Updated Chronic Disease Management

General Practice has changed dramatically in the last ten years. We are now managing patients in the community who a few years ago would have needed hospital referral and follow up. As a consequence GPs, GP Registrars and Practice Nurses have to continually acquire and maintain new knowledge and skills.

 

One of the areas that have transformed the care and outcomes for patients are primary care evidence based chronic disease management services.

 

In order to deliver quality chronic disease management services within primary care we have to have:

 

• A patient centred approach.
• Consistency from the multidisciplinary team in terms of targets, schedules of care, clinical management etc.
• Validated and maintained disease registers.
• Robust call and recall systems.
• Accessible, pragmatic, evidence based, primary care orientated guidelines.

 

Unfortunately one of the great challenges we face in general practice is keeping pace with the rapidly changing evidence base for chronic disease management. To cope with this and to standardise care SunnyBank Medical Centre has created (and update six monthly) these chronic disease management guidelines. As there are conflicting national guidelines in some areas of chronic disease management we have opted for pragmatic, achievable targets that fall between differing national guidelines.

 

 

Click on the topics below for the October 2009 updated evidence based guidelines from SunnyBank Medical Centre              

 

• CVD risk management & Lipids  
• Hypertension                       
• Ischaemic Heart Disease
• Heart Failure
• AF
• TIA & Stroke  
• Obesity                                      
• Diabetes
• Glucose Intolerance & IFG
• Chronic Kidney Disease
• Abnormal Liver Function Tests                        
• Asthma
• COPD
  

 

• Repeat prescribing in chronic disease 
• Please make an appointment - prescription attachment
• DMARD drug monitoring summary
  
• DVLA medical rules
• Fitness to fly

 

NEXT UPDATE  April 2010