Building Effective Policies for Comorbidity Management

​​​​Policies for managing comorbidities, as well as multimorbidity and multiple chronic conditions, vary based on the medical conditions involved; therefore, developing a uniform policy is not necessarily feasible given the differences between conditions. Approaches to comorbidity management often overlap with typical care management strategies. However, the presence of comorbidities often requires treatment adjustments based on disease-specific considerations, making individualized treatment plans the most appropriate approach. Professional organizations have developed guiding pri​​​nciples that healthcare organizations can use to tailor comorbidity management best practices. For example, see the following guiding principles for managing comorbidities developed by a working group convened by the American Geriatrics Society:

• Elicit and incorporate patient preferences into medical decision making 
• Recognize the limitations of the evidence base in interpreting and applying the medical literature to individuals with multimorbidity 
• Frame clinical management decisions within the context of risks, burdens, benefits, and prognosis (e.g., remaining life expectancy, functional status, quality of life) 
• Consider treatment complexity and feasibility when making clinical management decisions 
• Choose therapies that optimize benefits, minimize harm, and enhance quality of life
  

• Tailor care to meet personal goals and priorities 
• Identify people who may benefit from care that takes multimorbidity into account by considering factors such as presence of frailty; falls; difficulty with daily activities or medication management; and need for multiple services or frequent use of emergency care 
• Establish what is important to the patient 
• Identify the impact of disease and treatment burden on quality of life 
• Review medications—consider stopping nonessential treatment and consider nonpharmacologic approaches 
• Develop an individualized management plan 
  

Regarding action steps, it may be helpful to view comorbidities from a broad perspective that narrows down to individualized tasks. Consider the following framework that is informed by the aforementioned professional guidelines: 

• Elicit patient goals and priorities and incorporate these goals into the patient's care plan: 
  • Ensure advance care planning opportunities exist throughout the course of treatment, since patient goals may shift and change as conditions progress. 
  • Engage in shared decision making to create a partnership between providers, patients, and their families or surrogate decision makers. 
  • Ensure all proposed treatments and care plans adhere to informed consent requirements. 
  • Provide all patient education and decision-making materials in a culturally and linguistically appropriate manner, based on the literacy needs of the patient and their decision makers. 

• Coordinate care: 
  • Integrate care among the patient's care team (e.g., specialists, primary care, behavioral health, aging services) to support person-centered care; adopt a unified approach to the care plan; reduce inconsistencies and confusion; protect against unnecessary or overly burdensome treatments; and support alignment with patient care goals. 
  • Use effective communication strategies that have been proven to aid in care coordination. 
  • Assess the patient's access to or reliance on informal caregivers and involve them in care planning to the extent possible or as consented to. 
  • Consider the use of specific care models as appropriate (e.g., Guided Care practices, Program of All-inclusive Care for the Elderly programs, Patient-Centered Medical Home designation, Generalized Risk-Adjusted Cost-Effectiveness framework). 
  • Understand that every care transition and clinical intervention has the potential for additional risks—whether planned or unanticipated—and include such risks in patient education and care planning discussions. 
  • Optimize electronic health record interoperability, especially during care transitions and handoffs. 

• Manage medications: 
  • Reconcile medications at initiations or modifications (e.g., dosage, modality) of the current medication list and during key events, such as care transitions, acute illnesses, and progression of disease or condition symptoms/stages. 
  • Minimize inappropriate prescribing and adverse drug reactions by using the "start low, go slow" approach to medication initiations, considering nonpharmacologic interventions, frequently reviewing medications, and consolidating dosage schedules and treatments as appropriate.​ 

• Address aspects of basic health and well-being that can impact multiple conditions, including: 
  • Nutrition 
  • Physical activity/exercise 
  • Function/independence 
  • Sleep disturbance 
  • Mental health 
  • Safety of environment and adequacy of support in current level of care 
  • Caregiver stress 

Learn how ECRI can help you address the increasingly complex aging services care delivery and regulatory environment.