Oswald Medical Centre
Oswald Medical Centre
Chronic Disease Clinics
chronic diseases are conditions that are present longer than 6 months, usually for years and not usually curable or communicable to others. They are becoming more prevalent as the population ages. Proper management can minimise symptoms and complications for patients improve their longevity.
Some examples of chronic diseases managed in primary care are
- Diabetes
- Asthma
- COPD
- Ischaemic heart disease
- chronic mental health problems
- heart failure
- chronic kidney disease
The main aims of chronic disease management in primary care are to
- educate and enable patients to manage to a certain extent their own health
- monitor and identify progression of their condition so that active steps can be taken to step up or down their treatment.
The clinics are usually run by our practice nurses, with support from the doctors in the practice and sometimes from specialists in the concerned field in secondary care.
Once a patient has been diagnosed with a chronic condition, they are included in a register and will be invited for review of their condition usually on an annual basis. Some patients may have more than one chronic disease but the the surgery will try to manage all conditions in one appointment if possible.
Each patient gets an individual care plan tailored to their specific needs, guided by set standards and targets, mainly QOF (quality and outcomes framework) and NICE guidelines which is a nationally agreed framework set by the department of health so that up to date standardised, evidence based care can be given.
