As our population ages and more of us are living longer with long term conditions, it is timely to focus on caring for people with multimorbidity.


The following information was compiled by Dr Carol Atmore whilst she was the Director of Long Term Conditions at the Ministry of Health and it formed the basis of two presentations at recent General Practice conferences.


A long term condition has been defined as any ongoing, long term or recurring condition that can have a significant impact on people’s lives.

The National Institute for Health and Care Excellence (NICE) guidance defines multimorbidity as two or more long term conditions which may include:

  • defined physical and mental health conditions such as diabetes or schizophrenia
  • ongoing conditions such as learning disability
  • symptom complexes such as frailty or chronic pain
  • sensory impairment such as sight or hearing loss
  • alcohol or substance misuse.

The National Academy of Sciences (UK) defines multimorbidity as including two or more of:

  • a physical non-communicable disease of long duration, e.g. CVD or cancer
  • a mental health condition of long durations, e.g. mood disorder or dementia
  • an infectious disease of long duration, e.g. HIV or Hepatitis C.

Multimorbidity is associated with:

  • reduced quality of life
  • higher mortality
  • polypharmacy
  • high treatment burden
  • higher rates of adverse drug events
  • greater health services use
  • greater use of unplanned care.

[1] National Institute for Health and Care Excellence Multimorbidity : clinical assessment and management, September 2016.

[2] National Academy of Sciences, Multimorbidity a priority for Global Health Research, April 2018.

New Zealand context

In New Zealand, life expectancy is increasing but:

  • 20-30% of the years of life gained over last 25 years are lived in poor health
  • inequalities exist in health outcomes by ethnicity and socioeconomic deprivation
  • multimorbidity affects 1 in 4 NZ adults (Health and Independence Report 2014).


Strategies to reduce incidence of individual conditions that compose common clusters include:

  • lifestyle modification (increase physical activity, improve nutrition, smoking cessation, alcohol moderation)
  • motivational interviewing
  • referrals to community providers for support eg Green Prescriptions
  • smoking cessation, treating hypertension and hypercholesterolemia.

Health Literacy

Individuals and whānau can often face a series of demands on their health literacy.

This is their capacity to obtain, process and understand basic health information and services in order to make informed health decisions. 

A health-literate health system reduces these demands on people and builds health literacy skills of its workforce, and the individuals and whānau who use its services.

It provides high-quality services that are easy to access and navigate and gives clear and relevant health messages so that everyone living in New Zealand can effectively manage their own health, keep well and live well.

People with low health literacy are at risk of adverse outcomes through:

  • trouble understanding appointment letters
  • difficulty filling in forms
  • finding it challenging to understand educational resources
  • misinterpretation of medication instructions.

Each part of the health system can contribute to building health literacy so that all New Zealanders can make informed decisions about managing their health, or the health of those they care for.

For more information see Health literacy.

Management and support

Supporting people with multimorbidity to manage their conditions requires a multipronged approach.

Clinical trials usually exclude people with multimorbidity. Applying multiple single disease guidelines has risks including[1]

  • poly-pharmacy with drug-drug or drug-disease interactions
  • contradictory recommendations
  • high treatment burden
  • inattention to social and personal context and
  • failure to align care with personal goals and preferences.

[1] Tinetti et al 2004, NEJM 351, 2870-74

The NICE multimorbidity guidelines 2016 include recommendations around optimising care for adults with multiple long term conditions by working with them to improve their quality of life by:

  • reducing treatment burden
  • reducing polypharmacy
  • reducing multiple appointments
  • reducing unplanned care
  • improving coordination of care across services.

People with multimorbidity who will benefit from improved management include:

  • people finding it difficult to manage their treatments or day to day lives
  • people receiving care and support from multiple services
  • people with complex physical and mental health needs
  • frequent users of after-hours or emergency care
  • people on multiple medications (10+ )

People with multimorbidity can be identified:

  • opportunistically during consultations
  • proactively , e.g PHO level risk stratification tools, practice initiated polypharmacy audits
  • frailty assessments (when well).

Frailty assessments can be:

  • informal - time to walk down the corridor
  • undertaken using tools, e.g. Clinical Frailty Score - see HealthPathways

Applying a multimorbidity approach

There are five steps in applying a multimorbidity approach:

1. Discuss the purpose of this approach

Taking a multimorbidity approach will improve a person’s quality of life.

A multimorbidity approach aims to get the most out of current treatments, reviewing treatment and follow-up arrangements that are burdensome and considering whether alternatives better meet people’s needs and goals.

2. Establish disease and treatment burden

Establish disease and treatment burden by considering how a person’s health problems affect their day to day life, their mental health and their wellbeing, for example:

  • treatment effects on day to day life  
  • number and frequency of different appointments
  • number of medications and any side effects
  • existence of depression and anxiety, and adequacy of any chronic pain management.

3. Establish patient goals, values and priorities

Consider and discuss the level of family and whānau involvement people want in any planning and ongoing treatment. 

Goals, values and priorities for health, views on quality vs quantity of health, benefits and harms of medications.

4. Review pros and cons of medications and other treatments

When reviewing the pros and cons of medications and other treatments, discuss the context of trials in single disease states.  Consider using the numbers needed to treat concept with the person e.g.

Discuss overall benefits of preventative treatments in people with multimorbidity, taking their views of harms and benefits into account.

5. Agree an individualised care plan

An individualised care plan includes goals and plans for the future health care – complete Advance Care Plan.

Identify who is responsible for care coordination, include consideration and decisions about starting, stopping, changing medications, follow-up regimes, and time for review.  Including an acute care plan (what to do if unwell) is also essential - Care Planning.

Decide how the plan will be shared across all involved in the person’s care.

System Support

System support opportunities for the adoption of a multimorbidity approach to patient care include:

  • planned proactive care
  • Health Care Homes
  • “Year of Care” approaches
  • teamwork within practice – doctors, nurses, clinical
  • pharmacists and others
  • teamwork across your local health system – district nursing, community mental health, community allied health, Green prescription support
  • new roles, e.g. health care assistants, health navigators, health coaches, kaiawhina
  • technology enabled – patient portals, shared care plans
  • patient records viewable across the system.


 Consider what to do differently.

  • Ask ‘what matters to you?’
  • Think about people’s social and mental wellbeing as well as their physical health.
  • Check people have a care plan - who in your team is best placed to assist if not?
  • Look at their medication list – what’s unneccessary, what’s missing?
  • Check people have an Advance Care Plan – who in your team is best placed to assist if not?