Chronic Disease Management in Primary Care [PHC-03-EN]

Chronic Disease Management in Primary Care [PHC-03-EN]

Non-communicable diseases — principally cardiovascular disease, type 2 diabetes, chronic respiratory conditions, and hypertension — account for more than 70 percent of premature mortality in the WHO European Region, a burden borne disproportionately by countries across the South Caucasus where primary health care systems are still consolidating their preventive infrastructure. In Georgia, national NCD registries and the Universal Healthcare Programme have expanded coverage, yet evidence from facility assessments consistently identifies a structural gap: most primary care settings manage chronic conditions episodically rather than systematically, responding to acute presentations while failing to identify and recall inadequately controlled patients between visits. This reactive model produces avoidable complications, unnecessary hospitalisations, and clinical outcomes that fall well below the standards set by JCI accreditation frameworks and the WHO Package of Essential Noncommunicable Disease Interventions (WHO PEN). Practitioners who can design and operate proactive chronic disease management systems are therefore not a specialist luxury but a core requirement for any primary care team seeking ASF accreditation or genuine population-level impact.

This course is grounded in the WHO PEN protocols, the Chronic Care Model (Wagner et al.), and the Quality and Outcomes Framework principles that underpin evidence-based primary care internationally, supplemented by ISO 9001 quality management principles as applied to clinical service design. Teaching is structured around real-world case scenarios drawn from family medicine and outpatient clinic settings, with each module linking clinical evidence directly to the operational tools — disease registries, recall algorithms, care plans, and measurement dashboards — that participants can implement immediately in their own practice. Content has been developed in alignment with Georgian Ministry of Labour, Health and Social Affairs clinical protocols and ASF accreditation assessment criteria, ensuring local regulatory relevance alongside international evidence standards.

By the end of this course, participants will be able to:

• Construct a condition-specific patient registry that enables proactive identification of all individuals with a defined chronic disease within a defined practice population, stratified by risk level and control status.
• Design a structured recall and follow-up system — including recall intervals, responsible team roles, and escalation triggers — consistent with WHO PEN and ASF accreditation standards.
• Implement a standardised care plan template incorporating patient-specific targets, self-management tasks, and scheduled review milestones for at least three priority NCDs.
• Apply validated clinical performance indicators — including HbA1c control rates, blood-pressure-at-target proportions, and inhaler technique assessment rates — to monitor chronic disease outcomes at the population panel level.
• Evaluate the quality of an existing chronic disease management programme against JCI and ASF accreditation criteria, identifying specific structural and process deficiencies.
• Demonstrate effective multidisciplinary care coordination by mapping team roles, communication protocols, and referral pathways for patients whose chronic condition management involves nursing, pharmacy, nutrition, or specialist input.

Who Should Attend

This course is designed primarily for family physicians, general practitioners, and primary care nurses working in ambulatory or outpatient settings who carry direct clinical responsibility for patients with one or more chronic conditions. It is equally relevant for primary care facility managers, quality officers, and clinical leads who are preparing their institutions for ASF accreditation review or implementing NCD programme improvements under the Universal Healthcare Programme. Practitioners at any career stage will benefit, though those with at least one year of primary care experience will find the operational modules most immediately applicable.

Course Structure

The course is delivered fully online through the GMJ Academy platform across five self-paced modules, with an estimated study commitment of eight to ten hours; each module concludes with a structured knowledge check, and a final case-based assessment must be passed at 75 percent or above to qualify for the GMJ Academy certificate of completion. Participants who successfully complete the course are eligible for CME/CPD credits in accordance with the requirements of the Georgian Medical Chamber.