Identifying patients for tailored care
GPs should identify people with multimorbidity (two or more long-term conditions) who may benefit from a ‘tailored approach’ to their care – such as patients with both long-term physical and mental health conditions, the frail, people prescribed multiple medications (especially those on 15 or more) and those who frequently seek unplanned or emergency care .
This can be done opportunistically, but should also involve proactively searching electronic health records – which may include use of a validated tool like the QAdmissions tool.
Delivering a tailored approach
Agree an individualised management plan with the patient, including:
· goals and plans for future care
· who is responsible for coordination of care
· how the plan is communicated to everyone involved in patients’ care.
Explain that the purpose is to improve their quality of life is to find ways to reduce treatment burden and optimise their care. This may include identifying:
· treatments that could be stopped because of limited benefit;
· medicines with a higher risk of adverse events (eg, falls, fractures, confusion, GI bleeding, acute kidney injury);
· non-pharmacological alternatives to some medicines;
· alternative arrangements for follow-up to coordinate or optimise the number of appointments.
Use the database of treatment effects to find information on:
· effectiveness of treatments
· duration of treatment trials
· populations included in treatment trials.
Consider using a screening tool such as the STOPP/START tool in older people, to identify drug-related safety concerns and medicines the person might benefit from starting.
Ask if treatments for symptom relief are helping or causing any harms.
Consider stopping medicines that are supposed to offer prognostic benefit, especially if they have limited life expectancy or are frail
Discuss stopping bisphosphonates after three years, including patient choice, fracture risk and life expectancy in the discussion.