MyHealth: Managing complex multimorbidity in general practice

Multi-morbidity is the concurrent presence of two or more clinical conditions. The complex interactions of co-existing diseases means that medical management based on single-disease guidelines generally does not optimize care. However, there is little scientific knowledge available for appropriate diagnostic reasoning, care and treatment for multi-morbidity patients. In addition,patients with an increased number of health conditions tend to be older, taking more medicines, are more susceptible to adverse drug events, and more likely to be admitted to hospital. The current fragmented health care system does not meet these complex needs of patients with multi-morbidity. Integrated health care models with well-balanced treatment plans, tailored toward the needs of the individual person, are required.The development of a systematic approach to chronic disease management has been challenging in Australia despite the introduction of such initiatives as the Enhanced Primary Care package(1999); Medicare items for Chronic Disease Management (2005), Practice Nurse support items(2007) and practice incentive programs for the management of diabetes, asthma and mental health(2001). There are challenges in obtaining a complete and accurate list of medicines. There is little information available for GPs to decide which parts of single-disease guidelines are relevant for patients with multi-morbidity and less information available about which medicines can be safely tapered off and ceased. MyHealth is a proposed systematic approach to address these challenges.