Multimorbidity challenges the traditional medical model of healthcare, which has customarily focused on the ‘one’ disease model. Instead, multimorbidities have a tendency to ‘cluster’ according to conditions (eg cardio-metabolic conditions, osteoarthritis).
Most research to date has focused on a specific disease and pathology as standalones. Extrapolating effective interventions to the management of complex comorbidities is often problematic. Available guidelines and resources are often single-disease specific, and have to evolve to encompass the challenges of multimorbidity.2 Optimum management therefore challenges the traditional model of care.
Actual disease burden and polypharmacy are specific challenges for the patient, carers and healthcare providers.
Unplanned care is common and mitigating circumstances need regular appraisal with all the members of the patient’s healthcare team (refer to Part B. Collaboration and multidisciplinary team-based care ).
A further complicating factor is cognitive decline; dementia is the single greatest cause of disability in Australians aged ≥65 years (refer to Part A. Dementia). Depression is also present in approximately 30% of this group of patient population (refer to Part A. Mental health).
Role of general practice in multimorbidity
GPs have a critical role in the coordination of care of all patients, especially older patients whose care is often more complex and challenging. Appropriate time needs to be allocated to seeing the patient to reflect their complexity, and shared decision making with the patient and carers should be optimised. Risks and benefits of any intervention needs open and frank discussion. Refer to Box 1 for a list of questions to consider before doing any tests, treatments or procedures.3
Box 1. Five questions to consider before doing any tests, treatments or procedures
- Do you really need to perform the test or procedure?
- What are the risks of performing the test or procedure (eg side effects, false positive or negatives)?
- Are there simpler and safer options (eg lifestyle changes such as exercise and healthy eating)?
- What happens if the test, treatment or procedure was not performed?
- How much does it cost (eg less expensive tests, generic medications, insurance cover)?
Continuity of care, ideally with the same GP or GPs within the same general practice, has been associated with improved outcomes, and is associated with lower rates of hospital presentation.
A discussion around managing the effect of the comorbidities on quality of life and day-to-day functionality is paramount. It is important to ask what the aim of a particular intervention is before starting the intervention.
This discussion will help facilitate shared decision making and promote discussions around quality-of-life issues, and advance care planning. Formal documentation reflecting the conversation/consultation should be available to all relevant parties. This is especially critical on admission to an RACF.