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Chronic Disease Management

Chronic Disease Management Programme

The Structured Chronic Disease Management (CDM) Programme aims to prevent and manage patient chronic diseases using a population-approach. It helps to identify and manage GMS and GP visit card patients at risk of chronic disease or who have been diagnosed with one or more specified chronic diseases

This programme is for patients who have a medical card or GP visit card and have a diagnosis of one or more of the listed conditions below.

  • Type 2 diabetes
  • Asthma
  • Chronic obstructive pulmonary disease (COPD)
  • Cardiovascular disease, including heart failure, heart attack (angina), stroke and irregular heartbeat (atrial fibrillation)

What are the components to the Structured CDM Programme?

There are three components within the Structured CDM programme:

  1. Opportunistic Case Finding Programme (OCF)
  2. Structured Chronic Disease Treatment Programme
  3. Annual Chronic Disease Management Prevention Programme (PP)

What patients qualify under each of the programmes?

Different patients, determined by age, qualify for different components of the programme, depending on the year. 

  • 2022 = CDM Programme rolled out to include all people aged 18yrs and over.
  • 2022 = Opportunistic Case Finding (OCF) and Prevention Programme (PP) for people aged 65 years and over.
  • 2023 = Final /Phase 3 OCF and PP rolled out to include people aged 45 years and over.

CDM Phasing Table

Chronic Disease Treatment Programme (CDM): Age – All adults age 18 and over
Opportunistic Case Finding Programme (OCF): Age 45 and over