The Chronic Disease Management programme
A chronic disease is a long-term health condition that needs ongoing treatment and management. Cardiovascular disease and diabetes are chronic diseases.
The Chronic disease treatment programme is for people who have a medical card, GP Visit card or a Health Amendment Act card and have a specified chronic disease such as a cardiovascular disease, COPD, Asthma and Type 2 diabetes.
The programme is designed so that you can work with your GP on:
- monitoring your condition
- identifying early treatment
- supporting the way you manage your condition
The programme emphasises:
- lifestyle and medical risk factor control
- disease management
- the creation of a patient care plan
We will work with you to develop this plan.
The programme is for:
- people who are age 45 or older
- people who have a medical card, or GP visit card or Health Amendment Act card
- people who are at risk of heart disease or diabetes and
- all adults aged 18+ diagnosed with gestational diabetes or pre-eclampsia since January 1, 2023.
Benefits of the programme
The programme is designed so that you and your GP can work together to manage your condition by:
- an annual, bi annual review with your GP and practice nurse
- a review of your medicines
- a plan to help you manage your risk factors
- health promotion advice
- appropriate medical treatment
- referrals to support services, if needed
- care in your community, close to your home
Registering for the programme
If you are at risk of cardiovascular disease, diabetes or both, we will ask you if you want to take part in the programme.
We will arrange a review with you and register you for the programme.
How the programme works
The programme is free and includes one/two reviews in every 12 month period.
Each review includes one visit with the practice nurse which may include blood tests and an ECG and then then a review with your GP . You can see your GP and practice nurse during the same review or separately at different times.
Your GP or practice nurse will give you advice on lifestyle changes that will help you manage your risk factors.
They will refer you to support services if you need them. For example, they may refer you to help to stop smoking or to manage your weight.
You can still visit your us as normal outside of the scheduled programme reviews.
Care plan
You will get a written care plan after each review. This care plan will help you learn about your risk factors and the steps you can take to improve your self-management.
You can work with us to set your own goals.
Your information
We will record certain information about you at each structured review.
This will include your:
- name and age
- chronic disease risk factors
- medical history
- details of any symptoms or tests you have had since your last visit
Your GP will send information to us at the end of each structured review. This will include your name and address, medical or GP card number, and medical history.
Your personal information is stored in line with current data protection regulations. You will have full and open access to the personal information we keep about you. You can ask for it from us at any time.
Read the privacy statement for the Chronic Disease Management Programme (PDF 472KB, 1 page)
How we use your personal information
The information we gather is important in helping us to improve our understanding of chronic diseases.
It will improve the way we detect, treat and prevent chronic disease. It will also help us deliver an improved service to people with a risk of developing cardiovascular disease or diabetes.
Opting out of the programme
It is your choice to take part or not. You can leave the programme at any time by letting us know. This means that you will not receive reviews and other care planning under the programme. You can always re join the programme if you wish.
Speak to us or if you have any questions about the programme.