What level of complex medical management is required for patients with various chronic conditions?

Complex Medical Management for Patients with Multiple Chronic Conditions

Complex medical management for patients with multiple chronic conditions requires a patient-centered, team-based approach with careful consideration of treatment complexity, feasibility, and patient preferences to optimize outcomes related to morbidity, mortality, and quality of life.

Understanding the Need for Complex Medical Management

The level of complex medical management required varies based on several factors:

• More than 50% of older adults have three or more chronic diseases, with distinctive cumulative effects for each individual, requiring tailored management approaches 1
• Multimorbidity is associated with higher rates of death, disability, adverse effects, institutionalization, increased healthcare resource utilization, and poorer quality of life 1
• Standard clinical practice guidelines (CPGs) that focus on single diseases may be cumulatively impractical, irrelevant, or even harmful for patients with multiple conditions 1

Assessment and Stratification of Management Complexity

The complexity of medical management should be stratified based on:

• Number and severity of chronic conditions 1
• Functional status and prognosis of the patient 1
• Treatment complexity and feasibility 1
• Patient preferences and priorities 1

Prognostic Assessment to Guide Management

• Decisions should be prioritized based on life expectancy: short-term (within 1 year), midterm (within 5 years), and long-term (beyond 5 years) 1
• Patients with limited life expectancy should focus on short-term decisions (e.g., glucose monitoring intensity), while those with longer life expectancy may address longer-term preventive measures 1
• Use validated prognostic tools appropriate for the specific setting (community vs. nursing home) 1

Core Components of Complex Medical Management

1. Interdisciplinary Team-Based Care

• Implement integrated and/or collaborative care models with multidisciplinary teams 1
• Include primary care clinicians, specialists, pharmacists, mental health professionals, and case managers as needed 1
• Establish a "primary" clinician or patient-centered medical home to coordinate care and help patients make informed decisions 1

2. Medication Management

• Conduct ongoing comprehensive medication reviews to reduce polypharmacy 1
• Assess medication regimen complexity using tools like the Medication Regimen Complexity Index (MRCI) 1
• Consider tapering or discontinuing medications with unfavorable risk-benefit profiles, especially those affecting cardiovascular or central nervous systems 1
• Stop medications one at a time with careful monitoring 1
• Partner with pharmacists for medication optimization 1

3. Patient-Centered Decision Making

• Elicit and incorporate patient preferences into all clinical decisions 1
• Provide clear explanations about potential benefits, harms, and uncertainties of treatments 1
• Recognize when patients face "preference-sensitive" decisions that require more extensive discussion 1
• Document the reasoning behind treatment decisions after careful discussion with the patient 1

4. Preventive Care Considerations

• Implement systematic approaches for preventive services like immunizations 1
• Create patient registries and effective reminder systems for tracking preventive care 1
• Empower staff to identify people with specific conditions requiring preventive interventions 1

Management Challenges and Solutions

Addressing Treatment Complexity and Burden

• More complex treatment regimens increase risk of nonadherence, adverse reactions, poorer quality of life, greater economic burden, and caregiver strain 1
• Assess adherence using validated tools such as the Medication Management Ability Assessment (MMAA) or Drug Regimen Unassisted Grading Scale (DRUGS) 1
• Implement medication management interventions like reminder systems and education 1
• Care transitions represent important opportunities to reevaluate treatment complexity and adherence 1

Managing Multiple Chronic Conditions

• Review all chronic conditions present in the patient when formulating treatment plans 1
• Consider how management of one condition may impact other conditions 1
• Recognize that patients with multiple chronic conditions are often excluded from clinical trials, limiting the applicability of standard guidelines 1
• In patients with multiple conditions, certain diagnostic approaches (e.g., ctDNA vs. metastatic biopsy) may be preferred based on safety and feasibility 1

Addressing Healthcare Disparities

• Recognize that patients from racial/ethnic minorities may experience disproportionate comorbidities, obstacles to care, and insurance issues 1
• Consider geographic location and distance from appropriate treatment facilities as barriers to complex care 1
• Strive to deliver the highest level of care to vulnerable populations 1

Implementation Strategies for Complex Medical Management

• Develop awareness of risks and benefits of various interventions among patients and providers 1
• Educate staff and patients to reduce fears and misperceptions about treatments 1
• Create systematic tracking systems and effective reminders for chronic disease management 1
• Ensure that episodic or acute care settings offer appropriate interventions or provide information on how to obtain them 1
• Consider the strength of evidence and certainty when making recommendations, particularly when evidence is limited 2, 3, 4

By implementing this comprehensive approach to complex medical management, clinicians can better address the needs of patients with multiple chronic conditions and optimize outcomes related to morbidity, mortality, and quality of life.