Managing your long-term health condition
through the Chronic Disease Management (CDM) programme
Many patients have a long-term health condition that needs ongoing medical monitoring and treatment. These are also referred to as chronic diseases and include conditions like diabetes, cardiovascular (heart) disease, COPD, and asthma. When these conditions are monitored regularly, it can help to reduce worsening symptoms and reduce the need for hospital visits.
The HSE has introduced a programme in collaboration with General Practitioners (GPs), to provide structured, ongoing management of certain long-term health conditions. The programme is funded by the HSE for patients with Medical Card and Doctor Visit Cards.
Who is eligible for this programme?
You are eligible for the programme if you are 18 years or over and have a Medical Card or Doctor Visit Card (DVC) and have a long-term health condition (also known as a chronic disease) such as:
- diabetes (Type 2)
- COPD (Chronic Obstructive Pulmonary Disease)
- asthma
- cardiovascular disease (including heart failure, heart attack/angina, atrial fibrillation (irregular heartbeat) or stroke.
How does it benefit me?
Health research shows that regular, planned management of long-term health conditions can improve outcomes for patients, helping you to manage your condition better and reducing worsening symptoms and the need for hospital visits. By taking part in the CDM programme, you will:
- See the Practice Nurse and GP for a structured review of your condition, including any medications you take. For patients on long-term medication, this means only one or two more appointments at the practice than you would already be used to.
- Learn about ways you can manage your symptoms yourself in everyday life and lifestyle changes you can make to improve your condition.
- Discuss a personalised Care Plan for managing your condition.
- Have the opportunity to discuss any new concerns with your GP and Practice Nurse, helping with early detection of new complications or conditions.
- Receive your prescription to your pharmacy of choice, taking account of any changes to treatment and medication as a result of the GP review.
Overall, patients taking part in the CDM programme report positive experiences and are happy to have ongoing checks for their health conditions. You can see the HSE leaflet about the CDM Programme here.
How do I register and book an appointment?
Many of our patients with long-term conditions are already registered on the CDM programme and attend for regular visits. If you are diagnosed with a new long-term health condition, we will contact you to explain this programme and can register you. You will be asked to attend for a visit with the Practice Nurse first which may include tests such as Blood Tests, ECG or Blood Pressure Monitor. The Practice Nurse will also begin the scheduled review with you, asking about your symptoms, lifestyle etc. You will then see the GP for further consultation and a review of your medication. These visits may or may not be on the same day – it may be necessary to wait for test results to come back before you see the GP.
Depending on your symptoms and health condition, some patients may first be registered for the Prevention Programme (which is still part of the CDM programme), which requires a different level of regular monitoring and less frequent tests. The Practice Nurse or GP will discuss the Prevention Programme with you and register you if you are eligible. The HSE leaflet about the CDM Prevention Programme is available here.
How often will I attend and how will my reviews be scheduled?
You will usually have two scheduled reviews each year (approximately every 6 months), one each with the Practice Nurse and GP (so 4 appointments in total). This may include visits on different days if you need monitoring tests such as Bloods, as the GP will need the lab results before they can fully review your condition and medications. Once you are registered on the programme, we will include you in our recall system and we will contact you by telephone or SMS/text message when your regular review is due.
What happens with my information?
Agreeing to be registered for this programme, you allow your information to be shared with the HSE including your name, age, health conditions, medical history and details of symptoms or tests you have had since your last visit. The information gathered is used by the HSE to improve understanding of long-term health conditions and help to detect, treat, and prevent chronic illnesses. Your personal information is used anonymously by the HSE and they ensure you cannot be identified. You can see more information about the HSEs data protection here.
Below are some resources that may be useful in helping you to manage your long-term health condition:
Diabetes: Diabetes Ireland – a patient organisation offering support, education and motivation: www.diabetes.ie
