Understanding the Chronic Disease Management Programme and Patient Movement Between Programmes

The Chronic Disease Management Programme (CDMP) is structured to support patients at different stages of chronic disease risk and management. It consists of three distinct programmes designed to identify, prevent, and treat chronic diseases effectively.

Firstly, the Opportunistic Case Findings (OCF) programme targets patients who visit their General Practitioner (GP) for reasons unrelated to chronic diseases but who may be at risk due to factors such as smoking or obesity. In this scenario, the GP registers the patient on the programme and conducts an OCF assessment to identify potential risks early.

The second component is the Prevention Programme (PP). This programme focuses on patients identified as having a high risk of developing chronic diseases. Once registered, these patients undergo regular and structured assessments and tests carried out by their GP to monitor and mitigate risk factors before a chronic disease develops.

Finally, the Treatment Programme (TP) is designed for patients who have already been diagnosed with specific chronic diseases. These include Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease (COPD), Asthma, Ischaemic Heart Disease, Cerebrovascular Accident (stroke), Transient Ischaemic Attack (mini-stroke), Heart Failure, and Atrial Fibrillation. Patients on this programme receive ongoing management and treatment tailored to their condition.

A common question among GPs is how patients can transition between these programmes. The pathway typically allows patients to move forward from Opportunistic Case Findings to the Prevention Programme, and then to the Treatment Programme as their health status changes. It is also possible to move directly from Opportunistic Case Findings to the Treatment Programme if a diagnosis is made. However, moving a patient backward from the Treatment Programme to either the Prevention Programme or Opportunistic Case Findings is generally not permitted, except in cases where an error has occurred.

To address errors, the system allows for a Treatment Programme registration to be deleted, but only if the patient has not yet undergone any reviews within that programme. Typically, after registration, a patient is reviewed by their GP within four months and subsequently on an annual basis. If multiple reviews have been conducted, such as for asthma management, the patient cannot be removed from the Treatment Programme.

This brings us to a practical scenario involving a patient diagnosed with gestational diabetes who the practice wishes to register on the Prevention Programme. Upon review, it was noted that the patient is coded in the system as having asthma, a diagnosis from childhood that is now largely irrelevant clinically. Because of this asthma coding, the system automatically registered her under the Chronic Disease Management Treatment Programme, overriding the intended Prevention Programme registration.

In such a case, the question arises: is it possible to reverse this registration and move the patient back to the Prevention Programme? According to the programme guidelines, patients can move forward from Prevention to Treatment, but not backward. However, if the Treatment registration was recent and no reviews have been conducted, the registration may be deleted to correct the error. If reviews have already taken place, the patient must remain in the Treatment Programme.

While this issue often requires assistance from IT support within the Practice Management System, understanding these protocols helps clarify what is possible. It is important to verify whether any Treatment Programme reviews have been conducted for the patient. If none exist, the Treatment registration can be removed, allowing for correct registration on the Prevention Programme. Otherwise, the patient will remain in the Treatment Programme as per system rules.

In summary, the Chronic Disease Management Programme is designed with a clear progression path from risk identification to treatment. Movement between programmes is typically unidirectional, reflecting the patient's evolving health needs. Errors in registration can be rectified under specific conditions, but once treatment reviews commence, programme changes are restricted to ensure continuity and accuracy in patient care management.