UPDATED CHRONIC DISEASE MANAGEMENT

Click on the topics below for the July 2017-18 updated evidence based guidelines based on those from Brig Royd Surgery

• CVD risk management & Lipids
• Hypertension
• Ischaemic Heart Disease
• Heart Failure
• AF
• TIA & Stroke
• PVD
• Type 2 Diabetes
• IGR/IFG/Gestational DM
• Chronic Kidney Disease
• Abnormal Liver Function Tests
• Asthma
• COPD
• Osteoporosis
• How long should an CDM review appointment be with the Practice Nurse?
• What bloods need to be done at the annual review?
• Please make an appointment - prescription attachment
• DVLA medical rules
• Fitness to fly

Home BP monitoring diary
Spreadsheet for admin team to calculate average of home BPs
Staggered home blood glucose monitoring diary
Peak Flow Diary from Patient.co.uk

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 2019