1. Take a holistic approach
Diseases cannot be understood outside the context of the patient who suffers from them, and it is necessary to consider each patient’s co-existing physical conditions as well as their mental health and social circumstances, and interactions between these. Although a holistic approach is the bread and butter of generalism, and primary care is the key setting for this, there has been an increasing focus over the past decade on evidence-based medicine that is promoted by single-disease guidelines. Yet most patients seen in general practice have multiple chronic conditions and so a single-disease approach is not always appropriate.
2. Have a means of identifying the patients with multimorbidity in your practice
This is likely to involve some development of electronic medical records systems. As well as single disease registers, consider developing a multimorbidity register. Multimorbidity is usually defined as two or more long-term conditions and according to NICE can include:
- Defined physical and mental health conditions such as diabetes and schizophrenia.
- Ongoing conditions such as learning disability.
- Symptom complexes such as frailty.
- Sensory impairment such as sight or hearing loss.
- Alcohol and substance misuse.1
Polypharmacy is common in multimorbidity and can be used as a proxy measure to identify patients, which is explained in detail in the NICE guideline.
3. Focus on quality of life (QoL) as well as (and at times instead of) indicators of disease control
Improving QoL in the present may be more important to patients than aiming for longer life if the latter means they have to endure an excessive treatment burden from medication and medical interventions. When offering an approach to care that is appropriate to patients with multimorbidity, NICE suggests assessing:
- How the patient’s conditions and treatments interact and how this affects QoL.
- The patient’s individual needs, preferences, priorities, lifestyle and goals.
- The benefits and risks of following recommendations based on single-disease guidelines.
- Improving QoL by reducing treatment burden, adverse events and unplanned care.
- Improving co-ordination of care.
4. Diagnose and treat mental illness
Mental health problems are particularly common in multimorbidity. Patients with higher numbers of physical conditions are at increasing risk of common mental health problems such as depression and anxiety. Mental illness is often under-recognised and is associated with poor outcomes. In elderly patients depression and dementia often co-exist, and such patients usually have a high number of physical conditions as well.
5. Build the therapeutic relationship through continuity of care and developing effective consultation skills
The CARE approach provides a simple framework for consulting and can be used in training of healthcare staff.2 It has been used in a complex intervention for patients with multimorbidity living in areas of high deprivation called CARE Plus, which involves targeted longer consultations for multimorbid patients, with a care plan based on a patient-centred approach, support and training for practitioners, and additional self-management support for patients. This may be an effective and cost-effective approach in general practice.3 Of course, many other tools and approaches are also available, as outlined in NICE guidelines.
6. Use clinical judgment and wisdom
Do not slavishly follow guidelines that may not be appropriate to the patient in front of you. Guidelines are important but they are only that, and often do not consider the issues of multimorbidity.
7. Deal with polypharmacy by simplifying treatment regimens
Use medication aids to promote adherence, ensure that patients understand their treatments and stop prescriptions for treatments that are of limited value. NICE gives detailed guidance on this issue in multimorbid patients. Working with a pharmacist as part of your multidisciplinary team may be an efficient way to deal with polypharmacy and medication optimisation.
8. Consider offering longer consultations specifically for this group of patients
This could either be by always offering multimorbid patients more time or by allowing greater flexibility in the appointment system. This can be challenging, but can be hugely rewarding clinically and may be of major benefit to targeted patients.
9. Maximise continuity of care
Ensure that each patient who has burdensome multimorbidity is allocated a doctor who has overall responsibility for them. There are a number of ways of doing this, ranging from maintaining informational continuity through good record keeping in the electronic notes, to making every effort to ensure high-burden multimorbid patients see the same GP and nurse whenever they book an appointment.
10. Integrate the work of GPs and practice nurses
Sharing annual reviews, such as the doctor conducting a medical review at the end of a holistic assessment of the patient’s lifestyle, priorities and self-management goals by the nurse, is one way that the work of the primary care practitioners involved in the care of multimorbid patients can be integrated.
Professor Stewart Mercer is a GP and professor of primary care research at the Institute of Health and Wellbeing, University of Glasgow
- NICE. NG 56: Multimorbidity: clinical assessment and management. London: NICE; 2016
- Bikker A et al. Embracing empathy in healthcare. Radcliffe: London; 2014
- Mercer S et al. The CARE Plus study – a whole-system intervention to improve quality of life of primary care patients with multimorbidity in areas of high socioeconomic deprivation. BMC Medicine 2016;14:88