Using care plans to better manage multimorbidity

Abstract

The care plan was used successfully to manage and prioritise multimorbidity. Downstream implications include improving efficiency in patient management, and better health outcomes for patients with complex multimorbidities.

Is Australian primary care practice equipped to provide multimorbidity care?

“…Hearing and responding to the patient voice within the clinical encounter, to ensure their priorities and preferences for care are considered and integrated, appears central to the provision of high quality multimorbidity care (135,136). Acknowledging that patients' goals and preferences may differ from those of their clinicians, possibly leading them to disengage with treatment advice (70,135), Stewart et al (137) argue effective care requires clinicians and patients to find "common ground" between their respective disease and illness informed perspectives.…”

“…Care plans have been emphasised as a mechanism for enhancing the provision of multimorbidity care by supporting patient-centred care (12,21,62,141,248,335), although in practice patients report diverse experiences and different levels of engagement in care planning processes (275,321,390,391). To achieve greater consistency in care planning and the resultant care plan broader system level interventions are required (136,392).…”

“…The trial involved significant investment, with multiple system level changes including: merging evidence-based guidelines; training primary care practice staff in goal setting and problem solving; changes to practice based information technology; and automating recall for review (136,392). A multiple condition care plan template, informed by clinical practice guidelines, was developed to support clinicians and patients to record and track changes across clinical data for all their conditions.…”

“…A multiple condition care plan template, informed by clinical practice guidelines, was developed to support clinicians and patients to record and track changes across clinical data for all their conditions. The template required extensive review of the patient's goals and preferences along with barriers to achievement; the development of multidisciplinary care arrangements; and established prompts for guidelinerecommended checks (136). In comparison with usual care, patients achieved significant clinical improvements in depression and cardiovascular disease risk (136).…”

“…The template required extensive review of the patient's goals and preferences along with barriers to achievement; the development of multidisciplinary care arrangements; and established prompts for guidelinerecommended checks (136). In comparison with usual care, patients achieved significant clinical improvements in depression and cardiovascular disease risk (136). Guidelinerecommended checks were also more frequently performed, multidisciplinary care arrangements and communications were well structured and managed, and patients' goals were comprehensively monitored (136).…”