The national framework for the integrated prevention and management of chronic disease.

Due to an ageing population and improvements in healthcare, the prevalence of chronic disease (CD) is rising in Ireland and internationally. In Ireland, CD care is often characterised by siloed, reactive care, culminating in repeated hospital admissions. This is neither patient-centred nor sustainable. Health services need to evolve to meet changing population need. How can Irish health services meet population need in a sustainable way? The National Clinical Programmes (NCPs) in Ireland draw together healthcare professionals from primary and secondary care to improve specific areas within the health service. Public Health Practitioners (PHPs) have been central to the population health approach taken by the NCPs. Over the past decade, an integrated approach to CD care with an emphasis on prevention and population health has been advocated by PHPs, underpinned by a compelling epidemiological case. The use of a generic model of care for the prevention and management of CD, within an integrated approach to service delivery, is associated with positive health outcomes. The ‘‘National framework for the integrated prevention and management of chronic disease in Ireland’’ is a national clinical model that focuses on shifting the vast majority of CD care into the community. The Framework takes a generic approach to the prevention and management of four major CDs: type 2 diabetes; asthma; COPD; cardiovascular disease. It is now being implemented under PHP leadership. The sustained action of many PHPs over the past decade has resulted in the funding of this seminal programme. This project highlights the importance of working alongside Primary and Secondary Care Clinicians in achieving service reform. Key messages: This Framework provides an integrated approach to CD care and will transform service delivery. PHPs have a central role in the development and delivery of sustainable, evidence-based health services. [ABSTRACT FROM AUTHOR]