Best Practices for Multimorbidity Management in Community Settings

Multimorbidity—the presence of two or more long-term health conditions—has become a central concern for community health systems. A person may be living with diabetes, cardiovascular disease, chronic kidney disease, arthritis, depression or obesity at the same time, with each condition affecting the others. Treatment becomes difficult when services operate separately, medication lists grow, and care plans are built around diseases rather than daily life.

The 2023 APEC Conference on Promoting Community-based Non-Communicable Diseases Integrated Care Model highlighted practical ways to bring prevention and chronic disease management closer to where people live. Its focus on ageing populations, integrated services and hybrid knowledge sharing remains relevant in Australia, where local primary care teams, Aboriginal Community Controlled Health Services, pharmacies, hospitals and digital providers all have a role in coordinated care.

Build one shared picture of health

Effective multimorbidity care starts with a complete picture of the person, not a series of isolated diagnoses. A community team should record current conditions, symptoms, medicines, allergies, functional limitations, mental health needs, social circumstances and the person’s own treatment priorities. This helps clinicians recognise interactions that may be missed during a short appointment focused on one disease.

A shared care plan can identify who is responsible for monitoring blood pressure, adjusting medicines, arranging pathology, supporting physical activity and following up after hospital discharge. It should also state what the patient needs to do, which warning signs require urgent attention and when the plan will be reviewed. Plain English matters, particularly when several professionals are involved and health information is being discussed with family members or carers.

Australia’s Medicare-funded general practice system provides an important foundation, but coordination can be uneven between metropolitan clinics and smaller services. My Health Record, secure messaging and linked clinical systems may reduce duplication when they are used consistently. A patient in western Sydney should not have to repeat their entire history to every service, just as someone in regional Queensland should not lose continuity because a visiting specialist is available only once a month.

Design care around priorities and capacity

Disease guidelines are useful, yet applying every recommendation to every person can create an exhausting and sometimes unsafe workload. Clinicians need to agree on priorities with the patient. For an older adult with heart failure, diabetes and osteoarthritis, preventing falls, maintaining independence and simplifying medicines may be more valuable than pursuing several tightly controlled targets that increase dizziness or treatment burden.

Shared decision-making should consider expected benefits, side effects, cost, travel, culture, health literacy and the person’s readiness to change. A staged plan is often more realistic than a long list of instructions. The first stage might address smoking, medication reconciliation and an overdue cardiovascular review; later stages can add exercise, nutrition support or weight-management services once the basic routine is stable.

Decision-making capacity also deserves careful attention when cognitive impairment, delirium or serious illness is present. Capacity is specific to a decision and can change over time, so it should not be assumed absent because a person is older or has a diagnosis of dementia. When care moves towards advanced illness, practitioners can draw on capacity assessment guidance to support respectful, well-documented choices involving the patient, substitute decision-makers and family.

Make the multidisciplinary team work

Multimorbidity management improves when each professional contributes a defined skill while the patient experiences one connected service. A GP or nurse practitioner may coordinate the overall plan; a practice nurse can track recalls and education; a pharmacist can review medicines; a dietitian can adapt nutrition advice; and a physiotherapist can prescribe safe movement for pain, frailty or cardiovascular risk.

Community pharmacists are particularly valuable in Australia, where they are often the easiest health professionals to reach without an appointment. They can identify adherence problems, explain dose changes and alert the wider team to potentially harmful combinations. Referral pathways should be clear, with agreed response times and a method for sending recommendations back to the coordinating clinician.

Integrated care should also include Aboriginal health workers, interpreters, social workers and culturally safe services. Aboriginal Community Controlled Health Services can connect clinical care with family, community and broader wellbeing in ways that mainstream services may not replicate. For people from culturally and linguistically diverse communities, translated material alone is insufficient; conversations should allow time for beliefs, family roles and practical barriers to be understood.

Extend follow-up beyond the clinic

Regular follow-up is more useful when it checks how the care plan is working in everyday life. A brief phone call, nurse-led review, home visit or pharmacist conversation may reveal missed doses, food insecurity, transport problems or worsening symptoms before they result in an emergency presentation. Measures can include blood pressure and glucose where appropriate, but also confidence, mobility, sleep, mood and the ability to manage routine activities.

Telehealth can help people in remote and regional areas avoid long journeys, particularly for medication reviews, education and follow-up after a hospital admission. The value is greatest when virtual appointments are linked to local pathology, physical examinations, community nurses and reliable escalation pathways. Practical examples of rural telemedicine follow-up show why technology should strengthen local relationships rather than replace them.

In Australia, distance can mean a very different service experience for someone in the Kimberley, the Riverina or northern Tasmania compared with a patient near Melbourne’s inner suburbs. Internet access, private space, device ownership and digital confidence all affect participation. Offering a phone option, arranging an assisted video appointment through a local service and providing face-to-face alternatives helps prevent telehealth from widening inequity.

Prevent avoidable treatment burden

Polypharmacy is common among people with several chronic conditions, and the risks rise when medicines are prescribed by different services. A structured medication review should compare the dispensing record with what the patient actually takes, including over-the-counter products, complementary medicines and medicines left over from previous prescriptions. The review should look for duplication, adverse effects, dosing complexity and opportunities to deprescribe safely.

A written medicines list in large, clear print can be useful for older people and carers. Dose administration aids may support adherence, while synchronising repeats can reduce trips to the pharmacy. Clinicians should explain why a medicine is being continued or stopped and arrange follow-up after a change, rather than assuming that a printed prescription solves the problem.

Affordability is part of clinical safety. PBS costs, gaps in supply, transport expenses and the price of healthier food can shape whether a plan succeeds. Services should identify these barriers early and connect people with pharmacists, social workers, community transport, food programs or financial counselling where available. Weight management also needs a non-judgemental approach: sustainable nutrition, movement and sleep support are more useful than advice that ignores disability, pain, culture or household budgets. Patient education resources such as practical health support can complement, but should never replace, personalised clinical advice.

Measure coordination and keep learning

Community programs need measures that show whether care is becoming safer, more accessible and more meaningful. Useful indicators include unplanned hospital admissions, medication discrepancies, missed follow-ups, preventive screening, blood pressure control and referrals completed. Patient-reported measures can show whether people understand their plan, feel involved in decisions and can manage their conditions at home.

Data should be reviewed by age, location, socioeconomic status, language, disability and Aboriginal or Torres Strait Islander identity where appropriate and governed safely. A service may appear successful overall while people in outer regional areas or those experiencing housing insecurity receive fewer reviews. Local teams can use regular case discussions to examine these gaps and test small changes, such as a combined diabetes and heart-health clinic or a single post-discharge call.

The APEC conference model also demonstrates the value of sharing tools across countries and professional groups. Program books, presentation slides and virtual participation materials can help teams compare approaches, but implementation must be adapted to local resources and community priorities. In Australia, an effective model is one that works for a large urban practice, an Aboriginal community service and a small rural clinic—not a design that assumes every patient can attend multiple specialist appointments.

Health leaders, primary care teams and community organisations can turn these principles into action by auditing one high-risk patient group, mapping local referral pathways and agreeing on a shared care-plan template. The conference’s registration information provides a starting point for engaging with the event’s resources and wider discussion about integrated non-communicable disease care.

Use the available conference materials to bring clinicians, pharmacists, allied health professionals, carers and community representatives into the same conversation. Start with one practical improvement—such as a medication review after hospital discharge or a culturally safe group education session—measure what changes, and build the next step around what patients and local teams say they need.