Conceptual Development of a Patient-Centered Consultation Framework for Multimorbidity Management in Primary Care (CARESTEP)

Abstract

Multimorbidity management in primary care faces significant challenges, including conflicting disease-specific guidelines, fragmented care, and suboptimal patient engagement. To address these barriers, we introduce the CARESTEP, a patient-centered consultation framework designed to facilitate the management of patients with multimorbidity in primary care. CARESTEP encompasses 8 integrated components, including Comprehensive review, Alternatives, Risk-benefit analysis, Engagement, Shared decision-making, Teaching, Evaluation and Planning. The framework systematically incorporates biomedical, psychosocial, and functional dimensions to facilitate holistic, individualized care. It emphasizes the need to assess treatment burden, generate feasible therapeutic options, and conduct structured risk-benefit analysis as the foundation for shared decision-making. CARESTEP also promotes tailored patient education, addresses implementation barriers, and fosters sustainable self-management through dynamic follow-up planning. CARESTEP provides a conceptual yet practical framework that explicitly guides primary care physicians through each decision point in complex consultations. We also used several cases to illustrate the key steps of CARESTEP, and further validation of its impact on patient outcomes and cost-effectiveness in diverse settings is warranted.

Introduction

Multimorbidity, defined as the co-occurrence of 2 or more chronic conditions in an individual, affects approximately 33% of the global population and over two-thirds of older adults, with its prevalence continuing to rise rapidly. ¹ Managing multimorbidity in primary care settings presents considerable challenges, as primary care physicians (PCPs) face substantial difficulties in making optimal clinical decisions during consultations for patients with multimorbidity. ² This complexity arises because multimorbidity management is highly individualized, yet PCPs often operate with limited patient information, lack comprehensive decision-making frameworks, and frequently rely on previous clinical experience or single-disease evidence and guidelines that may not adequately address the intricate interactions between multiple conditions and medications. ³ While existing consultation frameworks such as the Ariadne Principles and SHERPA provide valuable guidance for PCPs managing multimorbidity, they are often overly general and fail to account for the staged nature of multimorbidity management, potentially limiting their practical applicability and implementation in routine clinical practice.^4,5

To address these specific gaps, we therefore developed CARESTEP, a patient-centered, adaptable consultation framework designed for multimorbidity management in primary care. Its development followed a sequential, multi-method process consisting of: (1) a systematic literature review to synthesize existing consultation frameworks and identify core principles; (2) a modified Delphi study with a multidisciplinary expert panel that identified and prioritized 10 high-priority consultation challenges through iterative consensus building; and (3) the incorporation of formative feedback from a network of 426 primary care physicians to evaluate and improve the framework’s steps (see Supplemental File). CARESTEP integrates a multi-stage approach comprising 8 sequential steps: comprehensive review, alternatives, risk-benefit analysis, engagement, shared decision-making, teaching, evaluation and planning. It is conceptualized as a triangular process (Figure 1), structured around 3 dynamic phases: option appraisal, collaborative deliberation, and plan implementation. This structure guides a sequential yet adaptable consultation, which iterates conditionally upon a change in patient status to accommodate the evolving needs of multimorbidity care.

Figure 1.

The CARESTEP framework. This framework structures multimorbidity consultation into 3 phases: pre-decision phase (C, A, R), decision-making phase (E, S), and post-decision phase (T, E, P). Solid arrows indicate sequential progression, and a dashed return arrow loops back from the post-decision phase to the pre-decision phase to indicate continuous re-evaluation if condition changes.

CARESTEP is designed for flexible, longitudinal application rather than as a rigid protocol. The initial consultation comprehensively addresses all steps, while subsequent follow-ups efficiently target only components requiring updates, thus minimizing time burden without compromising care continuity. This paper introduces the core principles of the CARESTEP framework, with key steps illustrated through 4 case examples (see Supplemental File) that reflect real-world constraints.

Key Stages of the CARESTEP Framework

Comprehensive Review

The initial step of the CARESTEP framework emphasizes conducting a thorough, multi-dimensional review that encompasses the full spectrum of factors influencing multimorbidity management. It involves 3 key domains: clinical review (all diagnosed conditions and medications, investigations, and potential drug-disease/drug interactions), functional assessment (daily living, cognitive function, mobility including disability-related needs, and overall quality of life), and psychosocial evaluation (social support networks, financial constraints, cultural background, and mental health status).

When reviewing patients’ medical history, PCPs adopt a holistic interviewing approach that allows patients to narrate their illness experience while gathering information across all domains. The review explores how multiple conditions interact and impact the patient’s daily life. For instance, when consulting a patient with diabetes, hypertension, and osteoarthritis, the physician evaluates how joint pain affects physical activity, medication adherence, and overall diabetes management. It also involves identifying the patient’s treatment burden—the workload of healthcare and its impact on patient functioning and well-being. ⁶ Understanding treatment burden is crucial as it often influences patient adherence and quality of life more significantly than individual disease severity. ⁷ Similarly, for a patient with visual impairment, the assessment would explore how this impacts medication management or glucose monitoring.

Alternatives

PCPs synthesize information from the comprehensive review and generate a range of therapeutic options (pharmacological and non-pharmacological interventions) that consider practical constraints and evidence-based recommendations for each condition. Pharmacological alternatives include medication options with different mechanisms of action, dosing regimens, and side effect profiles. Non-pharmacological alternatives include lifestyle modifications, behavioral interventions, rehabilitation programs, and assistive devices that may reduce medication burden while improving overall health outcomes.

The intensity and timing of interventions need to be considered when the alternatives were generated. This includes stepped-care approaches where less intensive interventions are considered first, as well as scenarios where more intensive initial treatment might be necessary given the patient’s clinical complexity. Resource-based alternatives form another crucial consideration, as PCPs must work within the constraints of available healthcare resources. This includes considering treatment options that are accessible, affordable, and feasible within the local healthcare system. ⁸ The internal deliberation process prepares the groundwork for subsequent decision-making by ensuring that PCPs have thoroughly considered the available treatment options informed by evidence, clinical expertise, and practical constraints. This process explicitly notes practical constraints such as drug affordability, formulary availability, access to allied health programs, and scheduling simplicity to ensure generated options are realistic and implementable.

Risk-Benefit Analysis

For each treatment alternative initially identified, PCPs analyze their potential risks and benefits, weighing the potential advantages and disadvantages of each option across multiple dimensions, considering both quantitative evidence and qualitative factors that influence treatment outcomes. The risk-benefit analysis begins with clinical efficacy evaluation, where PCPs assess the expected therapeutic benefits of each alternative based on available evidence. ⁹ For multimorbid patients, the physicians analyze the potential for synergistic benefits when treatments address multiple conditions simultaneously.

The analysis of risks includes potential adverse effects, contraindications, and drug-drug/disease interactions, considering the cumulative risk of adverse events when multiple interventions are combined. Meanwhile, whether the treatment burden is proportionate to the expected clinical benefit is considered. Both short-term and long-term implications of each alternative should be assessed that interventions provide immediate symptom relief versus long-term disease modification, and whether initial risks may be justified by future benefits. The analysis also incorporates patient-specific factors (eg, age, functional status, cognitive capacity, and life expectancy) that modify the risk-benefit profile of each intervention. For instance, aggressive cardiovascular risk reduction may be less beneficial in patients with limited life expectancy or severe functional decline. ¹⁰

Engagement

Before making decisions from the alternatives, there is a need for encouraging patients to participate deeply in the consultation process, creating a supportive environment that builds patients’ confidence and motivation for participation. Establishing therapeutic rapport between PCPs and patients is important to engage patients effectively. This involves using empathetic communication techniques, acknowledging the challenges patients face, and validating their concerns and frustrations. Trust-building is particularly crucial in multimorbidity management, as patients often have complex relationships with the healthcare system and may have experienced fragmented or conflicting care in the past. ¹¹

However, many patients face barriers to participation that need to be addressed, including health literacy limitations, previous negative healthcare experiences, or feelings of overwhelm when facing complex medical decisions. ¹² Furthermore, cultural backgrounds and health beliefs must be considered, necessitating culturally adapted explanations and a respectful approach to individual preferences to fully support engagement. Patient’s communication preferences, language needs, and cognitive capacity should be assessed by physicians to make appropriate adjustments and ensure effective engagement. Once barriers are identified and addressed, PCPs emphasize that decision-making is a collaborative process where medical expertise and patient experience complement each other rather than compete, clarifying that patients’ preferences, concerns, and even disagreements are crucial for developing effective treatment plans. This supportive communication enables patients to express their authentic thoughts and feelings without fear of judgment or dismissal.

Shared Decision-Making

In the shared decision-making process, PCPs and patients discuss each potential treatment option to jointly determine the most appropriate therapeutic approach based on the prioritized health problems and treatment goals. This process transforms the physician’s alternatives and risk-benefit considerations into a transparent, interactive dialog that incorporates patient values, preferences, and circumstances into the treatment regimen. Physicians present the treatment alternatives in an accessible and balanced manner, explaining each option’s potential benefits, risks, and requirements using plain language to provide patients with sufficient information to make informed choices. Risk-prediction tools and decision aids are recommended as they present the potential benefits and risks of treatment more intuitively and scientifically. ¹³

The complexity of multimorbidity requires PCPs to help patients understand how different treatment choices might interact and influence their overall health. Reaching consensus often requires iterative discussions where initial preferences are explored, concerns are addressed, and options are refined based on emerging perspectives. PCPs may revisit and reconsider alternatives as new information emerges about patient preferences or as patients gain better understanding of different choices. The shared decision-making process also addresses practical implementation considerations that may influence treatment success. This includes discussing how chosen treatments will be monitored, what support systems are needed for implementation, and how decisions might be revisited if circumstances change. When caregivers are present, their perspectives and concerns could be incorporated into the discussion. ¹⁴ Note that the agreed-upon treatment plan needs to be confirmed as a true consensus by physicians who explicitly confirm that patients understand and feel comfortable with the chosen approach, and that they feel prepared to implement. The decision-making process concludes with patients expressing genuine commitment rather than mere compliance with physician recommendations.

Teaching

Following the determination of decisions, PCPs then provide patients with the knowledge and skills necessary to effectively implement their agreed-upon treatment regimen and maintain optimal self-management. This teaching process transforms the shared decisions into actionable, sustainable health behaviors. It begins with confirming patient understanding of how the chosen treatment plan addresses their various conditions. When teaching medication use, PCPs ensure patients understand the purpose, dosing, timing, and potential side effects of each prescribed medication. This education extends beyond basic instructions to include practical strategies for medication management, such as organizing pill boxes or setting reminders, and identifying warning signs of problems that need to contact their healthcare providers.

Education is adapted to literacy and capability using brief written or pictorial materials, demonstrations, and actionable strategies that fit daily life, such as practical guidance for healthy eating during social occasions. ¹⁵ It also requires careful consideration of functional limitations and safety concerns common in multimorbidity. For example, PCPs are expected to provide specific, achievable recommendations of physical activities that account for conditions such as arthritis, heart disease, or balance problems that may limit certain types of exercise.

Evaluation

The evaluation process serves as a quality assurance checkpoint that determines whether patients are able to manage their multimorbidity, while identifying areas that require support or treatment modification. The teach-back method is recommended to be used to verify comprehension where patients are asked to demonstrate their knowledge by explaining key concepts in their own words. ¹⁶ If gaps in understanding are identified, immediate re-education using simplified explanations or visual aids should be provided. Equally important is evaluating practical barriers, including physical limitations, cognitive challenges, or socioeconomic constraints that may hinder plan execution.

When patients understand but face implementation difficulties, PCPs need to collaboratively adjust the treatment approach, such as simplifying complex regimens, reducing monitoring frequency, or connecting patients with support services to address specific barriers. Sometimes, physicians may note that patients have concerns about the treatment plan since the initial decision-making discussion. These concerns should be explored thoroughly, as they may reflect practical insights that emerged as patients considered implementation in their daily lives. Addressing these concerns may require returning to earlier steps, such as re-examining alternatives or engaging in additional shared decision-making discussions.

Planning

Physicians in the final step establish a comprehensive follow-up plan that ensures continuity of care and ongoing optimization of multimorbidity management. Key considerations include the stability of each condition, medication safety, and the patient’s self-management capacity, which balance necessary oversight with minimizing unnecessary visits. For example, stable patients may require less frequent follow-ups, while those with complex regimens or fluctuating symptoms benefit from closer monitoring. The plan also integrates condition-specific targets alongside patient-centered outcomes, ensuring alignment with the patient’s broader health goals.

To enhance feasibility, PCPs need to clarify communication protocols, coordinate with specialists to avoid fragmented care, and preemptively address potential setbacks through contingency planning. ¹⁷ Periodic comprehensive reviews should be scheduled to reassess treatment efficacy, adjust goals, and address emerging needs. Additionally, technology integration could be considered in the following-up plan, including remote monitoring devices, smartphone applications, or other telehealth platform. ¹⁸ By embedding these elements, the follow-up plan becomes a living framework that sustains patient engagement, mitigates treatment burden, and responds proactively to evolving clinical and psychosocial contexts.

Discussion

The CARESTEP framework offers a conceptual framework that aims to bring a shift in multimorbidity consultation by introducing a comprehensive, patient-centered framework that synthesizes and advances existing consultation frameworks. Unlike traditional approaches that often address multimorbidity management in a fragmented manner, CARESTEP integrates key principles from established frameworks while introducing innovative elements specifically designed for the complexity of multiple chronic conditions. ¹⁹

One distinctive feature of CARESTEP is its systematic integration of risk-benefit analysis and alternatives evaluation as core components of the consultation process. While existing frameworks such as the Ariadne principles are strong in identifying priorities, treatment burden, and patient goals, they provide limited guidance on building a comprehensive set of options or on formally appraising interactions and proportionality before shared decision-making. ⁴ CARESTEP addresses this gap by separating option construction from analysis. PCPs first produce a resource-sensitive option set, then complete a structured risk-benefit profile that considers efficacy, interaction and contraindication checks, and whether expected benefit justifies treatment burden, which then guides shared decision making. ²⁰ Safe multimorbidity care depends on anticipating how options may synergize or conflict across conditions and over time. This sequence is especially relevant in primary care in China, where constrained formularies and limited access to allied health services make realistic and implementable choices essential.

The framework’s emphasis on shared decision-making demonstrates a sophisticated evolution from previous consultation frameworks by contextualizing patient preferences within the complex landscape of multimorbidity. While previous consultation frameworks like the Calgary-Cambridge guide emphasize patient-centered communication, CARESTEP specifically addresses the unique challenges of achieving meaningful patient participation when multiple treatment goals may compete or conflict.^21,22 The shared decision-making component in CARESTEP is innovative in its integration with the preceding risk-benefit analysis, aligning empathic communication with a structured evidentiary base and ensuring that patients are equipped with comprehensive information to make informed decisions about their complex care needs.

Another advancement of CARESTEP is its incorporation of continuous evaluation and planning components that extend beyond the immediate consultation. While PRACTICAL and REAL highlight reflection and learning, CARESTEP formalizes patient-facing reassessment mechanisms that prompt deprescribing, linkage to supports, and goal recalibration at each visit. ²³ This explicit loop is essential for multimorbidity, where trajectories and priorities evolve, and it is often under-specified in frameworks that end with a plan.

Overall, the staged approach of CARESTEP addresses a critical gap in existing consultation frameworks by providing a structured yet flexible framework that can accommodate the variable complexity of multimorbidity. Unlike previous frameworks that may focus on specific aspects of care, CARESTEP’s sequential 8-step process ensures comprehensive coverage of all essential elements while maintaining practical applicability in time-constrained primary care settings. While upholding the patient-centered philosophy of earlier frameworks, CARESTEP offers a more systematic structure to manage complex cases. In practice, the staged sequence functions as a cognitive scaffold: this scaffold is dynamic, allowing priorities to be reassessed and specific components to be efficiently adjusted at subsequent visits without restarting the entire process. This enables follow-ups to focus on unresolved or high-risk issues through targeted updates, thereby reducing cognitive load and decision variability.

Despite its strengths, the CARESTEP framework should be considered in light of several practical considerations and areas for further development. First, the multidimensional design requires interdisciplinary skills that may present training challenges. The framework is designed to address time constraints through longitudinal, adaptive application, in which the initial comprehensive visit is followed by efficient, targeted follow-ups. Nevertheless, the upfront time investment may still pose a barrier in very high-volume settings. Second, seamless integration with existing EHR systems and workflows requires purposeful refinement, such as incorporating structured medication fields and adverse event documentation. Finally, although culturally sensitive engagement is embedded in the framework, further work is needed to develop explicit tools for adapting to diverse cultural contexts, such as validated cultural adaptation toolkits that include standardized health literacy assessments and culturally tailored communication guides. Building PCPs’ capacity for disability-inclusive care is critical to the framework’s implementation. This entails training on adaptive communication strategies and ensuring the comprehensive review adequately addresses patients’ physical, sensory, and cognitive needs. Additionally, establishing clear referral pathways to disability-specific support services is essential. Further work is needed to develop explicit tools for adapting to diverse patient contexts including both cultural backgrounds and disability-related needs.

These considerations highlight clear pathways for future development and implementation science. Priorities include pragmatic pilot studies to assess feasibility and acceptability in diverse primary care environments, particularly exploring how digital tools can streamline follow-up care and decision-support. ²⁴ To this end, a pilot study is planned to evaluate the CARESTEP framework’s real-world applicability, incorporating digital health solutions such as EHR integrations and mobile apps for data collection. This mixed-methods study will be conducted in diverse primary care settings and aims to recruit approximately 10 to 15 primary care physicians and 50 to 100 patients with multimorbidity. Quantitative measures will focus on feasibility metrics (eg, consultation time, adherence to the framework’s steps), acceptability scores (eg, physician and patient satisfaction surveys), and preliminary efficacy outcomes (eg, changes in patient-reported treatment burden or quality of life). Qualitative components will include semi-structured interviews with clinicians and patients to explore implementation barriers, facilitators, and perceptions of the framework’s utility. The pilot is expected to commence within the next year and will inform refinements to the framework and the design of a larger randomized controlled trial. Findings from this pilot will then guide subsequent phases, including full-scale trials to evaluate the framework’s effectiveness and cost-effectiveness, as well as usability testing with PCPs and patients to optimize engagement strategies and implementation workflows.

Conclusion

The CARESTEP framework represents a potential advancement in multimorbidity management by providing PCPs with a comprehensive, patient-centered consultation framework that integrates evidence-based principles while addressing the complexities. Through its 8-stage structured approach, CARESTEP offers a practical yet flexible solution to the challenges faced by healthcare providers in delivering holistic care. The framework’s emphasis on continuous evaluation and decision-making, combined with its integration of patient education and empowerment, positions it as a helpful tool for improving the quality of multimorbidity care. However, as a hypothesis-generating framework, it requires future empirical validation through pilot studies and trials to confirm its practical efficacy.