Multi-morbidity: a system design challenge in delivering patient-centred care.

The National Chronic Disease Strategy provides a framework to improve ‘chronic disease prevention and care across Australia’. It is framed around single chronic illnesses. However, multimorbidity is increasingly common in our ageing population. In 2010 ~13.6% of Australians were aged between 65 and 85 years and over half of these are known to have had at least five chronic conditions. The top five co-existent conditions in Australia are cardiovascular disease, diabetes, chronic obstructive pulmonary disease (COPD), obesity, kidney disorders and cancers. By the year 2050, more than one-quarter of Australians will be aged over 65 years and consuming over 66%of the projected increased health funding. Is the rise in multi-morbidity prevalence the ‘elephant in the room’ that, if ignored in shaping tomorrow’s health system, will play havoc with the financing and performance of that system? Multi-morbidity increases the complexity of both medical management and self-management. Findings of the Serious and Continuing Illness Policy and Practice Study (SCIPPS) provide evidence of the effects of multi-morbidity on self-management and suggest urgency for the development of policies that account for these effects. SCIPPS gathered data on the lived experience of communitydwelling Australians with co-morbid chronic heart failure, complicated type II diabetesmellitus andCOPD. The 52 participants aged between 45 and 85 years with these conditions and 14 informal carers lived in western Sydney and Canberra. Eightyseven percent of participants had multi-morbidity, a figure exceeding the 70% of older Australians known to have multiple chronic conditions. Self-managed care or the ‘active participation by people in their own health care’ is central to the National Chronic Disease Strategy that assumes the involvement of family and/or other carers in the process of achieving ‘better patient outcomes and improved health’. However, SCIPPS findings suggest that some groups of patients, particularly those with multi-morbidity, may not achieve these goals. Additional time required to manage illnesses, along with increased dependency on others, caused patients to reduce or neglect some health needs.Multi-morbidity, particularly with comorbid depression, jeopardised participants’ capacity to modify lifestyle factors such as reducing alcohol intake or increasing daily activity levels, the capacity to recognise the signs and symptoms of a single illness that affected the participants’ decision making and help-seeking behaviours, and the capacity to manage multiple medications. The interactions between various chronic illnesses multiplied the complexities of self-management to the degree that in some cases self-management may have been detrimental to the participant’s health. Reduced capacity to self-manage frequently resulted in depression and the interplay of symptoms sometimes caused patients to withdraw from otherwise helpful programs. Effective self-management may contribute to secondary prevention. Participants with multiple chronic illnesses, particularly older participants andmigrants, were frequently overwhelmed by the requirements of self-management, and experienced increased confusion and additional costs related to self-management. Economic hardships associated with self-management of multiple chronic illnesses arose through the accumulation of related out-of-pocket expenses. A single chronic illness, type two diabetes mellitus for example, might require lifestyle changes such as dietary modification and exercise, neither of which are covered by financial rebates, and might not of themselves cause undue financial pressure. However, compounding incidental expenses associated with the self-management of several illnesses, such as home oxygen in the case of comorbid COPD, the out-of-pocket costs multiply. The Medical Benefits Scheme, Pharmaceutical Benefits Scheme and Medicare rebates do not cover all expenses, leaving some patients with challenging out-of-pocket expenses. Although informal family carers minimise the financial and workforce pressures on the public health system, this comes at a cost to the carer. Fifty-seven percent of the SCIPPS carers were managing their own chronic condition and 71%of the carerswere