Chronic Disease Management

CHRONIC DISEASE MANAGEMENT

If you have one of the following conditions, we would like to see you on an annual basis to review your condition:

• Asthma / Chronic Obstructive Pulmonary Disease (COPD)
• Coronary Heart Disease, Atrial Fibrillation, Heart Failure and High Blood Pressure (Hypertension)
• Diabetes
• Non Diabetic hyperglycemia
• Dementia
• Learning Disabilities
• Mental Health
• Rheumatoid Arthritis
• Stroke and Transient Ischemic Attacks (TIAs)

An Annual Review may include blood tests and is required for all patients with a chronic disease. The purpose of an annual review is to ensure patients are taking the right medication and receiving the best possible care for their condition(s).

Our aim is to see our patients in the month of their birthday. Our annual review service includes a reminder for our patients when their annual review is due, although we do encourage patients to take an active role in helping to manage their own conditions, so if your birthday has passed and you have not received a letter, please do contact us to book yourself in.

The majority of our annual reviews are carried out by our nursing team. You may need an appointment: with a Healthcare Assistant and one with the Practice Nurse. Contact our reception team on 01803 553558. The reception team will advise accordingly and book your appointment(s) with the most appropriate clinician(s).

Our invite system for annual reviews is based on your month of birth. you will be contacted 2 times each year.  If you have not had an annual review since the 1st of April each year, you will receive your first invite within a couple of months of your birth month. If you do not book an appointment for your annual review, you will receive a second invite roughly 1-2 months after the initial invite.

It is important to attend your review appointment so we can ensure your condition is properly controlled and managed. If you run out of your repeat medication and have not had a review, we may not be to re-authorise your repeat medication.