The HSE has published the first review into the implementation of the chronic disease management (CDM) programme in general practice.
The report highlights the “high level of GP engagement” with the first phase of the CDM programme since roll-out began in 2020. According to the HSE, the programme has been taken up by 91 per cent of GPs and uptake by the eligible cohort of patients is “excellent” at 75 per cent. The older age groups in particular have “very high uptake rates”.
The report demonstrates that GPs are actively engaging patients with appropriate lifestyle interventions and encouraging patients to make healthier lifestyle choices to help prevent and manage chronic diseases.
This initial baseline report is a preliminary description of the activity and basic demographics, morbidity and lifestyle risk factors among patients enrolled aged over 65 in the first 20 months of the CDM programme.
The CDM programme was a key development in the GP agreement (2019), which commenced in 2020, and is being rolled out to adult patients over a four-year period with a target uptake rate of 75 per cent. It is estimated that approximately 430,000 patients with chronic disease, or at high risk of chronic disease, will be registered as participants when it reaches full implementation in 2023.
The programme supports GPs to identify and manage patients, with a medical card or doctor visit card, who are at risk of chronic disease or who have been diagnosed with one or more specified chronic diseases such as COPD, asthma, cardiovascular disease or type 2 diabetes. It focuses on prevention, patient empowerment, early diagnosis and intervention, multi-morbidity and the provision of care as close to patients’ homes as possible.
Key findings from the report include:
The data gives information on the current risk factor profiles for the lifestyle risk factors of smoking, alcohol, BMI and physical activity.
Commenting on the launch of the report, Dr Colm Henry, HSE Chief Clinical Officer, said: “The valuable data in this report provides a much clearer indication of the risk factors for ill-health, the health behaviours and the levels of the major chronic diseases that are present in a vulnerable cohort of the population. Promising trends in lifestyle risk behaviours have been shown with increasing numbers of reviews. Further reports will provide valuable information for practitioners and service planners.
“The chronic disease management programme is an example of the HSE’s commitment to enhancing healthcare in the community and bringing care closer to people’s home. As the chronic disease management programme is rolled out and fully implemented over time, it is envisaged that it will result in a reduction in hospital attendance by patients with the four conditions.”
Dr Denis McCauley, Chair of the IMO GP committee, said: “This report shows the remarkable progress in the roll-out of the chronic disease management programme since 2020. Despite the disruption to health services due to Covid-19, the high uptake rates among eligible patients is a fantastic testament to the hard work of GP teams across Ireland.
“The chronic disease treatment programme continues to be implemented, with the whole eligible GMS adult cohort now beginning the disease management programme. In addition, the opportunistic case finding and prevention programme commenced in the 65-year-old and over cohort earlier this year and will be expanded further in the coming years.”
Dr Joe Gallagher, ICGP Clinical Lead for cardiovascular disease, said: “As a GP, I know only too well the importance of supporting people with chronic diseases. This programme provides better healthcare outcomes for patients, reduces acute presentations and allows patients to become active partners in their own healthcare. It is a credit to both GPs and to the HSE for extending a modified programme to those aged over 70 and for accelerating the programme in 2020 to all those over 70 years of age. GPs were working in very pressurised circumstances over the last two years and achieving excellent uptake rates, and such a high proportion of the service being provided in person was very valuable in protecting these vulnerable patients with chronic disease.”
The full report is available on the HSE website: https://www.hse.ie/eng/services/publications/first-report-of-the-structured-chronic-disease-management-programme-in-general-practice.pdf
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