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

• Check person is on appropriate recall registers
• Adult health check, School-aged and young person’s health check (6–17 years), or Child health check (0–5 years)
• Combined check for chronic conditions
• Regular exercise and healthy diet
• Healthy sleep — cool wash before bed, regular sleep times, no smoking or drinks with caffeine (eg coffee, tea, cola) before bed
• Current treatments (eg prescription medicines, over the counter)
• Check they are working, monitor side effects
• Give tips for helping to remember to take medicines — take at same time of day, use dose aid, identify support people

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

• National Disability Insurance Scheme website