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Self-management support by region - HSE.ie

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Find a self-management support coordinator and services and programmes for adults with asthma, COPD, diabetes and heart conditions.

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These resources are to support healthcare professionals working with people living with specific long-term health conditions.

These conditions include:

Asthma

The Asthma Model of care for adults outlines the structure to follow to take care of patients with asthma or those at risk of getting it.
Asthma Model of Care (PDF, 5 MB, 67 pages)
Online asthma training

Online training for healthcare professionals who work with people with chronic respiratory conditions is avaialble in HSeLandD.

This course gives basic information about asthma and COPD:

You will learn how to help patients take care of themselves using:

asthma action plans

inhaler therapies

medicine support

To complete the module go to HSeLanD and search for 'asthma'.

Asthma Society of Ireland

The Asthma Society of Ireland has useful asthma resources.

These include:
Asthma resources - asthma.ie Inahalers and devices poster (PDF, 1.5 MB, 1 page)
For printed copies of the poster you can email reception@asthmasociety.ie.

Asthma Education Inclusion Project

This project provides resources about asthma.

These resources are for:
Asthma education inclusion project - asthma.ie Asthma education inclusion project - Traveller community - asthma.ie
Asthma adviceline

The free asthma adviceline offers education and support from asthma nurse specialists.

Phone: 1800 44 54 64

Monday to Friday, 9am to 5pm

WhatsApp nurse messaging service

Use this free text-based service to contact an asthma nurse with your asthma-related query.

When you send your first message, you will receive an initial automated response and one of the nurses will follow up within 72 hours.

WhatsApp: 086 059 0132

Register as a member

Register as a member to access a monthly newsletter and receive the latest updates and advice on asthma support, resources, and care.
Register a user account - asthma.ie
COPD

The model of care for COPD was created by the National Clinical Programme for COPD. It shows how health services are provided for individuals with COPD.
National Clinical programme for Respiratory End to End COPD Model of Care December 2019 (PDF, 2 MB, 86 pages)
Online COPD training

The HSE online training programme is for healthcare professionals who work with people with chronic respiratory conditions.

This course will give you a foundation in COPD and asthma:

You will learn how to help patients take care of themselves using:

COPD self-management plans

inhaler therapies

medicine support

To complete the module go to HSeLanD and search for 'COPD'.

Management of COPD - national clinical guidance

There is the national clinical guideline for caring for people with COPD.
Management of COPD - gov.ie
National Clinical Programme for Respiratory resources

The National Clinical Programme for Respiratory has COPD resources for healthcare workers.

These include:

pulmonary rehabilitation

COPD outreach

oxygen clinics

Pulmonary rehabilitation programme

The video-based education programme covers a range of topics.

These include:
Pulmonary rehabilitation education videos
COPD Support Ireland

COPD resources are available from COPD Support Ireland.

Resources include:

COPD and me booklet

COPD communication card

COPD inhaler posters

COPD resources - copd.ie
COPD adviceline

This is a freephone service for people who want to learn more about COPD.

It is for:

healthcare professionals who support people with COPD

people who would like to discuss their COPD with a respiratory nurse

people with COPD or their family members and carers

Freephone: 1800 83 21 46

Monday to Friday, 9am to 5pm

Type 2 diabetes

The National Clinical Programme (NCP) for Diabetes has developed resources which support the management of type 2 diabetes.
Diabetes resources Model of Integrated Care for Type 2 Diabetes Diabetic Foot Model of Care 2021 (PDF, 7 MB 52 pages)
Online Diabetic foot screening training

The diabetic foot screening module will show you how to do a:

diabetic foot screening

risk assessment

If foot screening is not part of your role, this course will help you understand:

what you need to consider about foot care when giving healthcare to people who have diabetes

information to give to people with diabetes to help them take care of their feet

To do the module go to HSeLanD. Search for 'diabetic foot screening'.

Training for nurses

The nursing management of adults with type 2 diabetes module aims to support nurses in the management of patients with type 2 diabetes.

To complete the eLearning module go to HSeLanD. Search for 'nursing management of adults with type 2 diabetes'.

Blood glucose testing

The NCP for diabetes has updated guidance on self-testing for people with type 2 diabetes.

Research has shown that blood glucose testing has a limited benefit for many patients who do not take insulin to manage their diabetes.
Blood glucose testing
Blood glucose test strips

The HSE Medicines Management programme has a list of blood glucose test strips to use. It includes the associated meters to use for adults with type 1 and type 2.
Blood glucose test strips
Nutrition and dietetic care guidelines

HSE Community dietitians developed these guidelines to support their clinical practice.

Community nutrition and dietetic care guidelines for the management of type 2 diabetes (PDF, 1.8 MB, 92 pages).

Diabetes Ireland

Information and a range of resources are available from Diabetes Ireland.

Diabetes Ireland runs webinars and events for people living with diabetes and for healthcare professionals.

Diabetes news is the official e-newsletter of Diabetes Ireland and contains all the latest news for the diabetes community.
News and monthly newsletter - diabetes.ie
Heart failure

The National Heart Programme launched this model of care in 2021.

This document outlines the guidelines for caring for patients with or at risk for heart failure.
Heart Failure Model of Care 2021 (PDF, 2.4 MB, 74 pages)
Online training

The The Introduction to Heart failure module provides an introduction to heart failure for all nurses working in both acute and community settings. It may also help other health and social care professionals involved in the care of patients with heart failure.

To complete the module go to HSeLanD. Search for ' Introduction to Heart Failure Module'.

Videos

A video by Dr Joe Gallagher for the Heart Failure Patients Alliance in conjunction with Croi and the Heartbeat Trust.
Heart failure signs, symptoms and living with heart failure (video)
A video by Dr Ken McDonald, a Consultant Cardiologist for the Heart Failure Alliance in conjunction with Croi and the Heartbeat Trust.
Heart failure (video)

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Resources by condition - for healthcare professionals - HSE.ie

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Resources and information for healthcare professionals about different long-term health conditions. These include asthma, COPD, heart failure and diabetes.

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Acute Conditions and Corresponding Specialists

1. Cardiovascular Emergencies (e.g., chest pain, arrhythmias, acute heart failure)

Cardiologist

Acute Cardiology Nurse Specialist

Emergency Medicine Specialist

Cardiac Physiologist

Radiologist (for imaging such as echocardiograms or angiography)

2. Acute Respiratory Conditions (e.g., asthma exacerbations, acute COPD, pneumonia)

Respiratory Consultant

Emergency Medicine Specialist

Respiratory Nurse Specialist

Pulmonologist

Physiotherapist (for airway clearance techniques)

3. Acute Neurological Events (e.g., stroke, seizures, traumatic brain injury)

Neurologist

Stroke Consultant

Acute Care Nurse Specialist in Neurology

Speech and Language Therapist (for immediate swallowing or communication issues)

Physiotherapist (for early rehabilitation)

4. Acute Gastrointestinal Issues (e.g., appendicitis, acute pancreatitis, gastrointestinal bleeding)

Gastroenterologist

Surgeon (general or gastrointestinal specialist)

Emergency Medicine Specialist

Dietitian (for immediate nutritional support)

5. Acute Diabetes Complications (e.g., diabetic ketoacidosis (DKA), hyperosmolar hyperglycemic state (HHS), severe hypoglycemia)

Endocrinologist

Diabetes Nurse Specialist

Emergency Medicine Specialist

Critical Care Specialist (for severe cases in ICU)

Dietitian (for immediate glucose stabilization and education)

Podiatrist (for diabetic foot ulcers that present acutely)

6. Acute Renal Conditions (e.g., acute kidney injury, nephritic syndrome)

Nephrologist

Acute Care Nurse Specialist in Renal Medicine

Critical Care Specialist (for dialysis or renal support in critical care)

7. Acute Infectious Diseases (e.g., sepsis, meningitis, severe pneumonia)

Infectious Disease Specialist

Microbiologist (for diagnosing and managing infections)

Acute Medicine Specialist

Emergency Medicine Specialist

8. Acute Orthopedic and Trauma Cases (e.g., fractures, dislocations, acute musculoskeletal injuries)

Orthopedic Surgeon

Trauma Specialist

Physiotherapist (for early mobility support)

Occupational Therapist (for splints and assistive devices)

9. Acute Psychiatric Conditions (e.g., severe depression, acute psychosis, suicide risk)

Psychiatrist

Crisis Intervention Nurse

Clinical Psychologist

Social Worker (for crisis intervention and social support)

10. Acute Pain Management (e.g., post-operative pain, acute neuropathic pain)

Pain Management Specialist

Anesthesiologist (for interventional pain relief)

Clinical Nurse Specialist in Pain

Pharmacist (for medication optimization)

11. Acute Pediatric Conditions (e.g., febrile seizures, dehydration, acute respiratory distress)

Pediatrician

Pediatric Emergency Medicine Specialist

Pediatric Nurse Specialist

Speech and Language Therapist (for feeding/swallowing emergencies)

12. Acute Ophthalmology Issues (e.g., retinal detachment, acute glaucoma, eye trauma)

Ophthalmologist

Ophthalmic Nurse Specialist

13. Acute ENT Conditions (e.g., tonsillar abscess, sudden hearing loss, airway obstruction)

ENT Specialist (Otolaryngologist)

Emergency Medicine Specialist

14. Acute Dermatological Conditions (e.g., severe eczema, drug reactions, cellulitis)

Dermatologist

Infectious Disease Specialist (if related to skin infections)

15. Acute Oncology Issues (e.g., febrile neutropenia, cancer-related emergencies)

Oncologist

Acute Care Nurse Specialist in Oncology

Palliative Care Specialist (for pain and symptom management)

16. Acute Endocrine Conditions (e.g., thyroid storm, adrenal crisis)

Endocrinologist

Emergency Medicine Specialist

Diabetes Nurse Specialist

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Chronic Diseases and Corresponding Specialists

1. Cardiovascular Diseases (e.g., hypertension, heart failure, coronary artery disease)

Cardiologist

Cardiac Rehabilitation Nurse

Clinical Nurse Specialist (CNS) in Heart Failure

Cardiac Physiologist

Dietitian (focused on heart-healthy diets)

2. Diabetes Mellitus

Endocrinologist

Diabetes Nurse Specialist

Podiatrist (focused on foot care for diabetics)

Dietitian (for glucose management and dietary guidance)

Ophthalmologist or Optometrist (for diabetic retinopathy screening)

3. Chronic Obstructive Pulmonary Disease (COPD) and Asthma

Respiratory Consultant

Respiratory Nurse Specialist

Physiotherapist (for pulmonary rehabilitation)

Dietitian (to support nutritional needs in respiratory health)

4. Chronic Kidney Disease (CKD)

Nephrologist

Renal Nurse Specialist

Dietitian (for kidney-friendly nutrition)

Social Worker (to support psychosocial aspects)

5. Arthritis and Musculoskeletal Disorders

Rheumatologist

Occupational Therapist (OT) (to enhance functional ability)

Physiotherapist (for joint mobility and pain management)

6. Chronic Pain

Pain Management Specialist

Clinical Psychologist (for managing mental health impacts)

Physiotherapist (for pain relief through movement)

Occupational Therapist (to manage daily activities despite pain)

7. Neurological Disorders (e.g., Parkinson’s disease, multiple sclerosis)

Neurologist

Clinical Nurse Specialist in Neurology

Speech and Language Therapist (for communication issues)

Physiotherapist (for mobility and coordination)

Occupational Therapist (to support daily living)

8. Cancer (Oncology)

Oncologist

Oncology Nurse Specialist

Radiation Therapist

Palliative Care Specialist

Clinical Psychologist (for mental health support)

9. Mental Health Disorders (e.g., depression, bipolar disorder, schizophrenia)

Psychiatrist

Clinical Psychologist

Community Mental Health Nurse

Occupational Therapist (for reintegration into daily life)

Social Worker (to address social determinants)

10. Obesity and Metabolic Syndrome

Endocrinologist

Bariatric Specialist Nurse

Dietitian

Physiotherapist

11. Liver Diseases (e.g., cirrhosis, hepatitis)

Hepatologist

Clinical Nurse Specialist in Liver Disease

Dietitian (for liver-friendly nutrition)

12. Chronic Inflammatory Conditions (e.g., Crohn’s disease, ulcerative colitis)

Gastroenterologist

Clinical Nurse Specialist in Gastroenterology

Dietitian (for managing nutritional deficiencies)

13. Stroke and Post-Stroke Rehabilitation

Stroke Consultant (Neurologist or Geriatrician)

Speech and Language Therapist

Physiotherapist (for movement recovery)

Occupational Therapist (for regaining independence)

Dietitian (to address swallowing difficulties)

14. HIV/AIDS

Infectious Disease Specialist

Clinical Nurse Specialist in HIV

Psychologist (for mental health support)

Social Worker (for advocacy and social care)

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Ethnic and Cultural Groups

Irish Travellers: A distinct ethnic minority in Ireland, often facing social exclusion, discrimination, and poor health outcomes.

Roma Community: Historically marginalized across Europe, facing barriers to healthcare, education, and housing.

Migrant Workers and Refugees: Particularly those in direct provision or undocumented, experiencing challenges with access to services and integration.

Asylum Seekers: Individuals awaiting refugee status, often housed in direct provision centers with limited autonomy and access to resources.

2. Economic and Socially Disadvantaged Groups

Homeless Individuals: People experiencing homelessness or housing insecurity, with increased vulnerability to physical and mental health issues.

3. Gender and Sexual Minorities

LGBTQ+ Community: Facing discrimination, stigma, and higher rates of mental health challenges.

Transgender and Non-Binary Individuals: Experiencing barriers to accessing healthcare tailored to their needs.

4. Women and Girls

Single Mothers: Often at a greater risk of economic and social disadvantage.

Victims of Domestic Violence: Facing systemic challenges in escaping abuse and accessing support services.

5. People with Disabilities

Physical Disabilities: Facing barriers in accessibility, employment, and social inclusion.

Intellectual and Developmental Disabilities: Experiencing exclusion from mainstream education and employment opportunities.

Mental Health Challenges: Individuals living with mental illness often face stigma and limited access to appropriate care.

6. Older Adults

Particularly those who are isolated, living in poverty, or without family support, often facing age-related discrimination.

7. Individuals with Substance Use Disorders

Struggling with addiction and often excluded from mainstream healthcare and social opportunities.

8. Rural Populations

People living in remote or rural areas, experiencing limited access to healthcare, education, and employment opportunities.

9. Indigenous and Minority Language Speakers

In Ireland, this could include those from the Gaeltacht regions or non-native English speakers.

10. Justice-Involved Individuals

People with criminal records or currently incarcerated, facing social stigma and barriers to re-entry into society.

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Tissue Viability Clinics: Focus on the prevention and management of wounds, including pressure ulcers and leg ulcers. Services are provided by specialist nurses trained in wound care.

Cardiac Rehabilitation Clinics: Assist patients recovering from cardiac events or surgeries. They offer supervised exercise programs, education on heart-healthy lifestyles, and psychological support.

Sexual Health Clinics: Offer services related to sexual health, including sexually transmitted infection (STI) testing and treatment, contraception advice, and sexual health education.

Mental Health Clinics: Provide assessment and treatment for various mental health conditions. Services may include counseling, psychiatric evaluations, and support groups.

Physiotherapy Clinics: Address musculoskeletal issues, offering rehabilitation exercises, manual therapy, and education on injury prevention.

Occupational Therapy Clinics: Help individuals improve their ability to perform daily activities through therapeutic interventions and adaptive strategies.

Speech and Language Therapy Clinics: Assist individuals with communication and swallowing disorders through tailored therapy programs.

Podiatry Clinics: Focus on foot health, providing care for conditions such as diabetic foot ulcers, ingrown toenails, and biomechanical assessments.

Dietitian/Nutrition Clinics: Offer dietary advice and nutrition plans for conditions like obesity, malnutrition, and food allergies.

Maternity and Infant Care Clinics: Provide prenatal and postnatal care, including health checks, breastfeeding support, and parenting education.

Addiction Services Clinics: Support individuals dealing with substance abuse through counseling, medical treatment, and rehabilitation programs.

Orthopedic Clinics: Address bone, joint, and muscle issues, offering assessments, treatments, and referrals for surgical interventions if necessary.

Dermatology Clinics: Manage skin conditions such as eczema, psoriasis, and acne through medical treatments and lifestyle advice.

National Screening Programmes:

1. BreastCheck:

Purpose: Early detection of breast cancer.

2. BowelScreen:

Purpose: Early detection of bowel cancer.

3. CervicalCheck:

Purpose: Early detection of cervical cancer.

4. Diabetic RetinaScreen:

Purpose: Early detection of diabetic retinopathy, a diabetes-related eye disease.

Additional Screening Considerations:

Prostate and Lung Cancer Screening: The National Screening Advisory Committee (NSAC) evaluates proposals for new screening programs, including prostate and targeted lung cancer screening. The introduction of new programs is based on rigorous criteria assessing viability, effectiveness, and appropriateness.

Health Screening for Migrants: Organizations like Safetynet provide health assessments, including tuberculosis (TB) screenings, for new migrants in Ireland, addressing healthcare access barriers and ensuring timely medical attention.

Safetynet Primary Care:

Services: Provides healthcare to homeless individuals, migrants, and other marginalized groups through mobile health units and fixed clinics.

HSE Social Inclusion Services:

Objective: Aims to reduce health inequalities and improve access to services for vulnerable and excluded groups, including those dealing with addiction, homelessness, and members of the Traveller and Roma communities.

Sláintecare Healthy Communities Programme:

Initiative: A cross-government effort to reduce health inequalities by providing health and wellbeing services in areas where such inequalities are most evident.

Inclusion Health Framework:

Development: The Department of Health is developing a framework to prevent and address health and social inequalities experienced by marginalized groups.

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Technology to support positive health outcomes

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Technology to support positive health outcomes

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Health Apps and Patient Portals

MyHealth Digital Platform:

Developed by the HSE, it enables patients to manage appointments, access COVID-19 testing, and order antigen kits.

MyChild App:

Provides guidance on child health and development, helping parents monitor milestones and health checks.

2. Telehealth and Remote Monitoring Tools

Telehealth Consultations:

Patients can consult healthcare providers remotely via video calls, particularly useful for follow-ups and managing chronic conditions like diabetes or hypertension.

Remote Monitoring Devices:

Devices such as glucometers, blood pressure monitors, and wearable fitness trackers sync with apps to enable patients to track their health metrics and share data with their care teams.

3. Chronic Disease Management Platforms

Diabetes Smart App:

A tool for individuals with diabetes to track blood glucose levels, log meals, and receive tips for managing their condition.

Asthma eLearning Platform:

Provides resources for asthma patients to learn techniques for managing symptoms and triggers.

HeartWatch:

Apps that allow cardiac patients to track heart rate, blood pressure, and medication schedules.

4. Electronic Prescribing (ePrescribing)

Enables patients to manage their prescriptions electronically, reducing the risk of errors and simplifying medication refills.

Patients can request medication renewals and access pharmacy services online.

5. Online Mental Health Support

Aware's Online CBT Programme:

Offers Cognitive Behavioral Therapy (CBT) resources for individuals dealing with anxiety and depression.

SilverCloud:

An online platform providing evidence-based mental health support for stress, sleep issues, and other mental health challenges.

Jigsaw Online:

Digital tools and resources for young people to manage their mental health and well-being.

6. Lifestyle and Preventive Health Apps

Quit Plan App (HSE):

Supports smoking cessation with tracking tools and motivational resources.

Sláintecare Healthy Ireland Initiatives:

Digital tools that promote healthy eating, exercise, and preventive health practices.

7. Individual Health Identifier (IHI) and Health Records

Patients can access their Individual Health Identifier (IHI) to link with their health data securely.

This integration helps patients view their health records, lab results, and care plans.

8. Support for Rare and Complex Conditions

Patient Advocacy Groups' Digital Tools:

Organizations like the Irish Cancer Society and the Irish Heart Foundation offer apps and digital resources for managing specific conditions.

Rare Disease Platforms:

Tools for patients with rare diseases to connect with support networks and track symptoms.

Benefits of eHealth for Self-Management:

Empowerment: Patients are more engaged in their care.

Convenience: Reduced need for in-person visits.

Personalization: Tailored insights and reminders for individual health needs.

Improved Outcomes: Better adherence to treatment and awareness of health metrics.

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Electronic Health Records (EHR):

The implementation of EHRs aims to replace traditional paper-based records with comprehensive electronic medical records, facilitating seamless sharing of patient information across healthcare providers. This transition supports better clinical decision-making and improved patient outcomes.

Individual Health Identifier (IHI):

The IHI is a unique identifier assigned to each individual, ensuring accurate identification and linking of health information across various services, thereby enhancing patient safety and data integrity.

ePrescribing:

This system enables the electronic transmission of prescriptions from healthcare providers to pharmacies, reducing errors and streamlining the medication dispensing process.

Telehealth Services:

The expansion of telehealth initiatives allows for remote consultations and monitoring, increasing access to care, particularly in rural areas, and reducing the need for in-person visits.

MyHealth Digital Platform:

Launched in response to the COVID-19 pandemic, this platform enables individuals to book PCR tests and order antigen test kits, marking a significant step in public-facing digital health services.

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Chiropody/Podiatry Services: These services focus on foot health, providing care for conditions affecting the feet and lower limbs.

Day Care Services: Day centers offer social and recreational activities, as well as health services, to support individuals in the community, particularly older adults.

Respite Care: Provides temporary relief for caregivers by offering short-term care services for individuals with specific needs, allowing primary caregivers to rest or attend to other responsibilities.

Mental Health Services: Community mental health teams deliver assessment, treatment, and support for individuals experiencing mental health issues, promoting recovery and well-being.

Community Healthcare Networks (CHNs): Ireland is establishing 96 CHNs, each serving approximately 50,000 people, to deliver integrated primary healthcare services, including GPs and various health professionals, aimed at improving service coordination and accessibility.

Enhanced Community Care (ECC): The ECC program focuses on bringing more services closer to where people live, enhancing community health services, and integrating care for chronic diseases and older persons.

Health Service Executive

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Core Healthcare Professionals

1. General Practitioner (GP) – Provides overall medical care and coordinates services.

2. Public Health Nurse (PHN) – Focuses on child health, elder care, and community health services.

3. Registered General Nurse (RGN) – Offers nursing care in community settings.

4. Advanced Nurse Practitioner (ANP) – Provides expert clinical care and advanced nursing practices.

5. Consultant Physician – Specializes in areas like geriatrics, chronic disease, or pediatrics, depending on the team.

6. Physiotherapist – Assists with mobility, rehabilitation, and physical health improvement.

7. Occupational Therapist (OT) – Supports individuals in maintaining independence and managing daily tasks.

8. Social Worker – Addresses psychosocial challenges and social determinants of health.

9. Dietitian – Provides nutritional guidance tailored to specific health conditions.

10. Pharmacist – Manages medication regimens and offers patient education on drug therapies.

11. Psychologist – Offers mental health assessments and therapy.

12. Speech and Language Therapist (SLT) – Treats communication and swallowing disorders.

13. Palliative Care Specialist – Provides end-of-life care and symptom management.

Additional Specialists

1. Community Midwife – Offers prenatal, delivery, and postpartum care.

2. Mental Health Nurse – Supports patients with psychiatric and psychological needs.

3. Healthcare Assistant (HCA) – Provides personal care and assists with daily activities.

4. Case Manager – Coordinates services for patients with complex care needs.

5. Chronic Disease Specialist Nurse – Focuses on managing conditions like diabetes, COPD, and cardiovascular diseases.

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General Practitioner (GP) – Provides medical care and manages overall health.

Practice Nurse – Offers nursing care, health promotion, and chronic disease management.

Public Health Nurse (PHN) – Focuses on community and public health, including child health and immunizations.

Community Registered General Nurse (CRGN) – Provides nursing care in the community for patients with medical or post-hospital needs.

Physiotherapist – Assists with mobility, rehabilitation, and physical health.

Occupational Therapist (OT) – Supports individuals in maintaining independence in daily activities.

Social Worker – Addresses social determinants of health and supports families.

Speech and Language Therapist (SLT) – Helps individuals with communication and swallowing difficulties.

Dietitian – Provides nutritional advice for health promotion and disease management.

Psychologist – Offers mental health support and therapy.

Pharmacist – Advises on medication management and safety.

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ICPOP Kerry

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Pulmonary rehab

Diabetic nurse

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Social prescribing in your area

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Excellent

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Physio

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ICPOP

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Diabetes care

Weight management clinic

Venesection clinic

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Social inclusion team tallaght hospital

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Frailty ANP