Comprehensive Management of Multimorbidity

Identification and Assessment

The American College of Physicians recommends identifying patients with multimorbidity at risk of adverse events using prognostic models, either opportunistically during routine care or through systematic screening 1, 3
Patients with multiple conditions who take multiple medications face increased complexity in care management, according to the American Geriatrics Society 1, 2
The Mayo Clinic suggests considering patients with chronic multisymptom illness who may present with multiple poorly understood symptoms across different body systems 4

The American College of Physicians recommends eliciting patient preferences and expectations regarding their care, and engaging in shared decision-making with patients about treatment options and level of involvement 1, 2, 6
The Journal of Internal Medicine suggests discussing with patients the purpose of medication optimization to improve quality of life and function 5
Patients should be encouraged to express their personal values, aims, and priorities regarding treatment, according to the American Academy of Family Physicians 5

The American College of Physicians recommends applying guiding principles that optimize treatment benefits over possible harms 1, 2, 6
The Mayo Clinic suggests considering cognitive-behavioral therapy and mindfulness-based treatments for patients with chronic multisymptom illness 4
Exercise should be considered for patients with symptoms consistent with fibromyalgia syndrome, according to the American College of Rheumatology 4

The Journal of Internal Medicine recommends developing care plans that address ongoing medical and social care needs while focusing on enhancing social connectedness and community involvement 7
An individualized patient-held medication plan should be used, including specific information on drugs and instructions for usage, according to the American Geriatrics Society 7
Ongoing and adequate communication is essential, particularly around medicines and wider care plans, as suggested by the American Academy of Family Physicians 7

The Journal of Internal Medicine recommends reviewing and updating medication/care plans regularly to recognize and record changes in needs 7
Regular follow-up appointments should be scheduled to assess medication effectiveness and adverse effects, according to the American College of Physicians 5
Treatment effects and clinical parameters, as well as side effects, should be monitored at follow-up appointments, as suggested by the American Academy of Family Physicians 7

A multidisciplinary team approach should be implemented, especially involving clinical pharmacists when available, according to the American College of Clinical Pharmacy 5
Computerized decision support systems can support decision making and prescribing, but should not replace clinical judgment, as recommended by the American Medical Informatics Association 7
Regular self-assessment of the unit should be conducted to improve quality of care and service, according to the American College of Medical Quality 8