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.

For GPs, managing multimorbidity is one of the most complex aspects of primary care. A typical patient may simultaneously have:

• Type 2 diabetes
• Hypertension
• Osteoarthritis
• Depression
• Chronic kidney disease

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

Without a structured system, care quickly becomes fragmented.

This is why a chronic disease management plan plays such an important role in coordinating care for patients with multiple chronic diseases.

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What Is Multimorbidity?

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

Common combinations seen in general practice include:

• diabetes and hypertension
• COPD and heart 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 also identifies non-communicable diseases as the leading cause of mortality.

As populations age, multimorbidity is becoming increasingly common, making coordinated chronic disease care essential.

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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 challenges.

Conflicting Treatment Strategies

Treatments for one condition may worsen another condition.

Examples include:

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

Clinical decision-making therefore requires balancing competing risks.

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Polypharmacy

Patients with multimorbidity often take multiple medications, increasing the risk of:

• adverse drug reactions
• medication interactions
• reduced adherence

Medication reviews are therefore essential in chronic disease management.

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Fragmented Care

Patients may receive care from multiple providers including:

• GPs
• cardiologists
• endocrinologists
• physiotherapists
• psychologists

Without coordination, treatment plans can become disjointed.

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The Role of Chronic Disease Management Plans

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

These plans typically include:

• a list of chronic diagnoses
• treatment goals
• medication plans
• lifestyle interventions
• allied health referrals
• monitoring schedules

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

👉 Chronic Disease Management Plan: Complete Guide for Australian GPs

Patients with multimorbidity often benefit from a GP Chronic Condition Management Plan (GPCCMP), which supports coordinated care between the GP and allied health providers.

Services Australia outlines the requirements for GPCCMP care planning here:

👉 GP Chronic Condition Management Plan – Services Australia

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Setting Priorities in Multimorbidity

Not every chronic condition requires equal focus during every consultation.

A practical approach is to prioritise:

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

For example, a patient with diabetes, chronic kidney disease, and depression may require focus on:

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

Using SMART goals can help structure treatment priorities.

👉 Learn more here:
How to Write SMART Goals in Chronic Disease Management

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Lifestyle Interventions Affect Multiple Diseases

Many chronic diseases share common risk factors, including:

• smoking
• obesity
• sedentary lifestyle
• poor diet

Addressing these lifestyle factors can improve multiple conditions simultaneously.

For example:

• exercise improves diabetes, hypertension, and depression
• smoking cessation improves COPD and cardiovascular disease

You may also find this helpful:

👉 Quit Smoking Without Willpower

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Multidisciplinary Care

Patients with multimorbidity frequently benefit from multidisciplinary care.

Common allied health referrals under a chronic disease management plan include:

• dietitian
• physiotherapist
• exercise physiologist
• psychologist
• podiatrist

These referrals are supported through the Medicare Benefits Schedule chronic disease management items.

See MBS Item 965 for more information.

You can also read our breakdown here:

👉 The Real Power of Item 965 and 967

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Monitoring Patients With Multimorbidity

Patients with multiple chronic diseases require regular monitoring and review.

This may include:

• pathology monitoring
• medication reviews
• symptom tracking
• allied health follow-up

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

For a broader perspective on long-term care planning, see:

👉 Managing Chronic Disease as a Lifetime Project

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Technology and Multimorbidity Care

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

Modern AI clinical documentation tools can assist by:

• capturing consultation notes
• identifying chronic disease diagnoses
• generating structured care plans
• organising goals, referrals, and follow-ups

Learn more about AI documentation tools here:

👉 AI Scribe Complete Guide

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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, improving both patient outcomes and continuity of care.

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