Chronic Disease Management in Ireland Innovation, Insights, and Impact.

Since 2020 there has been significant reform in how the HSE delivers chronic disease care under The National Framework for the Integrated Prevention and Management of Chronic Disease (2020-2025). The Chronic Disease Management (CDM) programme was an initiative designed to help individuals manage long term health conditions. It was negotiated and agreed as part of these agreements (GP 2019 & 2023) between the HSE, IMO & DOH to deliver a structured care programme delivered by GPs for patients suffering with certain chronic diseases. The aim of the program is to deliver structured care plans, empower patients, reduce the impact of chronic diseases and improve long term health outcomes. CDM has been rapidly adopted by over 95% of GPs nationally providing structured care to 80% of eligible patients across Ireland. Clinical data from each review circa 50K messages per month is captured and stored in the CDM Clinical Data Repository (CDR). The CDR provides invaluable insights on the benefits realisation of the programme and service planning. The clinical publications to date have demonstrated the clear benefits and improvements in patients experience across lifestyle and clinical outcomes. Initially the GP Practice Management Systems (PMS) were enhanced with a CDM module, co-designed and co-created in partnership with HSE and PMS vendors to successfully capture patient review data and send it via Healthlink to the CDR and PCRS for payment reimbursement.

Delivery of results

Impact of technical changes results in significant service user and patient experiences. The delivery of the technical changes to enable this programme were completed through a cross functional team with representation from the ECC Programme Chronic Disease Management Service Team, GP PMS Vendors, PCRS and a number of Technology & Transformation Teams (Community Delivery, A2i-HIDS, IIS, CISO).

Functional changes made to the CDM GP PMS module results in significant improvements for end user and patient experiences. Phase on phase the programme has provided enhanced streamlining, consolidation and additional functionality in the prevention and management of chronic diseases.

Phase 1: Delivered the fundamentals of the CDM treatment programme, Datasets, Investigations Matrix and structured review criteria and integration requirements.

Phase 2: Introduced 2 additional programs Opportunistic Case Finding and Prevention Programme with associated datasets, Investigation Matrix and eligibility criteria.

Phase 3: Included 30 enhancements to expand and streamline existing programs. These enhancements included the enrolment of patients over 18 years with known diagnosed Stage 1 hypertension on the Prevention Programme and the Chronic Disease Management in Ireland www.ehealthireland.ie Innovation, Insights, and Impact. By Sharon Mullally Senior Project Manager and Ciaran Coughlan Project Manager, Community Delivery, HSE Technology and Transformation. enrolment of all women over 18 years with a history of GDM or Pre-Eclampsia on the Prevention Programme.

Phase 4: Introduces the reduction to 18 years+ for direct enrolment to the Prevention Programme (PP) for all PP criteria and the inclusion of Familial Hypercholesterolaemia, Peripheral Arterial and Valvular Heart Disease and Chronic Kidney Conditions. This has a positive impact on eligible patients’ health with access to necessary diagnostics to allow for prevention of developing chronic disease, timely accurate diagnosis, early intervention and proactive management of chronic conditions. Detailed messaging specifications outline the messaging structure and pathway from GP PMS through Healthlink to PCRS (payment) and CDR (analytics).

The Program from a Clinical perspective

There were 443,524 individuals registered on the CDM treatment Programme as at the end of June 2024. The CDM programme requires that GPs develop, discuss and record a care plan with each of their patients and that this plan is updated at each visit empowering patients in the management of their condition(s). The care plan includes anticipatory care, recommended actions for when the patient deteriorates and facilitates the development of patient-centred goals for treatment and behaviour change to be agreed and documented between patient and their GP - 53% (i.e. 98,494) of patients had a comprehensive patient centred care plan by January 2022, this had risen to 71% of patients by January 2023. To date 2 clinical reports on the CDM have been published, outlining the current Biometric risk factors (Medical) and lifestyle outcomes. CDM patients are experiencing lifestyle improvement across several categories. Behavioural changes have consistently improved seeing the number of smokers decrease, obesity levels decrease and physical activity increasing. The most impactful results are demonstrated across the Biometric Risk Factors. Results demonstrates a reduction in Total Patients with Hypertension of 45% and similarly in Total Patients examining Diabetes markers of 45% were experience between the first and third GP visit on the CDM programme.

The perspective of healthcare professionals further underscores the CDM programme’s success. Dr Lisa Devine, a GP in Bray, Co Wicklow, described it as an “absolute gamechanger.” She added, “From my point of view, it is one of the most positive things that has happened in the health service.” Patients are experiencing the benefits of structured care, gaining more accountability for the behaviours. Year on year there is a growing body of evidence highlighting the impact such a programme has on the preventative care to patients. This proactive programme is leading the way in healthcare delivery, optimising technology, improving patient care, streamlining care pathways. Patients are more empowered with early detection and intervention promoting healthier lifestyles and improving their quality of life managing their conditions.  

The Program from a Service perspective

 The CDM Programme delivers on the key objectives of the Slaintecare transformation programme, GP Agreements 2019 & 2023, ECC Programme and HSE NSP 2025 to support hospital avoidance and the transition of care into the community for all. This programme aims to ensure a population level approach to the prevention and management of specific chronic disease. It involves moving from the level of the individual to assess whole population needs with a view to targeting interventions at individual risk groups through the Structured Chronic Disease Management Programme. Evidence demonstrates that only 8% of patients were attending hospital for ongoing care of any of the conditions for which they were attending the GP under the CDM Programme. Dr Orlaith O’Reilly, HSE National Clinical Advisor Chronic Disease said: ‘The Chronic Disease Management programme is an example of the HSE’s commitment to enhancing healthcare in the community and bringing care closer to people’s home.’ The research produced from CDR analysis, comparing data from 2019 to 2023, shows the following key findings:

• 30% reduction in Emergency Department (ED) visits:.
•  26% reduction in admissions.
• 33% reduction in GP Out of Hours (OOH) visits.

These reports highlight the effectiveness of the programme in reducing the volume of routine care being managed in acute settings, ensuring that patients are efficiently cared for within their communities. By shifting care to community settings, the programme is enhancing patient outcomes while relieving pressure on acute services. Moreover, the quality of care delivered can now be effectively measured, providing valuable insights to ensure the service reaches all patients within their communities. This data-driven approach allows for continuous improvement, ensuring that the programme remains responsive to the evolving needs of the population it serves.

Conclusion

This programme is supported by the Service Business Administrator, who liaises with all relevant stakeholders to ensure that GPs are supported in delivering the Programme to their CDM patients. The CDM phases, which involve enhancements, expansion of services, and addressing additional requirements, are managed collaboratively between the CDM Programme’s Clinical Lead, Assistant National Director ECC Programme, and Technology & Transformation. The unique features of the Project team ensure that the focus remains on a patient-centric, enhanced experience of care that meets the needs of patients, communities, and service delivery users. It is supported by the integration of technology across the various stakeholders to streamline this process. This collective effort fosters a positive environment that encourages teamwork and innovation, and continuous improvements as the programme advances into its fourth phase. Over the years, several key figures have been instrumental in the successful delivery of CDM phases. Each team member has worked toward this vision with perseverance that has shaped something truly meaningful and impactful. Our heartfelt gratitude extends to Dr. Orlaith O’Reilly, CDM Programme Clinical Lead and to Pat O’Driscoll (T&T GM) and Marie O’Grady (ECC GM), whose dedication has left an indelible mark on the programme. We wish both Pat and Marie all the best in their retirements and thank them for their invaluable contribution to the Programme.