HSE award for chronic disease

The United Nations Interagency Taskforce (UNIATF) award recognises the Chronic Disease Management (CDM) programme’s work to develop the ‘GP Chronic Disease Contract and rolling it out despite the COVID-19 pandemic’. The Irish College of General Practitioners (ICGP) nominated the CDM programme for an award.

Commenting on the award, HSE National Clinical Advisor and Programme Group Lead for Chronic Disease, Dr Orlaith O’Reilly said: “It’s an honour to see the CDM Programme recognised in this way. The CDM Programme works with GPs across Ireland to prevent and manage patient chronic diseases using a population approach. Before this Ireland had no formalised structure for Non Communicable Diseases (NCD) management in primary care. We remain committed to the roll-out of this programme.

“The CDM programme provides a structured management programme for people with a history of cardiovascular disease, COPD, asthma and type 2 diabetes in general practice. It focuses on prevention, patient empowerment, early diagnosis and intervention, multi-morbidity and the provision of care as close to home as possible.

“The programme emphasises lifestyle and medical risk factor control, disease management and the creation of a patient care plan. The GP in partnership with the patient works to develop this plan. We rolled out an IT solution, embedded in What is a chronic general practice, which provides decision disease? support for NCD management. It also gives A chronic disease is a long-term health real-time return of data to a central data condition that needs ongoing treatment repository. This supports service planning and management. and quality improvement initiatives in primary care,” she added. The CDM programme supports GPs to Benefits of the programme identify and manage patients, with a The programme is designed so that you and your GP (family doctor) can work medical card or GP card, who are at risk of together to monitor your condition and chronic disease or who have been identify the best way to treat it now. diagnosed with one or more specified chronic diseases. Pat Healy, National Director, HSE Clinical Programme Implementation and Professional Development said: “I am The Chronic Disease Treatment Programme supports you by providing: delighted that the work of the HSE • set reviews of your chronic disease with your GP or practice nurse Structured Chronic Disease Management • a personalised care plan that you Programme has been recognised develop and agree with your GP • reviews of your care plan internationally. The development and and medicine • support you to manage your implementation of this programme condition happened because of groups and • early detection of any new conditions you may develop institutions working collaboratively, • early detection of complications including the Department of Health and in your condition • care in your community, DPER, the IMO, the HSE (Clinical close to your home Programmes, Primary Care, ICT, Public

HSE WINS INTERNATIONAL UN AWARD FOR TACKLING CHRONIC DISEASE

The HSE Chronic Disease Management (CDM) programme has scooped an international award for developing a structured illness and preventative care programme in general practice. The aim of the programme is to reduce morbidity and mortality from Non Communicable Diseases (NCDs).

Health doctors and managers), the GPs, practice nurses and the wider practice teams. It was to launch in March 2020, just as the COVID-19 pandemic spread to Ireland. But rather than pause the programme, and recognising the syndemic of NCDs and COVID-19, we accelerated the roll-out of the programme. We expanded the initial age cohort. We also brought remote consultations on stream to protect our most vulnerable patients.

“GPs have played a significant role in the role out of the CDM programme. Over 85% of GPs in Ireland have registered to provide the programme to date. Between March and December 2020, GPs and practice nurses undertook over 119,000 consultations for people aged over 70 years. Programme data shows that 90% of people with these conditions are being managed solely in general practice for their NCDs.”

A significant part of this programme is Making Every Contact Count. This focuses on interventions relating to tobacco, alcohol, sedentary behaviour and obesity or overweight. Year one data shows that smoking status, BMI and blood pressure were examined in over 90% of all consultations.

What is a chronic disease?

A chronic disease is a long-term health condition that needs ongoing treatment and management.

Benefits of the programme

The programme is designed so that you and your GP (family doctor) can work together to monitor your condition and identify the best way to treat it now.

The Chronic Disease Treatment Programme supports you by providing:

• set reviews of your chronic disease with your GP or practice nurse • a personalised care plan that you develop and agree with your GP • reviews of your care plan and medicine • support you to manage your condition • early detection of any new conditions you may develop • early detection of complications in your condition • care in your community, close to your home

Chronic Disease Treatment Programme