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Management of multiple long term conditions
Information on supporting patients who are living with 2 or more long terms conditions (multimorbidity).
About multimorbidity
As our population ages, more people are living longer with multiple long term conditions (multimorbidity). A long term condition is any ongoing, long term or recurring condition that has a significant impact on someone's life.
The UK's National Institute for Health and Care Excellence (NICE) defines multimorbidity as 2 or more long term conditions which may include:
- physical and mental health conditions such as diabetes or schizophrenia
- a learning disability
- groups of symptoms that happen together such as frailty or chronic pain
- sensory impairment such as loss of sight or hearing
- alcohol or substance misuse.
Multimorbidity guidelines — NICEexternal link
Multimorbidity is associated with:
- reduced quality of life
- higher mortality
- use of multiple medicines (polypharmacy)
- a high treatment burden for the patient
- higher rates of adverse drug events
- greater use of health services
- greater use of unplanned care.
Multimorbidity in Aotearoa New Zealand
In New Zealand, life expectancy is increasing, but:
- 20 to 30% of the years of life gained over the last 25 years are lived in poor health
- multimorbidity affects 1 in 3 adults
- more than 60% of people aged over 65 have 2 or more long term conditions.
The most common conditions affecting people with multimorbidity are:
- gastric acid disorder (19.6%)
- reactive airway disease (16.8%)
- cardiovascular disease (16.0%).
Health and Independence Report 2024 — Ministry of Healthexternal link
Preventing multimorbidity
The main strategies for preventing the development of multiple long terms conditions include:
- getting enough exercise
- good nutrition
- drinking alcohol in moderation
- stopping smoking
- supportive conversations that help people explore their own reasons for making change
- treating hypertension and high cholesterol
- referrals to community providers for support
- green prescriptions.
Managing multimorbidity
Supporting people with multimorbidity to manage their conditions requires requires multiple approaches.
There are risks to treating each condition as a single disease including:
- using multiple medicines at the same time leading to drug-drug or drug-disease interactions
- contradictory recommendations
- high treatment burden on the patient
- inattention to social and personal context
- failure to align care with personal goals and preferences.
(Source: Tinetti et al 2004, NEJM 351, 2870-74)
The NICE multimorbidity guidelines include recommendations around optimising care for adults with multiple long term conditions. This includes working with them to improve their quality of life by:
- reducing the use of multiple medicines
- reducing the number of appointments
- reducing unplanned care
- improving coordination of care across services.
Multimorbidity guidelines — NICEexternal link
People with multimorbidity who will benefit from improved management include:
- people finding it difficult to manage their treatments or day to day lives
- people receiving care and support from multiple services
- people with complex physical and mental health needs
- frequent users of after-hours or emergency care
- people on multiple medications.
People with multimorbidity can be identified:
- during consultations about something else
- proactively such as through PHO level risk stratification tools and practice-initiated polypharmacy audits
- through a review of their discharge summaries (either a proactive audit or reactive when they come into the practice)
- through frailty assessments (when well).
Frailty assessments can be:
- informal, such as a walk down the corridor
- formal, using tools such as the Clinical Frailty Score on HealthPathways.
Steps in applying a multimorbidity approach
There are 5 steps in applying a multimorbidity approach to healthcare.
1
Discuss the purpose of this approach
Taking a multimorbidity approach will improve a person’s quality of life.
A multimorbidity approach aims to:
- get the most out of current treatments
- review treatment and follow-up arrangements that are burdensome
- consider whether alternatives could better meet the person's needs and goals.
1
Discuss the purpose of this approach
Taking a multimorbidity approach will improve a person’s quality of life.
A multimorbidity approach aims to:
- get the most out of current treatments
- review treatment and follow-up arrangements that are burdensome
- consider whether alternatives could better meet the person's needs and goals.
2
Establish disease and treatment burden
Establish the disease and treatment burden by considering how a person’s health problems affect their day to day life and their mental health and wellbeing. Consider the:
- effect treatments have on their daily life
- number and frequency of different appointments
- number of medications and any side effects
- existence of depression and anxiety
- effectiveness of any chronic pain management.
2
Establish disease and treatment burden
Establish the disease and treatment burden by considering how a person’s health problems affect their day to day life and their mental health and wellbeing. Consider the:
- effect treatments have on their daily life
- number and frequency of different appointments
- number of medications and any side effects
- existence of depression and anxiety
- effectiveness of any chronic pain management.
3
Establish patient goals, values and priorities
Ask how much whānau involvement people want in any planning and ongoing treatment.
Either with the patient alone, or together with their whānau, consider and discuss their:
- goals
- values and priorities for their health
- views on quality versus quantity of health
- views on the benefits and harms of medications.
3
Establish patient goals, values and priorities
Ask how much whānau involvement people want in any planning and ongoing treatment.
Either with the patient alone, or together with their whānau, consider and discuss their:
- goals
- values and priorities for their health
- views on quality versus quantity of health
- views on the benefits and harms of medications.
4
Review benefits and risks of medications and other treatments
Discuss the overall potential harms and benefits of preventive treatments with the person in the context of their expected life span. Take their views of harms and benefits into account.
4
Review benefits and risks of medications and other treatments
Discuss the overall potential harms and benefits of preventive treatments with the person in the context of their expected life span. Take their views of harms and benefits into account.
5
Agree an individualised care plan
An individualised care plan includes goals and plans for the person's future healthcare.
Advance care planexternal link
When completing an advance care plan, you should include:
- who is responsible for care coordination
- consideration and decisions about starting, stopping, changing medications
- follow-up regimes
- when to review the plan
- an acute care plan (what to do if unwell).
Decide how the plan will be shared across everyone involved in the person’s care.
5
Agree an individualised care plan
An individualised care plan includes goals and plans for the person's future healthcare.
Advance care planexternal link
When completing an advance care plan, you should include:
- who is responsible for care coordination
- consideration and decisions about starting, stopping, changing medications
- follow-up regimes
- when to review the plan
- an acute care plan (what to do if unwell).
Decide how the plan will be shared across everyone involved in the person’s care.
Summary of steps
Consider what to do differently.
- Ask them ‘what matters to you?’
- Think about their social and mental wellbeing as well as their physical health.
- Check they have a care plan. If not, who in your team is best placed to help with this?
- Look at their medication list — what is unnecessary and what is missing?
- Check they have an advance care plan. If not, who in your team is best placed to help with this?