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Chronic Disease Management

Our team are dedicated to providing  preventative health care . 

We have comprehensive disease management programmes for patients with many chronic diseases.

The HSE in 2020 launched  the Integrated Care Programmes  an integrated model of care that treats patients at the lowest level of complexity that is safe, timely, efficient and as close to home as possible.

The Integrated Care Programme for the Prevention and Management of Chronic Disease (ICPCD) focuses on a number of chronic diseases that impact a large number of health service users.

Approximately 1 million people in Ireland today suffer from Diabetes, Asthma, Chronic Obstructive Pulmonary Disease (COPD) or Cardiovascular disease.The Irish longitudinal study on ageing, TILDA, reports that 64.8% of our over 65 age cohort live with co-morbidity. This is defined as the presence of two or more chronic conditions.

We have more people living with chronic disease and multiple co-morbidity, they are living longer with the disease, and while it is good that the range of treatments available is increasing and improving, this also comes at a cost. Unless we plan for these changes now, we are going to run into significant difficulties in ten years’ time.

The way we currently provide care for these chronic conditions is relatively ineffective, inefficient and ultimately unsustainable. Too many people end up needing hospital admission due to their chronic disease, which is something that these patients would prefer to avoid.

This programme aims to provide better care to people with chronic diseases. This will be achieved by providing a continuum of preventative, management and support services to patient with these conditions. This is built on an approach which helps people understand and care for their own condition in collaboration with their General Practitioner and the general practice team.

Presently all patients over 70 years of age with one or more known chronic diseases, will be invited to freely participated in the new programme. This will entail attending our practice for  extended appointments including appropriate investigations twice annually. The aim will to better educate, care and troubleshoot for the your future health to ensure a preventative and supported health enviroment.


Cycle of Care Patients with a medical card with Type 2 Diabetes can now have their condition reviewed twice a year- this assessment includes blood testing, blood pressure check, medication review, BMI measurement and a symptomatic foot review.

Studies have shown that Primary Care is the optimal setting to provide the best standard of Diabetes care for the majority of patients.

COPD( obstructive airways disease)/Asthma

We provide health management for patients suffering the effects of long term smoking on their lung health. Asthma Management Ireland has reported the 4th highest prevalence of Asthma worldwide. Our team provide education on asthma management and improve levels of control in our patients.


We have tailored a programme of care for those diagnosed with high blood pressure (BP). These patients are recalled for regular reviews to ensure the best gold standard and internationally recommended level of targeted care. This involves regular 24-hour BP monitoring, Ecg heart tracing, optimal weight-loss, diet and lifestyle changes and medication review.

Heart Disease

Patients who have had a previous history of a heart attack may be enrolled in a programme of care: Heart Health. This involves continuous 3 monthly assessment of cardiac function and is a nurse-led prevention service.