Chronic Disease Management Programme

The Structured Chronic Disease Management Programme is for patients who have a medical card or GP visit card and have or are at risk of developing a specified chronic disease:  Type 2 diabetes, Asthma, COPD and Cardio vascular disease.

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

It is provided by Kingsford Medical to ensure patients conditions are actively monitored to improve management of their conditions.

              

Am I an eligible patient and can I access this programme free of charge?

  • You are eligible to join this programme free of charge if you:

    • Have a medical card or a GP visit card

    • Are aged 18 years or over

    • Have a specific chronic disease(s) :

      • Type 2 Diabetes

      • Asthma

      • Chronic Obstructive Pulmonary Disease (COPD)

      • Cardiovascular Disease including: - Heart Failure - Heart Attack (Angina) - Stroke - Irregular Heartbeat (Atrial Fibrillation)

Next Steps: WhaT will Kingsford Medical be doing to include me in the CDM Programme?

We will be inviting you to register for the Structured Chronic Disease Management Programme.  We are also very happy for you to get in touch by phone or email and let us know you want to participate - this is the fastest way to enrol in the programme as it may take some time for us to get in touch with you if, for example, we do not have your mobile number or email address.

  1. You will be seen in the surgery by the practice nurse for blood tests and if necessary other tests such as ECG and 24 hour ABPM.

  2. You will then be given an appointment to see one of the GPs a week or two following this nurse visit

  3. You will be issued with a Care Plan at your GP review.

How will I benefit as a patient from participating ?

  • Structured reviews of your chronic disease

  • A personalised care plan developed and agreed with one of our GPs

  • Regular reviews of your care plan and medication

  • Opportunities for structured education and self-management support

  • Early detection of any new conditions you may develop

  • Early detection of complications in your condition(s)

  • Care in your community, close to your home.

How will the programme work for me?

There will be 2 free structured reviews in the surgery each year as part of the Chronic Disease Management Programme.

Each structured review includes 1 free visit to the GP and 1 free visit to the practice nurse at Kingsford Medical.

Your information

Once you are on the Chronic Disease Management Programme you allow certain information to be collected at each structured review as part of the programme. During each structured review, we will record your:

  • Name and age

  • Chronic disease diagnoses

  • Medical history

  • Details of any symptoms or investigations you have had since your last visit.

Why is my information useful?

Information gathered as part of the Chronic Disease Management Programme will play a vital role in helping to improve our understanding of chronic disease. It will improve the health services ability to detect, treat and prevent chronic diseases as well as deliver an improved service to those with chronic disease.

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.