Chronic Disease Management

Chronic Disease Management (CDM)

The CDM Programme aims to improve the health and well being of patients living with specific chronic diseases.

Patients are eligible to join the programme if:

  1. You have a Medical card or GP visit card.
  2. You are 70 years or over.  This will be extended to those aged 65 and over in 2021, 50 years and over in 2022 and to all adults by 2023.
  3. You have one of seven different conditions:
     – Type 2 Diabetes
     – Chronic Obstructive Pulmonary Disease (COPD)
     – Asthma
     – Ischaemic Heart Disease (angina/history of heart attack)
     – Heart Failure
     – Stroke
     – Atrial Fibrillation

We will be invite you to register for the CDM Programme once you are eligible.  We would also be delighted for you to contact us if you think you have missed a call from us.

Initially, a GP or practice nurse will talk with you to enroll you onto the programme, which  pconsists of reviews with us every 6 months.  Each review will be as follows

  1. The GP or practice nurse  will discuss your general health and well-being with you and focus on your specific chronic condition and health issues. Due to Covid 19 it may be decided that this is best done over the phone.
  2. If you need to visit the GP surgery to be seen in person by the GP and the practice nurse, blood tests and other tests such as ECG and 24 hour ABPM will be carried out as needed.
  3. You will be issued with a written Care Plan after your phone or surgery based review.
  1. Structured reviews of your chronic disease with your GP or practice nurse
  2. A personalised care plan developed and agreed with your GP
  3. Regular reviews of your care plan and medication
  4. Opportunities for structured education and self-management support
  5. Early detection of any new conditions you may develop
  6. Early detection of complications in your condition(s)
  7. Care in your community, close to your home, and avoiding busy hospital clinics
  8. Improvement in your overall health and wellbeing.

We look forward to seeing you. 

Opening Hours

Mon – Fri

09.00 -17.00

Sat – Sun


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