Managing patients with multimorbidity in primary care

Care of multimorbid patients is complex. Clinicians managing patients with multimorbidity often find themselves challenged on many levels due to complexities involved in clinical management decisions; inadequacy of good evidence for making informed, shared decisions; and time constraints.

Clinicians should keep in mind the following when managing patients with multimorbidity:

• think holism - consider physical, mental as well as social condition when managing a patient
  
  
• consider managing the functional decline of the patient and shared risk factors (blood pressure and smoking cessation) rather than diseases
  
  
• stringent disease specific targets is unlikely to be beneficial or might be even harmful in certain circumstances
  
  
• assess and treat for depression and anxiety
  
  
• use clinical judgement in the decision making process (rather than follow guidelines which may not be appropriate for the patient)

Several interventions have been proposed to improve healthcare in this patient group.

• provide continuity of care with one GP, where possible
  
  
• care coordination with specialist (multidisciplinary)
  
  
• promote patient centred care
  • share decision making - include patients in the management in order to target the aspects of care that will have the most impact on patients e.g. - at the beginning of a consultation inquire from the patient about - "What is bothering you most?" or "What would you like to focus on today?"
  • self management – although there are mixed results about the benefits of self management, it can be considered in patients expressing an interest in group based support
    
    
• extended consultation time
  • consider for complex patients
  • "specific extended consultations" will help deal with issued faced in the management of chronic diseases
  • maximise value of the consultation time (both patient and doctor) by adopting practice systems e.g. - meeting with the practice nurse before the consultation with the GP
    
    
• simplify treatment regimens to minimise polypharmacy
  • NICE state:
    • use an approach to care that takes account of multimorbidity for adults of any age who are prescribed 15 or more regular medicines, because they are likely to be at higher risk of adverse events and drug interactions
    • consider an approach to care that takes account of multimorbidity for adults of any age who:
      • are prescribed 10 to 14 regular medicines
      • are prescribed fewer than 10 regular medicines but are at particular risk of adverse events
        
        

Reference:

• (1) Wallace E et al. Managing patients with multimorbidity in primary care. BMJ. 2015;350:h176
• (2) NICE (September 2016) Multimorbidity: clinical assessment and management