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Multimorbidity: Managing Patients with Multiple Chronic Diseases in General Practice

Reno Riandito
multimorbiditychronic disease managementGPCCMPprimary carecare planning

Learn how GPs manage multimorbidity using chronic disease management plans, coordinated care, and structured clinical workflows.

Multimorbidity: Managing Patients with Multiple Chronic Diseases in General Practice

Multimorbidity: Managing Patients with Multiple Chronic Diseases in General Practice

In modern general practice, many patients do not present with a single illness.

Instead, they live with multimorbidity — the coexistence of multiple chronic diseases in the same patient.

A typical patient may simultaneously have:

  • type 2 diabetes
  • hypertension
  • osteoarthritis
  • depression
  • chronic kidney disease

Each condition brings its own treatment guidelines, medications, monitoring schedules, and lifestyle recommendations.

Without a structured system, care can quickly become fragmented.

Most patients do not have one chronic disease. They have several interacting conditions that evolve over time.

This is why structured chronic disease management plans play a critical role in coordinating care.

If you want the broader foundation first, start here:

Chronic Disease: Definition, Risk Factors and Long-Term Management

Table of Contents

What Is Multimorbidity?

Multimorbidity refers to the presence of two or more chronic conditions in the same patient.

Common combinations seen in general practice include:

  • diabetes and hypertension
  • COPD and cardiovascular disease
  • chronic pain and depression
  • chronic kidney disease and cardiovascular disease

According to the
Australian Institute of Health and Welfare,
chronic diseases account for the majority of Australia’s disease burden.

Globally, the
World Health Organization
identifies non-communicable diseases as the leading cause of mortality.

As populations age, multimorbidity is becoming the norm rather than the exception in primary care.

Why Multimorbidity Is Difficult to Manage

Healthcare systems and clinical guidelines are traditionally built around single-disease models.

However, real-world patients rarely fit neatly into these frameworks.

Managing multiple chronic diseases introduces several clinical challenges.

Conflicting Treatment Strategies

Treatments for one condition may worsen another.

Examples include:

  • NSAIDs worsening chronic kidney disease
  • beta blockers affecting asthma control
  • steroid therapy worsening diabetes

This means clinicians must balance competing risks rather than follow single-disease guidelines blindly.

Clinical guidelines are written for diseases.
General practice is about managing people with multiple diseases.

Polypharmacy

Patients with multimorbidity often take multiple medications.

This increases the risk of:

  • drug interactions
  • adverse drug reactions
  • reduced adherence

Medication review therefore becomes a core part of chronic disease care.

Fragmented Care

Patients with multimorbidity often see multiple providers:

  • general practitioners
  • cardiologists
  • endocrinologists
  • physiotherapists
  • psychologists

Without coordination, treatment plans may conflict or overlap unnecessarily.

Structured care planning helps maintain continuity.

The Role of Chronic Disease Management Plans

A chronic disease management plan (CDM plan) helps organise care for complex patients.

These plans typically include:

  • chronic diagnoses
  • measurable goals
  • medication management
  • lifestyle interventions
  • allied health referrals
  • monitoring schedules

If you're new to care planning, read the full guide:

Chronic Disease Management Plan: Complete Guide for Australian GPs

Patients with multimorbidity often benefit from a GP Chronic Condition Management Plan (GPCCMP).

Official requirements are outlined by:

Services Australia – GP Chronic Condition Management Plan

Prioritising Problems in Multimorbidity

Not every condition requires equal attention at every consultation.

A practical approach is to prioritise:

  • high-risk conditions
  • symptom-driving conditions
  • modifiable lifestyle risks

Example:

A patient with diabetes, chronic kidney disease, and depression may prioritise:

  1. glycaemic control
  2. cardiovascular risk reduction
  3. mental health stabilisation

SMART goals can help structure these priorities.

Related article:

How to Write SMART Goals in Chronic Disease Management

Lifestyle Interventions Affect Multiple Diseases

Many chronic diseases share common risk factors.

These include:

  • smoking
  • obesity
  • sedentary lifestyle
  • poor diet

Addressing these factors can improve several conditions simultaneously.

Examples:

  • exercise improves diabetes, hypertension, and depression
  • smoking cessation reduces COPD progression and cardiovascular risk

Related lifestyle article:

Quit Smoking Without Willpower

A single lifestyle intervention can influence multiple chronic diseases simultaneously.

Multidisciplinary Care

Patients with multimorbidity often require multidisciplinary care.

Common allied health referrals include:

  • dietitian
  • physiotherapist
  • exercise physiologist
  • psychologist
  • podiatrist

These referrals are supported through Medicare chronic disease management items.

See the official item reference:

MBS Item 965

You can also read the detailed explanation here:

The Real Power of Item 965 and 967

Monitoring Patients With Multimorbidity

Patients with multiple chronic diseases require regular review and monitoring.

Monitoring may include:

  • pathology testing
  • medication review
  • symptom tracking
  • allied health follow-up

Most chronic disease plans are reviewed every 3–6 months depending on complexity.

For long-term care strategy, see:

Managing Chronic Disease as a Lifetime Project

Example: Multimorbidity Care Plan Structure

Domain Example
Diagnoses diabetes, hypertension, depression
Goals HbA1c <7%, BP <130/80
Actions medication adjustment, dietitian referral
Monitoring HbA1c every 3 months
Review chronic care review consultation

This structure helps clinicians see connections between conditions and treatments.

Technology and Multimorbidity Care

Documentation requirements can make comprehensive care planning difficult during busy clinics.

Modern AI clinical documentation tools can help clinicians:

  • capture consultation notes
  • identify chronic diagnoses
  • generate structured care plans
  • organise goals, referrals, and follow-ups

Learn more about AI clinical tools here:

AI Scribe Complete Guide

Final Thoughts

Multimorbidity is increasingly common in general practice.

Managing patients with multiple chronic diseases requires:

  • coordinated care
  • structured care planning
  • lifestyle intervention
  • regular monitoring

A well-designed chronic disease management plan helps bring these elements together and improve continuity of care.

The challenge of multimorbidity is not simply treating multiple diseases.
It is organising care so those diseases are managed together.

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