The universal GP Training website for everyone, not just Bradford.   Created in 2002 by Dr Ramesh Mehay

Chronic Disease Management

Bradford VTS Clinical Resources



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CDM at a Glance

  • In recent years more and more people are successfully living with and managing chronic diseases.  
  • Chronic diseases are diseases of long duration and generally slow progression. 
  • They include heart disease, stroke, chronic respiratory diseases and diabetes.  
  • The care of chronic disease is delivered in both hospital and community settings but is also managed by patients themselves who we must enable to become experts in their own condition and its treatment.
  • Hypertension (high blood pressure)
  • Angina/Heart Attacks
  • Heart Failure
  • Strokes
  • Diabetes
  • Asthma
  • COPD (Chronic Obstructive Pulmonary Disease)
  • Renal (Kidney) Failure
  • Osteoporosis
  • Cancer Care
  • Drug & Alcohol misuse
  • Mental Health Disorders like Depression, Anxiety, Bipolar disease, Schizophrenia and so on.
  • Ensure disease control targets are being optimised to patient tolerance
  • Monitoring patients through annual reviews to see how they are doing and optimise care
  • Monitoring multiple chronic disease together rather than individually by different clinicians
  • Monitoring and optimising medication
      • compliance/concordance
      • reducing prescription request burden for regular medications
      • medication review dates on repeat template should match or be a few beyond the recall dates wherever possible

There is a growing epidemic of chronic disease in the UK due to tobacco use, unhealthy diets, physical inactivity and other risk factors.   Whilst it is important to prevent these diseases from happening in the first place (which we are also trying to do — termed ‘primary prevention’), it is also important to prevent them from getting worse or causing other problems in patients who already have them (this is called ‘secondary prevention’).  With good management of chronic diseases, people can live longer.

There is a growing epidemic of chronic disease in the UK due to tobacco use, unhealthy diets, physical inactivity and other risk factors.   Whilst it is important to prevent these diseases from happening in the first place (which we are also trying to do — termed ‘primary prevention’), it is also important to prevent them from getting worse or causing other problems in patients who already have them (this is called ‘secondary prevention’).  With good management of chronic diseases, people can live longer.

A good example of this is diabetes — if you don’t manage a patient with diabetes properly, their diabetes will get worse, and over a number of years, they may end up with kidney failure, blindness, heart attacks, strokes, gangrene of the legs and so on.  And then they end up being hospitalised.   If we treat a patient’s diabetes and get their sugars under good control, we can stop them from getting most of these things and reduce unnecessary hospitalisation.  Clearly, this is very good news for the patient (as it stops their lives from being hampered by illness, infirmity and disability) but it’s also good for the NHS in general because the cost of treating these  complications and subsequent hospitalisation would otherwise be very expensive.

Offering good co-ordinated care that is in line with national and local guidance reduces the fragmentation of care and also reduces the risk of clinical error (including medication errors) and thus litigation risk.  In summary, by optimising the management of a patient’s chronic disease, EVERYONE is a winner.

This drawing is from a lady with a long term condition (LTC).  The green line is her managing her chronic (long-term) condition.   The red bars indicate the times when she has to make contact with a health professional/service.   As you can see, this patient is an expert of her condition and she manages her condition on a day-to-day basis by herself.   It’s important that her health professionals support her when things are a bit rough (the red bars) and help her get back to the more stable green line.     But we can only do this with patients if we invest time in them by….

  1. educating them about their illness(es)  (filling in the gaps in their technical knowledge)
  2. giving them confidence with self-management
  3. facilitating shared decision making.

If we don’t do this, then we simply create dependancy on us (which in turn creates unnecessary pressure on GP and hospital services) but more importantly it is ethically unfair on patients because it limits THEIR freedom and THEIR choice about THEIR own lives.   Would you feel happy if this was taken away from you?

A good CDM programme should: 

  1. provide comprehensive care — multidisplinary care for entire disease cycle
  2. provide integrated care, care continuum, coordination of the different components
  3. be population orientated (defined by a specific condition)
  4. involve active patient management tools (health education, empowerment, self-care)
  5. be evidence-based on guidelines, protocols, care pathways
  6. involve information technology, systems solutions
  7. embrace continuous quality improvement

Chronic disease can rarely be treated in isolation. Many patients have more than one chronic disease and as health professionals, we need to try and look at the whole picture, rather than in fragmented parts.  A big focus of this is self-care.  By ensuring that knowledge of their condition is developed to a point where patients are empowered to take some responsibility for its management and work in partnership with their health and social care providers, patients can be given greater control over their lives. Self-management programmes can be specifically designed to reduce the severity of symptoms and improve confidence, resourcefulness and self-efficacy

(after Velasco et al, 2003)

The management of chronic disease requires a systematic, proactive and comprehensive approach — in other words, tackling the problem from many angles rather than just one way (e.g. medication alone).   You can achieve this comprehensive approach through

  • Keeping a register — of patients belonging to the various chronic diseases.
  • Reveiwing these patients periodically and checking concordance with medication (through medication reviews).
  • Having named care co-ordinators for some patients – particularly those with complex medical needs or multiple chronic diseases (i.e. those with a high-medium risk of clinical deterioration; The Kaiser ‘risk-pyramid’ model).   Think about an assigned  GP care co-ordinator or a Case Manager (a very senior and highly qualified community matron) who checks in on the patient at regular intervals and also on an as and when basis with a view to
        1. Improving health,
        2. Coordinating care from multiple providers (to reduce fragmentation and duplication of care)
        3. Reducing the use of health care services and
        4. Support patients and their carers
        5. Promoting self-care and providing the appropriate material.
  • Following national (National Service Frameworks) and local protocols (Local Enhanced Services)  to help ensure that every patient is looked after in the optimally advised way (evidence based practice of medicine).
  • Optimising diet, phsysical exercise and healty living choices.  Nurses, doctors and health trainers can provide patients with this information.  Develop written and video material.  
  • Optimising blood tests and other investigations periodically as advised by national experts.  
  • Risk-stratification tools and electronic disease registers- to identify patients who are at high risk of deterioration and subsequent hospital admission.   And then putting measures in place to achieve greater stability and control (named doctors, case manager, coordinating care, liaising with outreach clinics to optimise care, patient education and so on).
  • Multidisciplinary team working — working with health professionals with different specialties to help optimise care.  
  • Specialised clinics for particular clinical problems.  
  • Promoting self-help – help patients to understand THEIR condition so that THEY can start being involved in managing THEIR own conditions in order to get some control of THEIR own lives.  We will help patients develop a plan for self-management at home.
  • Effective clinical information systems – ensuring the recording of important things in the clinical notes so that care us properly co-ordinated and information shared where it needs to be.
  •  Review nurse entry –  any problems?
  • Quick scan of new journal to see if any outstanding requirements
      • outstanding QoF targets
      • other Alerts (both can be seen on home page)
  • Review CDM table to ensure all monitoring has been done
  • Review BP aim for target as per protocol
  • Review pathology:  (preferably within 3-4 days of receiving the task)
      • U+Es (remember decline and CKD)
      • Hba1c (targets for DMs and recognise at risk groups)
      • LFTs (drug monitoring e.g NOACS, antipsychotics, Amber and high risk drugs)
      • FBC (drug monitoring e.g NOACS, antipsychotics, Amber and high risk drugs)
      • Lipids (Qrisk ? statin start or increase)
      • Urine a:cr
  • Review medication
      • For all CDM meds that have been reviewed by nurse review, move dates on to match/or a few weeks beyond recall date (could be moved on by the nurses if trained), if all parameters are satisfactory.
      • For other meds or med problems that have been identified by the nurses.
          • Check if a review has been done recently.
              • If no review done – task admin/SMS patient to book review.
              • If problems related to meds highlight then task to pharmacist to do med review.
          • If meds have been reviewed in the previous year by Dr/nurse/ pharmacist and if no problems identified then just move date on to tally with CDM recall if it’s clinically safe.
    • IF PATIENT ELIGIBLE FOR SMR – Structured Medication Review (see HOME page on S1) :
        • If straight forward – no changes required/good concordance/no polypharmacy/no frailty issues – move the date on and tick the SMR box
        • If complicated – then task pharmacist to book for a SMR review


  1. If review date is up and a pharmacist review is needed, just move date by 1-2 months so patient does not struggle to get their medications if it’s safe.
  2. Please be aware that some meds e.g Amber drugs, high risk drugs that need monitoring, antipsychotics, strong pain relief, antidepressants may not tally with the CDM review as they have their own planned monitoring.
  3. Most CDM meds will be moved on for 1 year, others for 6 months depending on the next recall dates.
  4. Review dates add an extra safety net for patients to ensure they are receiving the appropriate monitoring for the medication that they are using.
  • Identify which chronic diseases are being reviewed
  • Review appropriate protocol/template
  • Review patients well being
  • Review understanding of disease condition and how they are coping
  • Discuss lifestyle measures
  • Undertake necessary monitoring requirements: e.g annual pathology, ECG, spirometry, foot checks etc
  • Discuss medication and identify any problems




CKD 3a/3b/4/5

Diabetes (DM)/
At risk/GDM




Mental Health

Learning Disability



√ – every 6m CKD 3a/3b

√ – every 3m CKD 4/5

√- DM only annual




√ –  AF, annually if on NOAC

√ –   once at 3m if new/change in statin for other conditions

√ –   once at 3m if new/change in statin

√ –   once at 3m if new/change in statin



√ + AST



Lipid profile

√ DM only




√ (Down’s syndrome only)



√ only if on NOAC***

√ CKD 3b/4/5 (eGFR<45)








Urinary Alb:Cr


√ DM only









√ DM



lifestyle advice

6 monthly Review


√ DM only (maybe more)


√ severe


Annual Review

√ at risk/GDM

√ mild/mod


Fib-4 score


  • KEY:  AF-Atrial fibrillation, CHD- coronary heart disease, CVA-cerebrovascular accident, TIA-Transient Ischaemic Accident, PAD-Peripheral Arterial disease, HF-Heart Failure,  GDM – gestational diabetes mellitus
  • Patients may need ECG or spirometry if any deterioration or changes in symptoms related to their chronic disease at annual review
  • *HbA1c can’t be used if the patient is pregnant, has anaemia or known haemoglobinopathy.          *** NOAC : Edoxaban, Rivaroxaban, Apixaban, Dabigatran
  • **Common Statins: Atorvastatin, Simvastatin, Pravastatin, Rosuvastatin.


  • BP <130/80 (DM/CKD/CVD/CVA),
  • BP<140/90 (HYPERTENSION),
  • BP<150/90 IF 80 YEARS AND ABOVE.  
  • LIPIDS: non HDL chol <2.5 or LDL <1.8


  • TESTS ARE ANNUAL UNLESS OTHERWISE STATED.                             
  • DO CVD RISK ASSESSMENT (QRISK) AND DOCUMENT AS NEEDED                                               
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