Ninety-one per cent of GPs signed up for CDM programme

Uptake of the initiative is ‘excellent’, says a new report into its implementation and rollout published by the HSE

Uptake of the Chronic Disease Management (CDM) programme by GPs and patients is ‘excellent’ with over 91 per cent of GPs signed up and around 75 per cent of eligible (65 years and older) patients enrolled, according to a new report published by the HSE.

The initial baseline report – the first of its kind on the CDM programme – 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 Chronic Disease Management programme, since it began in 2020.

The Chronic Disease Management programme was a key development in the 2019 GP Agreement, which commenced in 2020, and is being rolled out to adult patients over a 4-year period with a target uptake rate of 75 per cent.

The report also found almost 60 per cent of the patients enrolled in the programme have one of the specified chronic diseases (type 2 diabetes, cardiovascular disease, asthma, COPD). Almost 27 per cent were suffering from two, and 13 per cent were suffering from three or more of the specified diseases.

Approximately 430,000 patients with chronic disease, or at high risk of chronic disease, are estimated to be registered as participants on the CDM Programme when the programme reaches full implementation in 2023.

Additionally, the report presents information regarding current risk factor profiles for the lifestyle risk factors of smoking, alcohol, BMI, and physical activity.

Dr Colm Henry

Only nine per cent of enrolled patients are current smokers, while 13 per cent of patients, who agreed to a smoking intervention, were subsequently recorded an ex-smoker status. Some 52 per cent of patients enrolled in the programme were reported as having adequate levels of physical activity.

GPs carried out over 200,000 weight interventions with patients, with only 11 per cent of patients declined an intervention. Most patients had more than one review since January 2020 and encouragingly the cohort of patients’ average weight decreased by 1.5 kilogrammes between the first and the third visit.

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 also focuses on prevention, patient empowerment, early diagnosis and intervention, multi-morbidity, and the provision of care as close to patients’ homes as possible.

Commenting on the launch of the report, Dr Colm HenryHSE Chief Clinical Officer said that the 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,” he said.

“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 homes. 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.”

For more on the implementation of the Chronic Disease Management Programme see the September print edition of Irish Medical Times.

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