Remote Primary Health Care Manuals

Combined checks for chronic conditions

   

  • Many chronic conditions are closely related and lead to the same serious complications — heart attack, stroke, renal disease

  • Monitoring and management is very similar and most people have more than one chronic condition
  • Combined checks Table 4.1 are for all people with one or more of
    • Coronary artery disease (CAD)
    • Hypertension (high BP)
    • Abnormal blood lipids (fats)
    • Chronic kidney disease (CKD)
    • Diabetes 
    • Heart failure 
    • Schizophrenia, bipolar affective disorder, antipsychotic use 
    • Chronic obstructive pulmonary disease (COPD), bronchiectasis
  • Tools for completing chronic conditions checks may be available on your clinic information system

When to do checks

New Diagnosis

  • Complete assessment and GP management plan/team care arrangements at diagnosis
  • CAD, CKD, diabetes, heart failure, CLD — monthly reviews for the first 3 months to achieve good control and support self-management
  • Heart attack, cardiac surgery, acute heart failure — weekly reviews for cardiac rehabilitation, self-management support, and then medical follow up at 4 weeks (can be a case discussion)

Timing of ongoing recall cycles

  • Do annually
  • Frequency of recall (1, 3 or 6 monthly) is based on person’s diabetes status, level of absolute cardiovascular risk and chronic kidney disease risk — see Table 4.1
    • If check only applies to one condition, the condition is written on table, eg diabetes
    • If check is needed less often than recall schedule, the frequency is written on table, eg 6 monthly

Table 4.1 Combined checks for chronic conditions 

Checks First assessment
AND
Yearly recall		 Monthly recall — person with CKD 5 3 monthly recall — 

Person with diabetes, high CVR AND 1 or more conditions OR moderate to high CKD risk level

 Person on 6 monthly recall cycle — 

Person with high BP or hyperlipidaemia, no diabetes, low to moderate CVR AND 1 or more other conditions AND normal/low CKD risk level
Ask about
Current health/ priorities ✓ ✓ ✓ ✓
Chest pain, shortness of breath, ankle or leg swelling ✓ ✓ ✓ ✓
Medicines, any problems ✓ ✓ ✓ ✓
Problems in feet

Diabetes

Diabetes (every 3 months)

Diabetes

Diabetes

Problems with sex ✓
Contraception ✓
Smoking, Nutrition, Alcohol, Physical activity, Emotional and social wellbeing (SNAPE) ✓ Smoking Smoking Smoking
Check
Height ✓ Every 6 months Every 6 months *
Weight, waist circumference ✓ ✓ ✓ ✓
BMI ✓ Every 6 months Every 6 months ✓
BP, pulse rate and rhythm ✓ ✓ ✓ ✓
Teeth and mouth ✓      
Ear examination and hearing ✓      
Eyes — visual acuity/trichiasis ✓      
Skin Examination ✓      
Foot check  Diabetes Diabetes (every 3 months) Diabetes Diabetes
PHQ9  ✓
Immunisation status — give any due ✓
Hepatitis B status Once
Do
Urinalysis ✓
ECG ✓
Retinal eye check Diabetes
Cardiovascular risk assessment (not required if already assessed as high cardiovascular risk) ✓
Yearly plan: self management plan, clinical goals and team care arrangement ✓
Team care arrangement/GP management plan  
ATSIHP/nurse review ✓ ✓ ✓ ✓
Medical review ✓ ✓ ✓ Every 6 months ✓
Renal review/case conference CKD High or severe risk    
Specialist review Complex cases – – –
Dental review ✓
Optometrist  Diabetes
Podiatrist Diabetes

Checks with a tick (✓) are for everyone

Pathology recall cycle

Table 4.2 Monthly pathology — person with CKD 5  

HbA1c FBE LFT Lipids Urine ACR EUC and eGFR Mg, PO4, Alb, Ca Iron Studies CRP PTH
How often to check (months) 12* 1 1 6 6 1 1 3 3

* If diabetic check HbA1c every 3 months

Table 4.3 3 monthly pathology — person with diabetes, high CVR AND 1 or more conditions OR moderate to high CKD risk level 

HbA1c FBE LFT Lipids Urine ACR EUC and eGFR

Mg, PO4, Alb, Ca

 Iron Studies CRP
   PTH 

CKD 1–3a + low CVD risk

 12* 12 12 6 12 12

CKD 1–3a + mod-severe CVD risk

 12* 6 6 6 6 6 6

CKD 3b–4

 12* 3 3 6 3 3 3 3 6

*Repeat HbA1c in 3 months if more than 7% or if declining renal function. Repeat in 6 months if HbA1c less than 7% and no decline in renal function

Table 4.4 6 monthly pathology — person with high BP or hyperlipidaemia, no diabetes, low to moderate CVR AND 1 or more other conditions AND normal to low CKD risk level

HbA1c FBC LFT Lipids Urine ACR EUC and eGFR
CKD 1–3a + low CVD risk 12 12 12 6 6 6
Mental health metabolic monitoring 6 6 6 6 12 6
  • TFT 
    then level 2 (triangle dot points)
    • Do once when Type 1 diabetes diagnosed or CKD reaches mod-high
    • Do every 6 months for person taking lithium
  • 25-hyproxyvitamin D - (em dash) do on first assessment for person with CKD and eGFR less than 60