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Chronic Disease Management

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

The Structured Chronic Disease Management Programme is for patients who have a medical\GP Visit card and have or at risk of developing a specified chronic disease:  

cardiovascular disease, COPD, asthma and type 2 diabetes.

Structured Chronic Disease Management (CDM) Programme

The Structured Chronic Disease Management (CDM) Programme aims to prevent and manage patient chronic diseases.

This programme is for patients who have a medical card or GP visit card and have a diagnosis of one or more of the listed conditions below:

  • Type 2 diabetes

  • Chronic obstructive pulmonary disease (COPD)

  • Cardiovascular disease, including heart failure, heart attack (angina), stroke and irregular heartbeat (atrial fibrillation)

  • Asthma

To be eligible for the programme you must be aged 18 or over and have a medical card or GP visit card.

A chronic disease is a long-term health condition that needs ongoing treatment and management. The programme is designed so that you can work with your GP on:

  • monitoring your condition

  • identifying early treatment

  • supporting the way you manage your condition

Benefits of the Programme
The programme can help you and your GP to manage your condition and prevent hospital admissions through:
  • structured reviews of your chronic disease with your GP or practice nurse
  • a personalised care plan of your needs, preferences and choices developed and agreed with your GP
  • a review of your care plan and medicine by your GP
  • support to self-manage your condition
  • opportunities for structured education and self-management support
  • early detection of any new conditions you may develop
  • early detection of any complications in your condition
  • care in your community, close to your home

How the Programme Works

The programme includes 2 free reviews in every 12 month period that you are part of the programme. There is no charge for any tests carried out as part of your programme reviews.

Each review includes one visit with the practice nurse followed by a visit with your GP, including blood tests. You can see your GP and practice nurse during the same review or separately at different times. You will receive a written care plan after each review.

You can continue to visit your GP as normal outside of the scheduled chronic disease management reviews.

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Registering for the Programme

Your GP or practice nurse will register you for the programme if you want to take part in it and you are eligible.

Your Information
As part of the programme, your GP or practice nurse will record some information about you at each review.

This will include your:

    • name and age

    • chronic disease diagnosis or diagnoses

    • medical history

    • details of any symptoms or tests you have had since your last visit

Opting out of the Programme

It is your choice to take part or not. You can opt out of the chronic disease treatment programme at any time by letting your GP know.

If you opt out, you will not get any reviews and other care planning under the programme from that point. You can always rejoin the programme if you want.

​Speak to your GP or practice nurse if you have any questions about the programme.

This content of this page (and links to other sites) is for general information purposes only and does not substitute medical advice. While we endeavour to keep this website up-to-date, errors may occur. We advise all patients to discuss their health concerns with their GP. If you would like to suggest amendments or highlight new information that could be useful to others please don’t hesitate to get in touch.