First report of the Structured Chronic Disease Management Programme in General Practice
| dc.contributor.author | Health Service Executive | |
| dc.date.accessioned | 2023-01-13T12:11:49Z | |
| dc.date.available | 2023-01-13T12:11:49Z | |
| dc.date.issued | 2022-08 | |
| dc.identifier.uri | http://hdl.handle.net/10147/634849 | |
| dc.description | The Enhanced Community Care Programme, together with the GP Agreement 2019, is a practical demonstration that the Department of Health Sláintecare policy is actively working to change Ireland’s health service model to be less dependent on the acute hospital system by providing more care in the community, as close to home as possible which will allow our ageing population and those with Chronic Disease to maintain their independence and live well in the community. It not only supports our services to reduce the winter pressures on our acute hospital system but also is a local demonstration of active transformational change underway in bringing more enhanced community care services to towns and villages across Ireland. The Chronic Disease Management Programme for General Medical Scheme (GMS) or Doctor Visit Card (DVC) patients was a key development included in the 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%. The Programme, which is comprised of three components, envisages an uptake of 431,000 patients; • 120,500 on the Opportunistic Case Finding Programme, involving the opportunistic assessments to detect and diagnose diseases at an early stage, so that they can be appropriately managed • 253,500 on the CDM Structured Programme with 2 GP visits and 2 Practice Nurse visits a year • 57,000 on the High Risk Preventative Programme with 1 GP visit and 1 Practice Nurse visit a year The focus of this report is the first phase of implementation of the CDM programme commencing in 2020. It also encompasses modifications to the programme which were implemented in the context of the Covid-19 Pandemic. These occurred within the wider context of working towards implementing a whole system approach involving the development of 96 Community Healthcare Networks (CHNs) and 30 Community Specialist Teams (CSTs) for Chronic Disease and 30 Community Specialist Teams for Older People to support the implementation of integrated care across community and acute settings, in line with Sláintecare and the National Service Plan 2020. At the outset, in line with the rollout of the eHealth agenda incorporated the GP Agreement 2019, the data returns from the GPs participating in the CDM were identified as critical to the success of the programme. A key requirement outlined in the GP Agreement 2019 was the development of a bespoke ICT and quality assurance system to improve outcomes and ensure the accuracy of the assumptions underpinning the CDM programme, thus supporting service planning and the effectiveness and efficiency of the service. CDM data have been collected since the commencement of the programme in January 2020. This valuable data 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. Furthermore, in the longer term, this data will shed more light on the levels of GP engagement with the CDM programme in its initial stages to help with strategic implementation on an on-going basis. Such information will be valuable in supporting service planning, the judicious use of resources and targeting particular subsets of the population as the CDM programme is rolled out. | en_US |
| dc.language.iso | en | en_US |
| dc.publisher | Health Service Executive | en_US |
| dc.subject | CHRONIC DISEASE | en_US |
| dc.subject | GENERAL PRACTICE | en_US |
| dc.subject | SLAINTECARE | en_US |
| dc.title | First report of the Structured Chronic Disease Management Programme in General Practice | en_US |
| dc.type | Report | en_US |
| refterms.dateFOA | 2023-01-13T12:11:49Z |
