Chronic Disease Management
Chronic Disease Management Services
1. Service Aims
The Chronic Disease Management Service aims to provide proactive, structured care for patients with long-term conditions, improving clinical outcomes, supporting self-management, and reducing complications and avoidable hospital admissions. The service ensures that care is evidence-based, personalised, and integrated within the wider primary care team.
2. Service Objectives
- Identify and register patients with long-term conditions requiring active management.
- Develop and deliver personalised care plans tailored to individual patient needs.
- Optimise medicines management, including adherence support and monitoring of high-risk therapies.
- Monitor key clinical indicators, such as blood pressure, HbA1c, lung function, and lipid profiles, to inform treatment adjustments.
- Provide patient education and self-management support to encourage engagement and adherence.
- Collaborate with multidisciplinary teams, including community and secondary care services, to ensure continuity and coordination of care.
- Reduce avoidable hospital admissions and complications related to chronic disease.
3. Key Service Components
- Clinical Reviews: Structured, regular reviews for patients with diabetes, asthma, COPD, cardiovascular disease, and other long-term conditions.
- Medicines Optimisation: Ensuring safe, effective, and guideline-adherent prescribing.
- Patient Education and Self-Management Support: Tools, coaching, and resources to empower patients to manage their condition.
- Monitoring and Follow-Up: Tracking clinical indicators and outcomes to adjust treatment plans as needed.
- Multidisciplinary Collaboration: Coordination with GPs, nurses, pharmacists, and secondary care teams.
4. Outcomes and Benefits
- Improved clinical outcomes, such as better disease control and reduced complications.
- Increased patient knowledge, confidence, and engagement in self-management.
- Reduced avoidable hospital admissions and emergency visits.
- Optimised medicines use, supporting safety and cost-effectiveness.
- Enhanced coordination of care across primary and secondary services.