Patients participating in the Chronic Disease Management Programme

The General Practitioner (GP) Chronic Disease Management (CDM) Programme aims to bring the care for chronic disease further into the community and reduce hospital attendance by patients living with chronic disease.
The specified chronic conditions included in the CDM are Type 2 Diabetes; Asthma; Chronic Obstructive Pulmonary Disease and Cardiovascular Disease inc. Heart Failure, Ischaemic Heart Disease, Cerebrovascular Disease (Stroke/Transient Ischemic Attack, Atrial Fibrillation).
To support patients in managing their chronic condition(s), under the CDM Treatment Programme each patient receives two scheduled reviews with the GP in a 12-month period, each preceded by a practice nurse visit. These reviews include patient education, preventative care, medication review, physical examinations, scheduled investigations and individual care planning.
The Opportunistic Case Finding Programme identifies those at high risk of cardiovascular disease or diabetes for entry to the Preventive Programme and those with undiagnosed chronic disease(s) are enrolled under the Treatment Programme. Those enrolled under the Preventive Programme receive an annual GP and practice nurse visit.
The programme commenced in 2020 and has been rolled out on a phased basis to adult GMS (Medical Card and GP Visit Card) patients over a 4-year period. The programme is now fully operational and is on track to meet the target of 430,000 patients registered by Q4 2023.

More information can be found at the following link: