Multimorbidity Is Now Regarded as the Norm for an Aging PopulationCase management is a vital strategy for hospitals and health plans seeking to obtain the best possible outcomes for people with multiple comorbidities, research shows.
This state, called “multimorbidity,” means a patient is suffering from at least two chronic diseases such as cardiovascular disease, lung disease, and Type 2 diabetes.
The World Health Organization (WHO) defines multimorbidity as “the coexistence of two or more chronic conditions, where each must be a non-communicable disease, a mental health disorder, or an infectious disease of long duration.”
In a systematic review of 27 studies that examined five models of care, the Centers for Disease Control and Prevention (CDC) wrote care management, case management and disease management are the most promising models for those suffering multimorbidity.
The study also found that multimorbidity is now regarded as the norm for an aging population, and that focusing on a subgroup with multiple conditions may be the basis for improving healthcare outcomes.
Cost Burden Affects Patients, Organizations, and Communities
As of 2014, 42% of Americans had at least two chronic conditions and 12% had five or more. Those who had five or more chronic conditions also accounted for a disproportionate 41% of the total healthcare spending.
Hypertension and high cholesterol were the most common chronic conditions, both of which may lead to any number of cardiovascular diseases, including heart attack, peripheral vascular disease, stroke or coronary artery disease.
The management of multimorbidity has several significant challenges, not the least of which is major cost implications. Spending is a key factor driving the growth in Medicare expenditures. Patients must take on the additional cost of medications, doctor visits and lost work time.
Healthcare usage is significantly associated with the management of chronic conditions and leads to an exponential increase in financial costs and reduction in physical and mental well-being.
The impact also hits the healthcare facilities now juggling patients whose healthcare conditions may not easily fit on a specific specialty unit. In other words, although admitted for treatment of cardiovascular disease, those suffering from Type 2 diabetes continue to require the unique care needed to manage their condition.
Challenges in Healthcare Delivery
Despite the rising needs of individuals with multiple chronic conditions, the health care delivery model continues to employ a siloed approach, focusing on individual chronic diseases as opposed to an integration of care accounting for multiple conditions, medications and associated side effects.
Research into the cost for society and the healthcare system is an emerging field. However, there are studies that have tracked costs and the extent to which non-clinical factors contribute to an increasing burden associated with multiple chronic conditions. Globally, approximately one out of every three adults suffer from multimorbidity with a variation in prevalence rates from 16% to 58% in U.K. and 26% in U.S. studies based on the definition used for multiple chronic conditions.
Researchers have found that certain conditions cluster together more frequently, such as depression with stroke and Alzheimer’s disease, diabetes and cardiovascular disease and other communicable conditions with HIV and AIDS.
Although this may seem obvious in the clinical setting, clusters are important to identify in order to shift healthcare delivery and reduce overall costs to the patient, system and community. To date, the top risk factors for chronic disease are high blood pressure, high fasting glucose, smoking, high total cholesterol and high body mass index.
Case Management Central to Patient, Financial Goals
Patients are also faced with non-financial challenges such as learning how to manage overwhelming fatigue, emotional distress and activity limitations. Case managers are in a unique position to assist patients with the management of multiple diseases with the integration of emotional and mental health treatment.
Case managers also have the opportunity to assist patients in the organization of care, reducing the opportunity for confusion. In many cases, the heart specialist may not know what the endocrinologist is using to treat diabetes. One medication overlaps with another and suddenly the primary care physician is prescribing more medications to manage the side effects.
Case managers are able to recommend patients use a primary pharmacy and inform the pharmacist of the potential for medication interactions that must be evaluated.
It’s also important to keep the patient’s goals in perspective as a health care delivery model often overlooks the patient’s desire for their health. Some patients are interested in trying anything and everything, while others simply are interested in improving their quality of life.
When the patient is not comfortable with their care, this response can play a role in how they carry out their treatment and in the outcomes the patient experiences. Case managers are often able to help patients and physicians maintain realistic expectations in order to achieve a quality of life the patient is comfortable with and help the physician be successful in treatment.
In other words, the way in which the healthcare delivery system is organized encourages fragmented care and often reduced healthcare outcomes. Care coordination is usually the missing link that may help to organize medical and social service providers to offer the most effective and coordinated care possible to the patient.
Wallace, E., Guthrie, B., Salisbury, C. Managing Patients with Multimorbidity in Primary Care. (2015) The BMJ; 350:h176
Editorial. Making More of Multimorbidity: An Emerging Priority. (2018) The Lancet; 391(10131):1637
Editorial. Caring for People with Multiple Chronic Conditions. (2015) The Centers for Disease Control and Prevention Vol 12
The Hospital and Healthsystem Association of Pennsylvania (September 20, 2017) Report Quantifies Burden of Multiple Chronic Conditions
Hajat, C., Stein, E. The Global Burden of Mulitple Chronic Conditions. (2018) Preventive Medical Reports. 12:284
Buttorff, C., Ruder, T., Bauman, M. Multiple Chronic conditions in the United States. (2017) Rand Corporation