Chronic Disease Management

Chronic Disease Management

Chronic diseases are conditions that last 1 year or more and require ongoing medical attention or limit activities of daily living or both. They include conditions such as diabetes, asthma, chronic obstructive pulmonary disease (COPD) and cardiovascular disease. The HSE has established the Chronic Disease Management Programme in General Practice in line with international best practice and research as evidence shows that regular structured reviews of chronic medical conditions lead to improved patient outcomes through better condition management. The aim of Chronic Disease Management in General Practice is to provide:
    • 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
It is available to those who fit the following criteria:
    • Medical card holder or doctor visit card holder
    • Age 65 or older
    • Can attend the surgery
    • Has one of the following specific conditions:
      • Diabetes
      • Asthma
      • COPD
      • Atrial fibrillation (irregular heart rhythm)
      • Ischaemic heart disease (angina or history of heart attack)
      • Heart failure
      • History of stroke
Patients who are eligible are entitled to two structured reviews with their GP per year with each visit also including a nurse consultation. We are currently inviting patients to join this programme. For more information take a look at the HSE patient booklet here.