Chronic Disease Management

Tags
Clinical Terms
A systematic approach to healthcare that focuses on the proactive treatment, monitoring and support of patients with long-term conditions.

What is Chronic Disease Management in Primary Care Networks?

What is ?

Chronic Disease Management (CDM) within Primary Care Networks involves coordinated care strategies for patients with ongoing health conditions such as diabetes, hypertension, asthma, COPD, and heart disease. It emphasises prevention, regular monitoring, patient education, and self-management support to reduce complications, improve quality of life, and decrease hospitalisations. In the NHS, this often involves multidisciplinary teams working together to deliver personalised care plans and evidence-based interventions across the network.

Chronic Disease Management Best Practices

What is ?

  • Implement structured care plans with clear goals and regular review processes for patients with chronic conditions
  • Establish multidisciplinary teams that include GPs, nurses, pharmacists, and allied health professionals
  • Utilise digital tools for remote monitoring and virtual consultations to enhance accessibility
  • Engage patients in shared decision-making and support self-management through education
  • Develop standardised protocols across the PCN for consistent quality of care

Use Chronic Disease Management in a Sentence

What is ?

  1. Our Primary Care Network has implemented a comprehensive Chronic Disease Management programme that has reduced hospital admissions by 15% this year.
  2. Effective Chronic Disease Management requires both clinical expertise and strong communication between healthcare professionals and patients.
  3. The new funding arrangement allows Primary Care Networks to invest more resources in Chronic Disease Management, particularly for patients with multiple conditions.
Frequently Asked Questions about
Chronic Disease Management

What does Chronic Disease Management mean?

Chronic Disease Management refers to the systematic approach to healthcare that focuses on managing long-term health conditions such as diabetes, hypertension, and asthma. In Primary Care Networks, it involves coordinated care delivery, regular monitoring, preventive interventions, and patient education to improve outcomes, reduce complications, and enhance quality of life for people with ongoing health challenges.

How do Primary Care Networks deliver Chronic Disease Management?

Primary Care Networks deliver Chronic Disease Management through a team-based approach, bringing together GPs, practice nurses, clinical pharmacists, social prescribers, and other healthcare professionals. They implement structured care plans, shared protocols, regular reviews, and risk stratification to identify patients requiring different levels of support. Many PCNs also use remote monitoring technology, group consultations, and integrated care pathways to coordinate services across primary, community, and secondary care settings.

What chronic conditions are typically managed within a PCN's Chronic Disease Management programme?

Chronic conditions typically managed within a PCN's Chronic Disease Management programme include diabetes, hypertension, coronary heart disease, chronic obstructive pulmonary disease (COPD), asthma, heart failure, stroke, atrial fibrillation, chronic kidney disease, depression, dementia, and osteoporosis. PCNs also often manage patients with multimorbidity (multiple chronic conditions), with services tailored to meet the complexity of their care needs.

What are the benefits of effective Chronic Disease Management in Primary Care Networks?

Effective Chronic Disease Management in Primary Care Networks delivers numerous benefits, including reduced hospital admissions and A&E attendances, better control of conditions, improved patient outcomes and quality of life, enhanced patient experience through coordinated care, greater efficiency in healthcare resource utilisation, reduced health inequalities, and cost savings for the NHS. Patients benefit from having care closer to home with a team familiar with their individual needs and circumstances.

How are patients involved in Chronic Disease Management within PCNs?

Patients are central to Chronic Disease Management within PCNs, actively participating through shared decision-making about treatment goals, personalised care planning, supported self-management, health education programmes, and sometimes peer support groups. Many PCNs use the Patient Activation Measure (PAM) to assess patients' knowledge, skills, and confidence in managing their health, tailoring support accordingly. Digital tools like apps and online platforms also enable patients to track symptoms, medication adherence, and communicate with their healthcare team.

10x primary care outcomes with remote clinical pharmacists
Hand-off everyday clinical tasks to our remote pharmacists using ARRS funding, in less than 2 weeks.
Start Setup
New
The Complete ARRS Funding Guide
Everything you need to know about NHS Arrs Funding for 2025.
Read

Hire a remote pharmacist
by December 14

Save thousands of hours in pharmacist training, task allocation and prescription processing. Clinical Rx is the all-in-one remote pharmacist solution, ready to go in less than 2 weeks.
Start
 
Prescription Management
Medication Reviews
QOF Management
Discharge Letters
Clinical Supervision
Now
48-72 Hours
12-36 Months
6+ Months
2 Months
2-5 Hrs/Week
3-4 Hours
< 12 Months
1-5 Months
< 1 Week
Included in Contract
The All in One
Remote Clinical Pharmacist
Hand-off everyday clinical tasks using ARRS funding, in less than 14 days.
Prescription Management
17
Medication Reviews
17
Discharge Letters
17
QOF Support
17
LTC Reviews
17
Backlog Support
17
Supporting
Your Growth
Enjoy our tools, tips and techniques on how to 10x your clinical practice.
PCN Glossary
A-Z library of PCN terminology
17
Expert Guides
Learn from clinical experts
17
Case Studies
Hear from our partners
17
Calculators
See how much you can save
17
Clinical Rx © 2025
Terms
Privacy
Cookies Policy
Sitemap
{ "@context": "https://schema.org", "@type": "FAQPage", "mainEntity": [ { "@type": "Question", "name": "What does Chronic Disease Management mean?", "acceptedAnswer": { "@type": "Answer", "text": "Chronic Disease Management refers to the systematic approach to healthcare that focuses on managing long-term health conditions such as diabetes, hypertension, and asthma. In Primary Care Networks, it involves coordinated care delivery, regular monitoring, preventive interventions, and patient education to improve outcomes, reduce complications, and enhance quality of life for people with ongoing health challenges." } }, { "@type": "Question", "name": "How do Primary Care Networks deliver Chronic Disease Management?", "acceptedAnswer": { "@type": "Answer", "text": "Primary Care Networks deliver Chronic Disease Management through a team-based approach, bringing together GPs, practice nurses, clinical pharmacists, social prescribers, and other healthcare professionals. They implement structured care plans, shared protocols, regular reviews, and risk stratification to identify patients requiring different levels of support. Many PCNs also use remote monitoring technology, group consultations, and integrated care pathways to coordinate services across primary, community, and secondary care settings." } }, { "@type": "Question", "name": "What chronic conditions are typically managed within a PCN's Chronic Disease Management programme?", "acceptedAnswer": { "@type": "Answer", "text": "Chronic conditions typically managed within a PCN's Chronic Disease Management programme include diabetes, hypertension, coronary heart disease, chronic obstructive pulmonary disease (COPD), asthma, heart failure, stroke, atrial fibrillation, chronic kidney disease, depression, dementia, and osteoporosis. PCNs also often manage patients with multimorbidity (multiple chronic conditions), with services tailored to meet the complexity of their care needs." } }, { "@type": "Question", "name": "What are the benefits of effective Chronic Disease Management in Primary Care Networks?", "acceptedAnswer": { "@type": "Answer", "text": "Effective Chronic Disease Management in Primary Care Networks delivers numerous benefits, including reduced hospital admissions and A&E attendances, better control of conditions, improved patient outcomes and quality of life, enhanced patient experience through coordinated care, greater efficiency in healthcare resource utilisation, reduced health inequalities, and cost savings for the NHS. Patients benefit from having care closer to home with a team familiar with their individual needs and circumstances." } }, { "@type": "Question", "name": "How are patients involved in Chronic Disease Management within PCNs?", "acceptedAnswer": { "@type": "Answer", "text": "Patients are central to Chronic Disease Management within PCNs, actively participating through shared decision-making about treatment goals, personalised care planning, supported self-management, health education programmes, and sometimes peer support groups. Many PCNs use the Patient Activation Measure (PAM) to assess patients' knowledge, skills, and confidence in managing their health, tailoring support accordingly. Digital tools like apps and online platforms also enable patients to track symptoms, medication adherence, and communicate with their healthcare team." } } ] }