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.

Click on the topics below for the July 2011-12 updated evidence based guidelines based on those from Brig Royd Surgery              

• 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 
  
  
• Please make an appointment - prescription attachment
• Investigations prior to annual CDM review (at a glance)
• DMARD drug monitoring summary
• DVLA medical rules
• Fitness to fly

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 Brig Royd Surgery has created (and updated annually) 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.

NEXT UPDATE  July 2012