The Chronic Disease Management (CDM) Programme is structured to prevent and manage chronic diseases among patients, particularly those with medical or GP visit cards. It employs a population-based approach to identify and manage individuals at risk or diagnosed with specified chronic conditions.
Eligible Patients
Patients eligible for the programme include those with medical or GP visit cards and diagnosed with:
- Chronic obstructive pulmonary disease (COPD)
- Cardiovascular diseases such as heart failure, angina, stroke, and atrial fibrillation.
Benefits of the Programme
- Structured Chronic Disease Management
- Structured reviews conducted by your GP or practice nurse to manage your condition effectively.
- Development of a personalized care plan tailored to your needs, preferences, and choices in collaboration with your GP.
- Your GP will review your care plan and medications to ensure optimal management of your condition.
- Access to structured education and self-management support to enhance your understanding and management of your condition.
- Early detection of any new conditions or complications related to your chronic disease.
How the Programme Works
Frequency: Includes 2 free reviews every 12 months.
Cost: No charge for tests conducted during reviews.
Review Process: Consists of visits with the practice nurse, along with blood tests.
Documentation: Written care plan provided after each review.
Continued Care: You can still visit your GP outside of scheduled chronic disease management reviews.
Care Plan
Collaborative Agreement: Care plan agreed upon by you and practice nurse.
Content: Outlines management steps, available support, concerns, goals, and advice.