Entete 3

Managing patients with multimorbidity in primary care



By Emma Wallace and Susan Smith


Along with colleagues in the UK, we have recently published a Clinical Review on managing patients with multimorbidity in primary care in the BMJ [1]. The review outlines challenges for Family Physicians or General Practitioners (GPs) in care delivery. We identified areas where GPs experience difficulties in caring for patients with multimorbidity and suggest evidence-based practice management strategies:
1.    Disorganisation and fragmentation of care.
Identify patients as having complex multimorbidity and adopt a practice policy of continuity of care for these patients by assigning a named GP to the patient. Consider the following groups; a) Patients with ‘complex’ multimorbidity defined as ≥3 chronic conditions affecting ≥3 body systems; b) Patients with comorbid physical conditions and depression; c) Patients prescribed ≥10 medications; d) Patients who are housebound or resident in nursing homes.
2.    Inadequacy of current disease-specific guidelines.
At times, clinical judgement may mean an acceptance that in certain circumstances, pursuing stringent disease specific targets is unlikely to be beneficial and may in fact be harmful. Consider an approach of targeting function not disease and a focus on medicines management, including deprescribing where possible.
3.    Challenges in delivering patient centred care and barriers to shared decision making. Asking a patient at the outset of a consultation ‘What is bothering you most?’ or ‘What would you like to focus on today?’ can help prioritise management of aspects of care that will have most impact for the patient. Once patient priorities are identified, using available shared decision making tools may help support the process. Patient preference should guide the utilisation of lay-led self-management groups.
4.    Consultation time.
Consider adopting a practice policy of routine extended or ‘specific extended’ consultations for particularly complex patients. Ensure practice systems are in place to maximise the value of the GP consultation for both patient and doctor in reaching management decisions. Multidisciplinary team involvement is important and should be arranged where appropriate.

Reference
1) Wallace E, Salisbury C, Guthrie B, Lewis C, Fahey T, Smith SM. Managing patients with multimorbidity in primary care. BMJ 2015;350:h176.

One comment

  • 1
    catherine regan
    February 6, 2015 - 8:02 pm | Permalink

    that is a nice summary.
    At General Practice Training – valley to coast (vocational GP training program in NSW, Australia) we have been working on ways to teach this topic to our registrars. The initial approach was a multimorbidity matrix to get across a conceptual framework which included considering multiple drug / disease interactions, patient centred approach (doctor and patient agenda), continuity over time and linking to both guidelines and patient information. The aim was to engage but not scare registrars! We reported on this at AMEE in 2014. We progressed to a more linear template (but incorporating the same concepts) to use within practice in the Australian context and we are continuing to work on this.

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