Free Managing patients with multimorbidity
Lucy Archer Independent advanced nurse practitioner, Lucy Archer Healthcare Training and Consultancy, Colchester, Essex, England
Multimorbidity is becoming an increasing problem with more patients having two or more long-term conditions. This is putting an additional burden on healthcare resources while having a detrimental effect on the quality of patients’ lives. Clinicians need to consider how they can treat this cohort of patients better. This article will discuss the issues and challenges of dealing with multimorbidity and suggest how these patients can best be managed.
Primary Health Care. doi: 10.7748/phc.2018.e1386Citation
Archer L (2018) Managing patients with multimorbidity. Primary Health Care. doi: 10.7748/phc.2018.e1386Peer review
This article has been subject to external double-blind review and checked for plagiarism using automated softwareCorrespondence
Published online: 19 June 2018
Aims and intended learning outcomes
This article aims to help nurses better understand the management of multimorbidity and examine how the profession cares for patients with multiple long-term conditions.
After reading this article and completing the time out activities, nurses should be able to:
Multimorbidity exists when a person has two or more long-term conditions or health problems that cannot be cured. These health problems may include physical illnesses, mental health conditions, sensory impairment, learning disabilities, frailty, chronic pain and alcohol or substance misuse (National Institute for Health and Care Excellence (NICE) 2016). These ongoing health problems often require regular monitoring and treatment, as the symptoms and progression of the conditions can be controlled through medical management and lifestyle interventions.
Of the approximately 15 million people in the UK who have long-term conditions, 24% have more than one long-term condition and 20% have three or more (Department of Health (DH) 2012). These patients have increased mortality and poorer physical and psychological health outcomes (NICE 2016). They are also significant users of health resources – management of long-term conditions accounts for 50% of GP consultations and 70% of total health and social care spend (NHS England 2014). For these reasons service providers will need to consider how to best manage multimorbidity.
What causes multimorbidity?
There are a variety of reasons why patients experience multimorbidity. The prevalence of people having more than one long-term condition increases with age and social deprivation (Barnett et al 2012). In younger people, multimorbidity is usually linked to socioeconomic deprivation (DH 2012). Some long-term conditions are linked, as one can contribute to the development of another – for example, hypertension can increase the risk of stroke, chronic kidney disease, coronary heart disease and vascular dementia. Some diseases commonly occur together – having diabetes doubles the risk of developing cardiovascular disease (British Heart Foundation 2017), as high blood sugar levels can damage the artery walls, precipitating atherosclerosis and vascular damage.
Some people have multimorbidity because their conditions share a causative risk factor. For example, respiratory disease, cancer and cardiovascular disease are all linked to smoking. Some conditions also commonly occur with other chronic health problems – there is a high incidence of anxiety and depression with long-term conditions: about 20% of people with a long-term physical conditions have depression (NICE 2009a, 2009b); 30% of people with long-term conditions have mental health problems (Naylor et al 2012); and 46% of people with a mental health problem have a long-term condition (Naylor et al 2012).
Issues and challenges in managing multimorbidity
Time out 1
Using an example of a patient with multimorbidity you have cared for, what do you consider to be the issues and challenges in managing multimorbidity?
The logistics of managing multimorbidity depends on the conditions involved. Managing diseases that are closely related or have similar treatments is easier. For example, hypertension and coronary heart disease share treatment goals and management approaches, such as medication and lifestyle interventions.
The most challenging combination is a physical and a mental condition, as the treatments are usually vastly different and few clinicians are experts in dealing with both. Services for physical and mental health are also usually separate (Naylor et al 2016). There would be benefits to patients and service providers in integrating mental and physical health services. However, this will require the redesign of services and changes to educational curriculums, as well as funding streams (Naylor et al 2016).
Often one disease can dominate some or all the time in multimorbidity, but this can vary, further complicating management plans or decisions about who should treat the patient. Several clinicians or specialist services can be involved in management at any one time, which can confuse patients. Conflicting advice may be given and patients may be unsure whom to approach for advice and support.
Management of long-term conditions is usually guided by nationally agreed or recognised guidelines from generalist expert organisations, such as NICE and Scottish Intercollegiate Guidelines Network, or specific expert bodies such as the British Thoracic Society. However, these guidelines – and the services that are commissioned and developed to deliver care – are usually focused on single diseases so do not address the needs and challenges of multimorbidity.
In general practice, financial incentives for managing long-term conditions, such as the quality and outcomes framework, are based around single disease pathways, which impedes the effective management of multimorbidity. Computer systems are also not always able to take into account multimorbidity and patients are called for multiple annual reviews (Bower et al 2011).
Time out 2
What do you think might be the priorities of a person with multimorbidity? Compare these to what you think the priorities for a healthcare professional might be
Patients and clinicians often report a lack of time to manage multimorbidity effectively. Patients feel they are not managed holistically, as consultations often focus on one issue, so their needs are not met (Van der Aa et al 2017). This is usually because services focus on a single disease or condition and sometimes patients get conflicting advice from specialists. Clinicians say they have to prioritise patients’ problems and then manage them in order of seriousness until time runs out (Bower et al 2011). This is probably why patients do not feel their needs are being met. Clinicians focus on test results as an outcome measure, whereas the patient’s goal is usually a better quality of life.
Patients with multimorbidity struggle with this burden (Rosbach and Andersen 2017, Van der Aa et al 2017). As well as coping with symptoms and complex medication regimens, there is an emotional and financial burden. Multiple appointments, often for duplicate tests and investigations, are time-consuming and costly, as patients have to take time off work, travel to appointments or rely on relatives and friends for assistance. Frequent appointments also add to the psychological burden, as they constantly remind people of their conditions (Rosbach and Andersen 2017). Some patients reported that they limited their contact with healthcare professionals to preserve their autonomy (Mason et al 2016).
Multimorbidity often necessitates complex treatments, which patients find difficult to understand (Mason et al 2016, Rosbach and Andersen 2017, Van der Aa et al 2017). For example, to prevent deterioration of their condition, people with heart failure are advised to weigh themselves every day and titrate their diuretic therapy accordingly. This requires a basic understanding of the pathophysiology of heart failure, an understanding of the medication prescribed and the confidence to alter drug dosage. Patients’ ability to care for themselves can sometimes be undermined by comorbidity – for example, people with heart failure as well as mobility problems or poor vision will not be able to weigh themselves and titrate their medication accordingly.
A recurrent theme from patients is poor communication – they feel clinicians do not communicate well with them or other professionals involved in their care (Van der Aa et al 2017). Clinicians also report that they struggle to share information with other healthcare professionals involved in the management of people with multimorbidity (Smith et al 2010, Bower et al 2011).
Navigating the complex health and social care systems is another difficulty people with multimorbidity have highlighted, as they do not know where they should go for help and advice or what services are available to meet their needs (Mason et al 2016, Van der Aa et al 2017). For example, people with chronic obstructive pulmonary disease and heart failure may not know whether to contact their respiratory or cardiac nurses for advice when they are getting more breathless.
There is also a significant effect on the family and carers of those with multiple health problems. Carers report physical and emotional exhaustion, as well as not feeling valued by healthcare professionals (Mason et al 2016).
Multiple health problems tend to necessitate the prescription of multiple medications. Definitions of polypharmacy differ widely regarding the number of medications and duration of treatment, but it is most commonly considered to be the concurrent prescription of five or more medications (Masnoon et al 2017).
Polypharmacy is not necessarily an issue – if patients are prescribed correctly optimised, evidence-based medication regimens, appropriate polypharmacy improves patient outcomes (Masnoon et al 2017). However, polypharmacy can be problematic when the risk of harm to the patient from polypharmacy outweighs the benefits of the treatment – the increased drug interactions and side effects affecting patients’ quality of life and safety.
Complex drug regimens require the patient to have a good understanding of what they should be taking and when, as well as numerical skills and manual dexterity. Between one third and one half of all medications recommended for the management of long-term conditions are not taken as prescribed (NICE 2009a, 2009b). Some patients choose not to take the medication as they do not agree with the treatment or for financial reasons, such as the cost of the prescriptions; others do so unintentionally, often because of poor understanding or memory problems (NICE 2009a, 2009b). Concordance is also a continuum, as patients may take medication intermittently or in a way that they find acceptable or fits in with their lifestyle (Ross 2014) – for example, only taking diuretics if they are not going out.
Identifying people at risk from multimorbidity
Not all people with multimorbidity are at risk, but some will be. It is important that they are identified so that their complex needs can be managed appropriately. This can be done opportunistically when reviewing patients for other reasons, such as medication reviews or long-term condition clinics or when summarising the patient record.
Alternatively, a structured approach can be used to identify patients at risk. Appropriate searches using the electronic patient record can be useful (Box 1).
Practices have to use an appropriate tool, such as the electronic Frailty Index, to identify people with moderate to severe frailty, as they are at higher risk of adverse outcomes and have greater care needs (NHS England 2017a, 2017b). Many of them will have multimorbidity. There is a requirement to review these patients, assess their risk and then make appropriate interventions to reduce the risk (NHS England 2017a, 2017b).
Time out 4
Can you identify high-risk patients?
Use the searches suggested in Box 1 to identify high-risk patients in your area
What does good management look like?
Good management for patients with multimorbidity should address the concerns of clinicians, patients and carers, and improve patients’ outcomes (Box 2).
It is important to plan patients’ care, rather than just respond to crises (Smith et al 2010). Care of people with long-term conditions is ongoing so not all problems need to be dealt with at once. It is vital to assess patients’ individual needs and preferences and then negotiate treatment goals and priorities. The agreed management plan should include patient goals, current and previous medication and treatment, details of all the services involved, and information regarding self-management, as well as when to seek medical advice. By negotiating and planning care in this way, the focus shifts to the patients’ agendas rather than those of the clinicians.
With careful discussion and negotiation, clinicians can ensure that urgent issues are dealt with in a timely manner and meet the patients’ needs. For example, patients may be keen to improve their mobility and start an exercise programme, but if they have uncontrolled hypertension, that may need to be managed first.
People with multimorbidity have to manage their long-term conditions continuously. Patients who are supported in caring for themselves feel better, have increased control over their health, and are less likely to be admitted to hospital or experience depression (Mathers et al 2011). Effective self-management requires the patient to have sufficient knowledge and skills to manage their condition safely and to have support from clinicians when needed.
If there are several clinicians involved in a patient’s care, it is important that the management plan is shared with all concerned to improve and assist effective communication. Ideally, one clinician will be the named lead for the patient and coordinate the care. Shared records or access to each other’s records make this easier. If this is not possible, the patient should hold a copy of the management plan.
Something on which clinicians and patients agree is that to achieve good care, more time is needed to assess patients’ circumstances and needs, and to agree, action and monitor management plans (Smith et al 2010, Bower et al 2011, Van der Aa et al 2017). This includes longer consultations and more frequent reviews. Consideration also needs to be given on whether these reviews all need to be face-to-face and whether telephone consultations would be beneficial or appropriate. Some patients may prefer this approach if getting to appointments is difficult or painful, and the clinician may find this is a more effective use of their time and more flexible. The use of telehealth should also be considered, as it can enable remote monitoring of the patient and the sharing of information between professionals, and provide support and reassurance to the patient (Barbabella et al 2016).
If people with multimorbidity have patient reviews, rather than multiple disease-specific reviews, this could potentially release a significant amount of clinician time. It would also potentially reduce other aspects of duplication of care such as multiple blood tests. These patient reviews would necessitate an expert generalist approach rather than a specialist approach. However, this does not negate the roles of specialist practitioners, as they can be accessed for advice when needed (World Health Organization 2016).
There is sometimes a presumption that depression is linked to the physical condition and that by treating the physical disease, psychological well-being will improve (Bower 2011). This is not always the case, so it is important that the management of mental health is given the same priority as the management of physical health. All patients with long-term conditions should be screened for depression (Box 3). Once identified, depressed patients should be offered the appropriate support services.
Closer working between physical and mental health professionals and integrating care between mental health services and long-term conditions management could significantly improve many patients’ outcomes (Naylor et al 2012).
Effective management of multimorbidity uses the knowledge and skills of the whole multidisciplinary team, including pharmacists, physiotherapists, counsellors, palliative care services, dietitians and occupational therapists. Their specialist input can be a useful addition to patient management. However, it is important to ensure that the involvement of more health professionals does not further fragment care. This can be prevented by ensuring that all health professionals involved are included in and have access to the management plan.
It can be difficult for patients and carers to know where to go to access services, support and advice. Clinicians are not always aware of all the services available in their area, particularly if these are outside their scope of practice or speciality. To address this issue, Health Education England (2016) provided a competency framework to support the development of ‘care navigators’ whose role will be to help patients and their carers find support with long-term conditions, locate relevant services and get advice on issues such as finances. Care navigators will develop a directory of statutory and voluntary local services and useful sources of information and advice – these will be of use to clinicians as well as patients and their families. The development of the role of care navigator is expected to help patients and their carers to navigate through the complicated health and social care system. Health Education England (2016) has highlighted some examples of how this approach has improved the experience for patients and their carers in a variety of settings.
It is well recognised that supporting carers is instrumental in ensuring good outcomes for patients. Carers UK (2017) found that 42% of carers said that a break in their caring responsibility would enable them to care for their own health and reduce the burden of care, and that timely access to advice and information is vital in supporting carers and preventing them from reaching crisis point.
Effective medication reviews
Older patients and those with multimorbidity are at increased risk of adverse effects from their medication (Cumbria CCG 2013), so medication reviews are vital in ensuring good management. Effective medication reviews establish what medications patients are taking, including over-the-counter or herbal medications, how often they are taking these and if they are experiencing any adverse effects. The review should also monitor the effectiveness of the treatment – for example, whether it is controlling symptoms – and if the drug regimen or dose prescribed is evidence-based. Pharmacists can be a useful resource, providing medication reviews and supporting medication concordance (Smith et al 2010).
Appropriate medication regimens are an integral part of effective management to improve outcomes for people with multimorbidity. But concordance with treatment is not always good. Comparing what patients report they are taking each day with what was prescribed is a useful starting point, but sometimes asking patients how often they miss medication elicits a more accurate assessment of concordance. Establishing why patients are not taking their medication as prescribed requires good communication skills, open questions and active listening. Sometimes it may be necessary to prioritise certain medication to reduce patients’ risk of uncontrolled symptoms or deterioration of their condition.
Identifying problematic prescriptions, inappropriate prescription or medication that has been omitted is an important part of the medication review. STOPP/START (screening toolkit for older people’s potentially inappropriate prescriptions and to alert doctors to right/appropriate treatments) (NHS England 2017a, 2017b) is useful as it can identify prescribing issues and guide medical management. It suggests medication that should be discontinued in certain circumstances and combinations of drugs that are contraindicated. It also highlights drugs that should be prescribed in specific circumstances – for example, people with heart failure should have their prescription for a non-steroidal, anti-inflammatory drug stopped and be started on an angiotensin-converting enzyme inhibitor.
A medication review is an opportunity to ensure that appropriate monitoring, such as blood tests, is timely. This will reduce the chance of adverse effects and monitor the effectiveness of treatment.
To reduce the need for medication, it may be appropriate to consider non-pharmacological alternatives, such as increasing exercise or improving dietary intake, especially with those patients for whom concordance is an issue.
Multimorbidity is an increasing burden for patients, carers and clinicians. The management of people with multiple long-term conditions requires review, so that it can meet patients’ needs and reduce the burden of disease. Attention needs to be given to the complex difficulties of managing coexisting physical and mental health problems. Services for people with multimorbidity need to move away from a single disease-focused service, led by the needs of the clinician or service, to one that focuses on the needs of the patient and supports patients’ self-management.
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