As part of the 2019 GP Agreement, the Chronic Disease Management (CDM) Programme commenced at the end of January 2020 and is being is being rolled out on a phased basis to adult GMS and GP visit card patients over a 4-year period. The chronic diseases included are: Diabetes Type 2, Asthma, Chronic Obstructive Pulmonary Disease (COPD) and Cardiovascular Disease including Heart Failure.
Patients with an existing diagnosis of one of the specified conditions will participate in the structured treatment programme. Patients without an existing diagnosis may be assessed by their GP on an opportunistic case finding basis, and those identified as high risk of cardiovascular disease or diabetes will enter the preventative programme.
Patients in the CDM Programme will receive two scheduled clinical reviews with their GP in a 12-month period, each preceded with a visit to the practice nurse, while those in the preventative programme receive an annual practice nurse and GP consultation. The reviews include, as appropriate, patient education, preventative care, medication review, physical examination, investigations including blood tests, and the provision of individual care plans.
Patients identified at high risk of cardiovascular disease agree a self-management plan with their GP/practice nurse, setting goals for improvement. Referrals to support services for smoking cessation, harmful alcohol treatment and weight management are made as appropriate.