Details of the CDM Treatment. Programme In order to support patients in managing their chronic disease there are two scheduled reviews with the GP in a 12 month period, preceded by a practice nurse visit. These reviews are made up of a number of elements including: • Patient education. • Preventative care. • Medication review. • Physical examination. • Scheduled investigations, e.g., HbA1c for patients with diabetes. • Individual care plan. A patient centred approach requires that patients and their clinical providers work in partnership and ensures that patients are supported and empowered to be involved in their own care. Based on the models of care for the various chronic diseases developed by the National Clinical Programme and the existing Cycle of Care for diabetes, there will be two scheduled reviews in a 12 month period. Before each GP visit, the patient will visit the practice nurse to have blood drawn for the necessary tests so that the results are available for the next review. Each scheduled review will require 2 visits: a visit to the GP and to the practice nurse. The practice nurse visit will enable detailed education and review of the patient centred care plan and will include phlebotomy necessary for the programme. Subsequently, a clinical examination, medications review and an overall care plan will be reviewed by the GP. The practical result of this is that a GP or practice nurse develops a care plan with each patient registered on the Chronic Disease Programme. This care plan will take cognizance of the clinical aspects of the patient’s condition and their own goals for what they wish to achieve. The formulation of the plan will be an opportunity to support patients in learning about their own disease, the steps they can take to improve their own self- management, and the supports which may be available to them. It will help them to increase their awareness of a deterioration of their condition, how to recognise it and how to manage and respond to it through the development and implementation of an action plan if this should occur. From the diagnosis of a chronic disease and the Registration/First Visit, the care planning process will begin with the development of a care plan following a discussion and an agreement with the patient. This care plan is regularly reviewed and updated to reflect the current health and wellbeing of the patient as well as their future wishes and expectations. The scheduled reviews will be planned so they are of optimal value to the patient...
