Dr. Sarah M O’Brien
National Clinical Advisor & Group Lead for Chronic Disease, Consultant in Public Health Medicine Health Service Improvement, HSE
The HSE Enhanced Community Care Programme (ECC) was launched across Ireland in 2021 with a view to delivering a more sustainable, community-focused model of healthcare for patients, including patients with chronic disease.
What care is being delivered in the community?
The Irish Health Service is supporting patients to prevent and improve their management of chronic disease (ie. type 2 diabetes, COPD and asthma and cardiovascular conditions, including atrial fibrillation, heart failure) in their community through services delivered by new Community Specialist teams for chronic disease.
Twenty-six community-based chronic disease specialist multidisciplinary teams have been established across the country. Each team is led by Integrated Care Consultants in diabetes, respiratory and cardiology.
This service adds an extra layer of care in the community. It supports GPs’ care for people with more complex chronic disease and multi-morbidity, by giving patients timely access to specialist advice and intervention, as close to home as possible. In 2024, over 357,000 patient contacts were recorded across 26 community specialist teams in Ireland.
Move to person-centred care
These services drive early diagnosis, early intervention, self-management support and proactive management of chronic disease to enable patients to live well in the community and to support delivery of care at the lowest clinically appropriate level of complexity in line with the Sláintecare vision.
These multidisciplinary CD-CSTs with expertise across cardiology, respiratory and endocrinology can flex to meet the specific clinical needs of each patient. For people living with a chronic illness, it means getting the support they need through timely diagnosis, treatment and support to manage their health.
This service adds an extra layer
of care in the community.
Our focus is on keeping patients well in their own communities and providing care in the right place and time that meets their clinical needs, in line with the Sláintecare vision. These multidisciplinary teams with expertise in cardiology, respiratory and endocrinology can flex to meet the specific clinical needs of each patient.
The HSE remains committed to delivering community-based integrated care and supporting people to live well across communities.
How do patients access these teams?
If you are diagnosed with cardiovascular disease, COPD, asthma and/or type 2 diabetes, talk to your GP about the Chronic Disease Management Programme. To learn more, search ‘HSE Chronic Disease Management Programme.’
Chronic disease specialist multidisciplinary teams can be accessed via GP referral in line with the national referral guidelines.
GPs can use the HSE Areafinder to identify the nearest CD-CST team to their patient.
