HSE-funded programme

Chronic Disease Management

Introduced nationally in 2020 and expanded in the years since, the programme provides proactive, structured care designed to help people stay well for longer and reduce the need for hospital and Emergency Department visits.

Call to book a CDM review

Three programmes

What is the Chronic Disease Management Programme?

There are three parts to the programme. Your GP will let you know which one is right for you.

CDM

Chronic Disease Management (Treatment Programme)

Structured, ongoing care for people with certain long-term (chronic) conditions in general practice.

Who is eligible?: Medical card or GP visit card patients only.
Age: 18 years and over.
Conditions that qualify: Type 2 diabetes
Asthma
Chronic Obstructive Pulmonary Disease (COPD)
Heart failure
Atrial fibrillation
Ischaemic heart disease (heart attack/angina)
Stroke (CVA) or Transient Ischaemic Attack (TIA)
How often will you be seen?: Two structured reviews each year (approximately every 6 months) with your GP and practice nurse.

Prevention Programme

Regular reviews for people at increased risk of developing cardiovascular disease or diabetes.

Who is eligible?: Medical card or GP visit card patients only (most patients). Some patients (e.g. with a history of gestational diabetes or pre-eclampsia) may be eligible even without a medical card. Please ask your doctor.
Age: Usually 45 years and over for most patients; 18 years and over with hypertension. Specific provision for those with a history of gestational diabetes or pre-eclampsia (regardless of age).
You may be eligible if you have: High blood pressure (hypertension)
Pre-diabetes
Increased risk of cardiovascular disease (based on assessment)
History of gestational diabetes (or pre-eclampsia)
Other risk factors for cardiovascular disease or diabetes (e.g. high cholesterol, family history)
How often will you be seen?: One structured review each year (every 12 months).

OCF

Opportunistic Case Finding

A one-off health check to look for previously undiagnosed conditions in people at higher risk.

Who is eligible?: Medical card or GP visit card patients only.
Age: 45 years and over (with risk factors).
You may be offered a check if you have one or more risk factors, such as: Past history of high cholesterol
BMI over 30 (obesity)
Current smoker
Raised blood pressure
Chronic kidney disease (previously undiagnosed)
History of severe mental illness
Other cardiovascular or diabetes risk factors
How often will you be seen?: A one-off health check. If a condition or significant risk is identified, your GP will discuss the next steps, which may include further tests, treatment or enrolment in one of the other programmes.

Proven benefits

What are the benefits of the HSE-funded programme?

The HSE has found that, compared with before joining the programme, enrolled patients experienced:

30%
fewer Emergency Department attendances
26%
fewer hospital admissions
33%
fewer GP out-of-hours attendances

Regular, proactive care
Better control of your health
Early detection of problems
Medication review and optimisation
Personalised advice and support
Improved quality of life

Think you're eligible, or due a review?

If you think you are eligible, or if you are due a CDM review, please ring the practice on 01 853 2070 to make an appointment. If you would like a similar follow-up and review schedule, please speak to your doctor.

Blood tests

What blood tests are included in this programme?

These blood tests are covered by the HSE and are free for medical card and GP visit card patients, as part of the CDM, Prevention and OCF programmes, where clinically appropriate.

HbA1c
for diabetes monitoring
Cholesterol
total cholesterol, HDL, LDL, triglycerides
Kidney function
eGFR, creatinine, urea (CDM also includes urine albumin:creatinine ratio for early detection of kidney changes)
Liver function
e.g. ALT, AST, GGT
Full blood count (FBC)
check for anaemia and other changes
Thyroid function
TSH, if indicated

Please note

If you require other blood tests not covered in this programme (for example, blood test monitoring for osteoporosis treatment or others), a fee may apply. Please inform the nurse at the time of your appointment. Any questions? Talk to your GP or practice nurse.

Prefer to speak to someone?

Our reception team is happy to help during opening hours.

Call 01 853 2070