Chronic Disease Management

Chronic Disease Management (CDM)

(Diabetes, Heart Disease, Asthma, COPD – Chronic Obstructive Airways Disease)

In early 2020, the HSE and the Irish College of General Practitioners launched a new programme aimed at providing the best health possible to people living with chronic illnesses.

Who is an eligible patient?

You are eligible to join this programme free of charge if you:

• Have a medical card or a GP visit card
• Have a specific chronic disease(s) :
  • Type 2 Diabetes Mellitus
  • Asthma
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Cardiovascular Disease including: – Heart Failure – Previous Heart Attack or Angina – Stroke – Atrial Fibrillation
• Since the start of 2022, this applies if you are aged 18 years old or over.
  The practice will contact you if you are eligible

How does this work?

There will be 2 structured reviews in the GP surgery each year as part of the Chronic Disease Management Programme.
Each structured review includes 1 visit to your practice nurse including blood tests, followed by a visit to your GP at the surgery.

What are the benefits from participating ?

• • Structured reviews of your chronic disease with your GP or practice nurse
  • A personalised care plan developed and agreed with your GP
  • Regular reviews of your care plan and medication
  • Opportunities for structured education and self-management support
  • Early detection of any new conditions you may develop
  • Prevention and early detection of complications in your condition(s)
  • Care in your community, close to your home.

A detailed information leaflet on the proramme is available at HSE CDM Leaflet

Diabetes

The practice has a tradition of delivering high quality care for our diabetic patients. We know that best treatment of diabetes significantly reduce the possibility of serious complications. However poorly controlled diabetics have a higher risk of suffering from heart attacks, visual problems, kidney failure foot problems. Therefore our aim is to minimise the chance of falling victim to these illnesses. We believe that people who suffer from diabetes can live a healthy and enjoyable life.
We offer our diabetic patients a comprehensive assessment twice a year. This may be part of the CDM programme if you’re eligible. This assessment combines appropriate examinations of feet, heart, eyes and blood pressure as well as relevant blood tests.

Please talk to your doctor or nurse if you or your relation are a diabetic patient of this practice and would like to attend our service.

Heartwatch

Heart disease is a major cause of both illness and death in Ireland. In response to this, in 2001, GPs in the North East were the first to launch this initiative, now standard across Ireland. This service is available to our patients who have suffered a significant “cardiac event”. You should have a check evey 6 months if you have ever suffered a heart attack or have undergone heart bypass surgery or angioplasty.

COPD (Chronic Obstructive Pulmonary Disease) and Asthma

These are common conditions which can affect breathing at different stages through life. These conditions may change for better or worse in an individual. Therefore we recommend that all sufferers are reviewed regularly to ensure that the right treatments are being delivered by the right means. You can have better control of chest problems and better quality of life, with the right tests showing us the best treatment for you.

If you are a heavy smoker or suffer from cough or breathlessness, you may benefit from a simple breathing test. This test is called spirometry and is available in the practice. We would advise you to discuss this with your doctor