HSE Guide for GPs to the CDM Programme
Chronic Disease Management.
Over 18 , any DVC / GMS.
Max 3 of named 7 conditions.
- Asthma
- COPD
- Ischaemic Heart Disease
- Atrial Fibrillation.
- Heart Failure.
- CVA / TIA.
- Type 2 Diabetes.
Biannual review.
Bloods and physical.
Prevention Programme.
Over 18.
Criteria:
- Pre-diabetes ( HBA1c 42 or more)
- DVC / GMS or Private for GDM or PET.
- Q Risk 20%+
- HTN Stage 1 or more ( 140/90)
- NT ProBNP > 125
Annual review - bloods and physical.
Can stay as PP or progress to CDM.
Opportunistic Case Finding.
Over 45.
DVC /GMS.
Review every 5 years.
Criteria:
- Smoker
- BMI > 30
- eGFR < 60
- Ethnicity
- Severe mental illness
- ? Other
- Dyslipidaemia – HDL < 0.9 or TG > 2.82
May remain as OCF, progress to PP or even CDM.
