What is the Chronic Disease Management Programme?

Clontarf Family Practice is registered for the CDM Programme which aims to improve the health and well being of patients living with specific chronic diseases-Type 2 diabetes, Asthma, COPD and Cardio vascular disease.  We are running this service to ensure patients conditions are actively monitored to improve management of their conditions.

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

• Have a medical card or a GP visit card
• Are aged 18 years or over
• Have a specific chronic disease(s) :
• Type 2 Diabetes
• Asthma
• Chronic Obstructive Pulmonary Disease (COPD)
• Cardiovascular Disease including: – Heart Failure – Heart Attack (Angina) – Stroke – Irregular Heartbeat (Atrial Fibrillation)
• Can take a call from your nurse or GP/attend your GP surgery

Next Steps: What will my practice be doing to include me in the CDM Programme?

Your GP or practice nurse will be inviting you to register for the Structured Chronic Disease Management Programme.  We are also very happy for you to get in touch by phone or email ([email protected]) and let us know you want to participate – this is the fastest way to enrol in the programme as it may take some time for us to get in touch with you if, for example, we do not have your mobile number or email address.

1. Your GP or practice nurse will  talk with you and support your enrollment over the telephone initially.
2. They will discuss your general health and well-being with you and focus on your specific chronic condition and health issues. Because of Covid-19, if it is suitable, your GP/practice nurse and you will decide if it is necessary for you to attend at the GP surgery. Your clinical assessment may be conducted on the telephone. Due to the COVID-19 the HSE and your GP have had  to change the usual way of working to protect us all.
3. If you need to visit the GP surgery to be seen in person by the GP and the practice nurse, blood tests and other tests such as ECG and 24 hour ABPM will be carried out as usual by your GP/practice nurse.
4. You will be issued with a written Care Plan after your phone or surgery based review. 

How will I benefit as a patient 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
• Early detection of complications in your condition(s)
• Care in your community, close to your home.

How will the programme work for me?

There will be 2 free structured reviews in the GP surgery each year as part of the Chronic Disease Management Programme. This amounts to a total of 4 free visits per year.

Each structured review includes 1 free visit to your GP and 1 free visit to your practice nurse at your GP surgery.

Your information

Once you are on the Chronic Disease Management Programme you allow certain information to be collected at each structured review as part of the programme. During each structured review, your GP will record your:

• Name and age
• Chronic disease diagnoses
• Medical history
• Details of any symptoms or investigations you have had since your last visit.

 Why is my information useful?

Information gathered as part of the Chronic Disease Management Programme will play a vital role in helping to improve our understanding of chronic disease. It will improve the health services ability to detect, treat and prevent chronic diseases as well as deliver an improved service to those with chronic disease.