Abstract
The health care for patients having two or more long-term medical conditions is fragmented between specialists, allied health professionals, and general practitioners (GPs), each keeping separate medical records. There are separate guidelines for each disease, making it difficult for the GP to coordinate care. The TrueBlue model of collaborative care to address key problems in managing patients with multimorbidity in general practice previously reported outcomes on the management of multimorbidities. We report on the care plan for patients with depression, diabetes, and/or coronary heart disease that was embedded in the TrueBlue study. A care plan was designed around diabetes, coronary heart disease, and depression management guidelines to prompt implementation of best practices and to provide a single document for information from multiple sources. It was used in the TrueBlue trial undertaken by 400 patients (206 intervention and 194 control) from 11 Australian general practices in regional and metropolitan areas. Practice nurses and GPs successfully used the care plan to achieve the guideline-recommended checks for almost all patients, and successfully monitored depression scores and risk factors, kept pathology results up to date, and identified patient priorities and goals. Clinical outcomes improved compared with usual care. 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.
Highlights
The health care for patients having two or more long-term medical conditions is fragmented between specialists, allied health professionals, and general practitioners (GPs), each keeping separate medical records
Patients with multimorbidity have poorer quality of life, greater loss of physical function, and are prescribed multiple drugs with consequent difficulties with adherence. These patients are more likely to be admitted to and have longer stays in hospital.[3]. They already form the majority of GP workload in primary care, with more than half of patient encounters dealing with managing chronic conditions,[4] and this will increase as the population ages.[5,6]
The care-plan template (Figure 1) was developed to acquire all necessary information and provide it in a single document. It was designed around the overlapping management tasks, targets, and lifestyle changes recommended by the National Heart Foundation of Australia, Diabetes Australia, and the MacArthur Foundation for Depression so that it could act as a guide for the clinician through routine scheduling of tests and activities required for each patient
Summary
The health care for patients having two or more long-term medical conditions is fragmented between specialists, allied health professionals, and general practitioners (GPs), each keeping separate medical records. One-third of 65-year-olds have three or more chronic conditions.[2] Patients with multimorbidity have poorer quality of life, greater loss of physical function, and are prescribed multiple drugs with consequent difficulties with adherence These patients are more likely to be admitted to and have longer stays in hospital.[3] They already form the majority of GP workload in primary care, with more than half of patient encounters dealing with managing chronic conditions,[4] and this will increase as the population ages.[5,6] Recent articles[7,8] have highlighted that it is both timely and important to examine practical ways to better manage the healthcare of patients with multimorbidity
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