This practice aims to provide excellent care for all our patients medical needs. We cater for all family members, through every stage of life. General healthcare includes lifestyle medicine, screening and preventive healthcare, diagnosis and management of acute episodic illnesses and the Structured Chronic Disease Management (CDM) Programme​.

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CDM Programme​

The program includes three components: 

• Opportunistic Case Finding (OCF): Identifies eligible patients, aged 45 or older, who may have an undiagnosed chronic disease or are at high risk.

• Annual Chronic Disease Prevention Programme (PP): Provides an annual review for patients, including those with hypertension or at high risk of cardiovascular disease or diabetes.

• Structured Chronic Disease Treatment Programme: Provides ongoing management for patients who have been diagnosed with an eligible chronic disease.​

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Opportunistic Case Finding (OCF)

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The OCF Programme is for patients who have not previously been diagnosed with a chronic diseases, but may be at risk of developing one. OCF assessments take place on an opportunistic basis, that is, when a patient attends for another issue. The GP may offer an OCF assessment to a patient who has one or more of the following indicators.

 

• A current smoker

• BMI >30

• Previous BNP > or = 34pg/ml or NTproBNP > or = 125pg/ml

• Ethnicity

• History of gestational diabetes

• Dyslipidaemia

• Moderate or severe chronic kidney disease eGFR <60 ml/min

• History of severe mental illness

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The OCF assessment includes measurement of baseline details, QRISK3 assessment and blood tests

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The outcome of an OCF assessment depends on a patient’s risk of developing a chronic disease.

Patient’s risk: Low risk of developing a chronic disease - Repeat the OCF assessment in no less than five years

Patient’s risk: At risk of developing cardiovascular disease, diabetes or both - Register the patient on the Annual CDM Prevention Programme (PP)

Patient’s risk:  Diagnosed with a specific chronic disease - Register the patient on Structured Chronic Disease Treatment Programme

 

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Annual Chronic Disease Prevention Programme (PP)

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The Prevention Programme is for patients who have been referred from an OCF assessment as a result of one or more of the following:

• QRISK3 ≥ 20%

• Hypertension Stage 1 (BP 140/90 to 155/99mmHG) with no target organ damage

• Hypertension Stage 1 (BP 140/90 to 155/99mmHG) with target organ damage

• Hypertension Stage 2 or 3 (BP > 160/100mmHG)

• Gestational Diabetes (All cardholders & non cardholders if diagnosed since 01/01/2023)

• Pre-Eclampsia (All cardholders & non-cardholders if diagnosed since 01/01/2023)

• Pre-Diabetes or previous BNP greater than 34 pg/ml (if previously recorded) or NT pro BNP ≥ 125 pg/ml (if previously recorded)

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The programme includes one structured review consisting of one consultation with the GP and one with the practice nurse in every 12-month period. The patient can see both the GP and the practice nurse during the same review or separately at different times. There will be a minimum 9 month gap between each PP review.

 

The review includes:

• patient education

• preventive care

• medication review

• a physical examination

• an individual care plan, which is agreed with the patient.

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Structured Chronic Disease Treatment Programme

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We strive to provide the best possible standard of care for your chronic medical condition. Medical and GP visit card holders can avail of free twice yearly checkups with the nurse and doctor to cover all aspects of your chronic disease management. Patients who do not have a Medical or GP visit card can avail of the same service for the relevant fee as outlined in our fees section.

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​​The specified chronic diseases included in the programme are:

• Type 2 Diabetes

• Asthma

• Chronic Obstructive Pulmonary Disease (COPD)

• Cardiovascular diseases, including heart failure, heart attack and/or angina, stroke and/or TIA, and atrial fibrillation (irregular heartbeat) 

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What does the programme involve?

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Eligible patients receive structured chronic disease management that typically involves: 

• Regular reviews: Patients have scheduled appointments throughout the year with their GP and practice nurse.

• Personalized care: A written care plan is agreed upon between the patient and their GP to help them manage their condition.

• Tests and monitoring: These reviews include appropriate blood tests, blood pressure checks, and other assessments.

• Health promotion: Patients receive education and advice on lifestyle changes to help manage their risk factors.

• Referrals: Patients can be referred to specialist services like dietitians or physiotherapists if needed. 

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Data and Privacy

The practice will share information with the HSE as part of the programme in line with data protection regulations

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