Table 3.

Approaches for Integrating Multimorbidity into Clinical Practice

Consider multimorbidity and geriatric syndromes in designing care Routinely assess for the presence of multimorbidity and geriatric syndromes Maintain list in the EHR of all chronic conditions for each patient If appropriate, consider screening for frailty and geriatric syndromes (e.g., http://frailtytool.com) Evaluate potential impact of concordant and discordant conditions on CVD management Is the presence of comorbid conditions likely to reduce the benefit or increase the risk of CVD interventions (e.g., severe osteoarthritis may diminish the potential benefits of revascularization or heart failure therapies on functional capacity)? How will the presence of geriatric syndromes affect response to therapy (e.g., cognitive impairment may reduce adherence to medication and lifestyle interventions; urinary incontinence may reduce adherence to diuretic therapy)? Recognize polypharmacy and intervene proactively Discontinue or reduce non-essential medications (e.g., deprescribe) When starting a new medication, consider potential drug-drug and drug-disease interactions Assess patient priorities and goals of care Elicit patient priorities for health care Relative importance of quality of life vs. length of life General sense of how aggressive to be in pursuing goals Identify patient-specific goals (e.g., maintenance of independence, not becoming a burden, avoiding nursing home, avoiding hospitalization) Engage in shared decision-making Considering the patient’s priorities and goals, discuss realistic care options in a non-judgmental manner, outlining potential benefits and risks Communicate uncertainty in available data while avoiding any sense of abandonment. Come to a joint decision on how best to proceed that is aligned with the patient’s priorities and goals Guidelines and performance measures Guidelines Clearly acknowledge the limitations of guidelines in patients with multimorbidity and offer more flexibility in care options for these patients Emphasize the importance of shared decision-making, especially in patients for whom the evidence base is not robust Performance measures Develop more robust methods for identifying patients for whom performance measures are applicable and excluding those to whom the measures do not apply Develop novel performance measures that specifically assess quality of care in patients with multimorbidity

CVD: cardiovascular disease; EHR: electronic health record