Chronic Disease Management Programme

The roll-out of a new Chronic Disease Management Programme for GMS/GPVC patients has started.

If you wish to provide the Chronic Disease Management Programme, please complete, sign and return this Opt in Confirmation Form.

The first phase of the Programme is targeting GMS/GPVC patients, aged over 75 years, with the following chronic diseases:

  • Diabetes Type 2
  • Asthma
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Cardiovascular Disease including:
    • Heart Failure
    • Ischaemic Heart Disease
    • Cerebrovascular Disease (Stroke/ Transient Ischemic Attack (TIA))
    • Atrial Fibrillation

As part of the structured CDM programme, you will provide two scheduled reviews to patients in a 12-month period. Each of the twice-yearly scheduled reviews will require the patient to visit you and the Practice Nurse. Any planned investigations should be carried out at the practice nurse visit, prior to the GP consultation. These reviews will include patient education, preventative care, medication review, physical examination, investigations and an individual care plan.

The Structured Chronic Disease Programme will be expanded on a phased basis, becoming available to those aged 65 and over in 2021, 50 years and over in 2022 and to all adults by 2023.

Modified Structured CDM Programme 2020

Due to COVID-19 amendments to the Structured Chronic Disease Management Programme have been agreed.

The Modified Structured CDM Programme will operate from 01 July 2020 to 31 December 2020. It is extended to GMS/GPVC patients aged 70 years and over who have one or more of the listed chronic diseases. 

Eligible Patients who have received a Structured CDM Review between 01 January 2020 and 31 May 2020 will be eligible for a second review in 2020 once there is at minimum at least 4 months between reviews. The Modified Structured CDM Programme allows for eligible patients to have one review from 01 June 2020 to 31 December 2020 either by telephone or in the GP surgery.