Chronic Disease Management Programme

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

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The Structured Chronic Disease Management Programme is for patients who have a medical card, GP Visit card or a Health Amendment Act card and have a specified chronic disease:  cardiovascular disease, COPD, asthma and type 2 diabetes.

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The annual  Prevention Programme is for people who have a medical card, GP Visit card or a Health Amendment Act card and have a diagnosis of hypertension or who are at high risk of cardiovascular disease or diabetes, and all adults aged 18+ diagnosed with gestational diabetes or pre-eclampsia since January 1, 2023.

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The Prevention Programme is designed so that you and your GP can work together on reducing your risk of developing cardiovascular disease, diabetes or both.

Structured Chronic Disease Management (CDM) Programme

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

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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

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

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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

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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

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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.​

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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.

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

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Care Plan

A care plan is agreed between you and your GP or practice nurse. It outlines the steps that you need to take to manage your condition and the supports available to you. It can include your concerns, agreed goals between your reviews and advice.

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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.

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Annual Chronic Disease Prevention Programme

The annual chronic disease management prevention programme is for people:

  • Aged 45+ with a GMS/DVC/Health Amendment Act card at high risk of cardiovascular disease or diabetes.

  • Aged 18+ with a GMS/DVC/Health Amendment Act card diagnosed with hypertension.

  • Any adult (including private patients) aged 18+ diagnosed with gestational diabetes or pre-eclampsia since January 1, 2023.

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

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Benefits of the Programme

The programme is designed so that you and your GP can work together on reducing your risk of developing cardiovascular disease, diabetes or both.

The Prevention Programme supports you by providing:

  • an annual review with your GP and practice nurse

  • a review of your medicines

  • a plan to help you manage your risk factors

  • health promotion advice

  • appropriate medical treatment

  • referrals to support services, if needed

  • care in your community, close to your home

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Registering for the Preventative Programme

If you are at risk of cardiovascular disease, diabetes or both, your GP will ask you if you want to take part in the programme.

Your GP or practice nurse will arrange a review with you and register you for the programme.

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How the Preventative Programme works

The programme is free and includes one review in every 12 month period.

Each review includes one visit with the practice nurse followed by a visit with your GP. You can see your GP and practice nurse during the same review or separately at different times.

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Your GP or practice nurse will give you advice on lifestyle changes that will help you manage your risk factors. They will refer you to support services if you need them. For example, they may refer you to help to stop smoking or to manage your weight.

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You can still visit your GP as normal outside of the scheduled programme reviews.

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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

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How the HSE use your Personal Information

Your GP will send information to the HSE at the end of each structured review. This will include your name and address, medical or GP card number, and chronic disease history.

This information will help the HSE improve our understanding of chronic diseases. It will improve our ability to detect, treat and prevent chronic diseases in the future. It will help us to deliver an improved service to people with these chronic diseases.

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Your personal information is stored in line with current data protection regulations. You will have full and open access to the personal information the HSE keep about you. You can ask for it from the HSE at any time.

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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.

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

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