Multiple Chronic Conditions

The complex care needs of patients with two or more chronic conditions can be a challenge for the healthcare team, patient, and family. There are often multiple providers, medications, diagnostic evaluations and confusing and overlapping plans of care. This often leaves the patient confused and uncertain of their medical management. Use and implementation of evidence-based guidelines by the healthcare team begins with shared decision making between patient, family, and provider to effectively offer optimal outcomes and improve quality of life.

Communication between multiple providers must be a priority to facilitate high-quality patient care in the context of medical decision making. It is imperative to prevent polypharmacy from the use of multiple medications that can often reduce patient perceived quality of life. Communication between providers about changes in the plan of care, progress, and/or decline are important aspects in optimizing the patients plan of care.

Not only is communication between providers necessary for patients with multiple chronic conditions, but collaborative care is essential. The dedication of an interdisciplinary team to evaluate best practices ensure optimal patient-centered outcomes. Patients with multiple chronic conditions often experience uncertainties of disease and treatment; it is how the team respond and collaborate that will either benefit, or harm, the patient. Management of a patient’s multiple chronic conditions require ongoing evaluation and revisions of care by the interdisciplinary team.

Another focus of multiple chronic conditions is in keeping the patient’s individualized goals in perspective. As healthcare providers we are here to help, and our goals often overlook the patient’s goals. While one patient may want to try anything and everything, another patient may want to focus on quality of life. There is a dynamic interplay between the provider’s guidance and the patient’s values and preferences. If a patient is not comfortable (either physically or emotionally) with their care, this negative response can influence care outcomes.

Resources & Guidelines