The Chronic Disease Management (CDM) Programme

The Chronic Disease Management (CDM) Programme is a HSE initiative to provide better care for people with certain chronic diseases in General Practice. It aims to help patients manage their conditions through regular reviews with a GP or practice nurse, personalised care plans, and access to support services. It is open to to those with a medical or doctor visit cards and involves two visits annually to the GP which are focussed exclusively on the management of the target conditions. The medical conditions included in the programme currently are

  • Type 2 Diabetes
  • Heart Failure
  • Asthma
  • Chronic Obstructive Pulmonary Disease
  • Atrial Fibrillation
  • Ischaemic Heart Disease
  • Stroke
  • Pre-eclampsia or Gestational Diabetes (diagnosed since January 2023)

The visit to the GP or Practice Nurse will focus on the risk factors which we know from strong research evidence are likely to make your condition worse if not addressed fully. These include smoking, poor diet, lack of exercise and obesity. We will also review your medications to make sure you are on the correct dose and that they are not causing side effects. The programme is supported by a range of allied community based programmes which can help you manage your condition better. These include both online and in-person educational programmes for Diabetes and COPD as well as the very popular EX-Well programme which promotes exercise and physical activity.

For most conditions, blood tests will be taken once per year to check that your cholesterol, blood sugar and kidney function are all within range. Data from the programme is returned anonymously to HSE to provide important information about the prevalence and impact of chronic diseases in Ireland. Data is stored under strict GDPR rules and a copy of the the HSE privacy statement covering the control of data gathered under the CDM programme can by accessed here.

If you are a registered patient with one of the conditions listed above and not already enrolled in our CDM programme, please contact the practice on 01-2881550 for further information. More information about the programme can be obtained from the HSE website by clicking here.