Providing care as close to home as possible: structured chronic disease management

Dr Orlaith O’Reilly

National Clinical Advisor & Group Lead for Chronic Disease & the Integrated
Care Programme for the Prevention & Management of Chronic Disease

In line with Sláintecare, the Structured Chronic Disease Management Programme (CDM) in general practice is enabling the delivery of person-centred care for chronic conditions as close to home as possible.

The CDM programme provides a structured management programme in general practice for people who are at risk of, or have a diagnosis of, cardiovascular disease, COPD, asthma and type 2 diabetes. It focuses on disease prevention, patient empowerment, early diagnosis and intervention and the provision of care.

A structured approach to care

The programme provides two structured visits to the practice nurse and two visits to the GP every year. Part of the HSE’s Enhanced Community Care programme is helping over 230,000 people with chronic diseases to avoid hospitals and stay well at home. It is available to patients aged 18 years and above who have a medical card or GP visit card.

Delivering person-centred care

The programme emphasises lifestyle and medical risk factor control, disease management and the creation of a patient care plan. The GP works with the patient to identify what matters most to them in managing their chronic conditions to develop a care plan and achieve their goals.

Helping patients live well and manage their chronic conditions is at the heart of the CDM programme, and a wealth of resources are being rolled out across Ireland. For example, 30 new cardiac rehabilitation teams and 30 new pulmonary rehabilitation teams are being established in communities across Ireland to support patients following a heart attack or COPD admission.

Patient uptake has been positive with 75%
of the eligible population enrolling within
the first 20 months of its rollout.

Demonstrating a positive impact

HSE published that since the inception in January 2020, 91% of GPs have signed up to deliver the programme. Patient uptake has been positive with 75% of the eligible population enrolling within the first 20 months of its rollout.

Addressing risk factors for chronic diseases — such as obesity — is an essential component. The initial report indicated that GPs delivered over 200,000 weight interventions to patients in the first 20 months of the programme. The cohort of patients’ average weight decreased by 1.5 kg between the first and third visit to their GP.

Award-winning programme

The CDM programme won an international award from the United Nations Interagency Taskforce in 2021, in recognition of its contribution to the prevention and control of chronic disease in Ireland. The HSE remains committed to the delivery of this seminal programme in general practice.