Chronic disease management in Naas

Long-term conditions are managed best when they are reviewed on a schedule rather than only when something goes wrong. The practice runs structured reviews so that changes are spotted early and treatment is adjusted before a condition destabilises.

What this covers at our Naas clinic

Reviews are available for the main long-term conditions managed in Irish general practice, including those covered by the HSE Chronic Disease Management Programme for eligible patients.

• Type 2 diabetes — bloods, blood pressure, weight, foot and eye screening referral
• Asthma — symptom control, inhaler technique and treatment review
• COPD — symptom review, inhaler technique and exacerbation planning
• High blood pressure (hypertension) — monitoring and medication review
• Cardiovascular disease and stroke — risk-factor and medication review
• Atrial fibrillation and other heart rhythm conditions
• High cholesterol and overall cardiovascular risk
• Medication review and repeat prescription alignment
• Referral to specialist services where a condition needs escalation

What to expect

1. Recall and booking

   Patients on a structured programme are reviewed at set intervals. The practice will let you know when a review is due; you can also phone to arrange one.

2. Before the review

   Some reviews need bloods taken in advance so results are available on the day. Reception will tell you if that applies and when to come in.

3. The review appointment

   Your clinician goes through symptoms, measurements and results, checks technique for any inhaled or injected treatment, and reviews your medication.

4. The plan

   You leave with a clear plan — what is working, what is changing, what to watch for, and when the next review is due.

Who this is for

Structured reviews are for patients living with a diagnosed long-term condition.

• Patients with type 2 diabetes, asthma or COPD
• Patients with high blood pressure, heart disease or a previous stroke
• Patients eligible for the HSE Chronic Disease Management Programme
• Anyone on long-term medication that needs periodic review
• Patients recently discharged from hospital with a new diagnosis

The HSE Chronic Disease Management Programme

The Chronic Disease Management Programme is a HSE scheme providing structured GP care for eligible medical card and GP visit card holders living with certain long-term conditions. It funds regular planned reviews in general practice rather than leaving care to be picked up in hospital.

Eligibility depends on your card status and diagnosis. The practice can confirm whether you are eligible and enrol you if so. Where a patient is not eligible, reviews are still available and the practice can confirm the applicable charge.