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Improved patient outcomes from Chronic Disease Management Programme

Better outcomes for patients which allows them to become active partners in their own healthcare, is one of the positive results of the HSE Chronic Disease Management (CDM) programme, according to Dr Joe Gallagher, ICGP Clinical Lead for Cardiovascular Disease: “The programme supports GPs to identify and manage patients, with a medical card or doctor visit card, who are at risk of chronic disease or who have been diagnosed with one or more specified chronic diseases such as COPD, asthma, cardiovascular disease or type 2 diabetes. It focuses on prevention, patient empowerment, early diagnosis and intervention, multi-morbidity and the provision of care as close to patients’ homes as possible.

According to Dr Gallagher: As a GP, I know only too well the importance of supporting people with chronic diseases.  This programme provides better healthcare outcomes for patients, reduces acute presentations and allows patients to become active partners in their own healthcare.  It is a credit to both GPs and to the HSE for extending a modified programme to those aged over 70 and for accelerating the programme in 2020 to all those over 70 years of age. GPs were working in very pressurised circumstances over the last two years and achieving excellent uptake rates, and such a high proportion of the service being provided in person was very valuable in protecting these vulnerable patients with chronic disease.”


The HSE recently published a review on the implementation of the CDM programme which highlighted the high level of GP engagement with the first phase of the programme – it has been taken up by 91% of General Practitioners. The review showed how GPs are actively engaging patients with appropriate lifestyle interventions and encouraging patients to make healthier lifestyle choices to prevent and manage chronic diseases.

Commenting on the review, Dr Colm Henry, HSE Chief Clinical Officer said: “The valuable data in this report provides a much clearer indication of the risk factors for ill-health, the health behaviours and the levels of the major chronic diseases that are present in a vulnerable cohort of the population. Promising trends in lifestyle risk behaviours have been shown with increasing numbers of reviews. Further reports will provide valuable information for practitioners and service planners.

“The Chronic Disease Management programme is an example of the HSE’s commitment to enhancing healthcare in the community and bringing care closer to people’s home. As the Chronic Disease Management programme is rolled out and fully implemented over time, it is envisaged that it will result in a reduction in hospital attendance by patients with the four conditions.”

Dr Denis McCauley, Chair of the Irish Medical Organisation (IMO) General Practitioner Committee said: “This report shows the remarkable progress in the roll out of the Chronic Disease Management programme since 2020. Despite the disruption to health services due to COVID-19, the high uptake rates among eligible patients is a fantastic testament to the hard work of GP teams across Ireland. The Chronic Disease Treatment Programme continues to be implemented, with the whole eligible GMS adult cohort now beginning the Disease Management Programme. In addition, the Opportunistic Case Finding and Prevention Programme commenced in the 65 year old and over cohort earlier this year and will be expanded further in the coming years.”

 Intervention for patients who are current smokers

 An important part of the CDM contract allows GPs to offer a suitable intervention for patients who are current smokers. Only nine percent of enrolled patients are current smokers. Thirteen percent of patients, who agreed to a smoking intervention, were subsequently recorded an ex-smoker status.   The review showed how GPs carried out over 200,000 weight interventions with patients, with only 11% of patients declined an intervention. Most patients had more than one review since January 2020 and encouragingly the cohort of patients’ average weight decreased by 1.5 kilogrammes between the first and the third visit.  Some 52% of patients enrolled in the programme were reported as having adequate levels of physical activity, while some 28% of patients with increased risk drinking patterns were identified by GPs. However, some 56% of patients with high risk/harmful drinking patterns declined any intervention at that time. It is encouraging to see that the cohort of patients with high or harmful drinking patterns reduced from 1.5% on the first consultation to 0.6% on the third visit. This emphasises the value of doctors continuing to engage this small proportion of patients who need their help.