 
    • Document what support they can provide (eg housing, food, childcare, time on country)
    • Record carers' contact details in patient file notes 
    • Consider Centrelink (eg carer, pension), respite 

Legal considerations

  • Advocacy — Children’s Commissioner, Ombudsman, domestic/family violence support service
  • Guardianship, power of attorney
  • Advance care planning, will, accessing superannuation
  • Legal advice

Follow-up

  • Follow-up will depend on health care needs and patient’s individual needs and goals 
  • The management plan should outline when and who is responsible for follow-up care

Supporting resources