Step 1

Who to target?

Consider a multimorbidity approach to care in adults with three or more conditions and other risk factors such as: ○Significant polypharmacy (10 or more medicines) ○High healthcare utilisation ○Social vulnerability

Step 2:

Plan time for a multimorbidity assessment ○Consider who is best place to start the clinical assessment if a team-based approach is possible ○Incorporate disease monitoring in the process to reduce treatment burden for patients for example, may see nurse first for initial review, identification of patient priorities and monitoring blood tests and then return for physician review with results to complete management plan

Step 3:

How to approach an assessment: ○Consider disease and symptom burden ○Identify patient priorities and create plan to address these

Step 4:

Plan a review ○Tailor this to the individual patient to minimise treatment burden

Approach to care: ⇒Patient, family and carer orientation ⇒Consider frailty. Informal assessment can consider time taken to walk into the consulting room. More formal assessment can also be completed quickly assessing gait speed with with more than 5 seconds to walk 4 metres indicating frailty (ref NICE guidance) ⇒Consider physical capacity and daily functioning at all ages and refer to allied health colleagues such as physiotherapist or occupational therapists who can intervene to improve physical capacity and function if needed. Referral to rehabilitation programmes may also be appropriate depending on patient priorities ⇒Consider appropriate risk factor management, for example, glycaemic targets in older people with diabetes and complex multimorbidity may differ based on risk of hypoglycaemia if aim for tight blood sugar control ⇒Consider deprescribing and medication appropriateness based on age and life expectancy. Involve community or practice-based pharmacist if available ⇒Consider options for self-management support. Group based approaches may suit some patients if available in local primary care settings ⇒ Consider comorbid depression and anxiety. Initial assessment could involve use of a brief practical screening tool, asking 2 questions339: ○ During the last month, have you often been bothered by feeling down, depressed or hopeless? ○ During the last month, have you often been bothered by having little interest or pleasure in doing things? ⇒Identify social concerns or isolation and consider social prescribing, i.e referral to non-medical community based supports, if available.