Management of patients with multimorbidities during Covid-19

Promoting primary care services to mitigate undetected deterioration or a surge in the presentations of post-lockdown non-Covid-19 related morbidities should be a priority

Encompassing forms of arthritis, chronic respiratory diseases, diabetes, coronary heart disease and cancers, a chronic disease is a health condition that is long-lasting and persistent. Approximately one million people in Ireland today have a chronic disease.

The Irish Longitudinal Study on Ageing (TILDA) reports that 64.8 per cent of 65-year-olds in Ireland live with one or more chronic illnesses, otherwise termed ‘multimorbidity’. This is compounded by one-in-three patients also having a coexisting mental health condition. Multiple medications are often being prescribed in the management of multimorbidities. This is commonly referred to as ‘polypharmacy’.

Polypharmacy can result in further health complications, and be costly and challenging for both patients and healthcare professionals to manage. While multimorbidity has emerged as one of the greatest healthcare challenges, it is also recognised as the success of our healthcare professionals and our healthcare system.

Chronic disease management with the middle-aged and older populations accounts for the majority of healthcare utilisation and expenditures. Currently though, the complexity of healthcare delivery for people living with chronic diseases has been challenged by the acute public health crisis resulting from the Covid-19 pandemic.

Cocooning with limited access to outdoor exercise for anyone over 70 years or having an underlying chronic illness was introduced in Ireland by the HSE in March 2020 as a measure to protect the health and safety of the most vulnerable populations in our communities. These measures, as described by Heckman, a Canadian geriatrician, are likely to impede patients with multimorbidities’ routine access to healthcare, particularly primary care, increase psychological and physical manifestations of their chronic conditions, and therefore could indirectly increase healthcare burden.

Non-Covid patients

Noted as the ‘missing’ non-Covid patients, concerns regarding the drop-off in patients with non-Covid health concerns attending primary care in Ireland have been repeatedly expressed by Irish GPs. This has contributed to valid concerns that these patients could be experiencing relapses, a deterioration of their illnesses, or suffer new complications and potentially trigger a non-Covid-19 surge or ‘tsunami’ in morbidities, mortalities and healthcare demands as we emerge from lockdown. Heckman concludes that effective chronic disease management should be an integral part and therefore run in parallel to our pandemic response.

While the present focus on acute care response to Covid-19 by service providers in primary care and hospitals is justified, we need to evolve to effectively incorporate chronic disease management in parallel as a priority. Therefore, as healthcare professionals and researchers, we need to prioritise the exploration of safe but proactive re-engagement with patients with multimorbidities to re-engage with the primary healthcare services.
With over a third of adults reporting that Covid-19 is negatively impacting their access to medical care, healthcare practitioners are being advised to adopt alternative ways to provide necessary healthcare, particularly for patients with complex needs, such as with chronic illnesses. This includes identifying who is ‘high priority’, reassessing their needs in light of their current medication regimens, and proactively engaging with their patients using safe and appropriate means, such as remote consultations.

Fortunately, some of our existing structures can support parallel acute crisis care and chronic disease management.

Medication reviews

The National Institute for Health and Care Excellence (NICE), a UK-based advisory institute that provides guidance on best practice in healthcare provision, recommends medication reviews as part of routine assessment and management of people with multimorbidities and/or who are prescribed multiple medications. Medication reviews can be described as a structured revision and agreement of a patient’s medication regimen in light of past and current health concerns between healthcare professional(s) and patients. The main aims are for patients to know, understand and agree with the medications they are prescribed to take.

Additionally, it enables healthcare professionals to review each medication critically to confirm if they are appropriate, necessary and not contraindicated with other medications or their patients’ medical conditions.

MyComrade

There are a number of interventions in the literature that can inform this process. One of these is MyComrade, which the authors of this article are currently involved in pilot testing as a cross-border (Northern Ireland and Republic of Ireland) initiative. The intervention principally involves a collaborative medication review between two healthcare professionals, either two GPs or a GP and a pharmacist, who together review the medication prescribed in light of their medical condition of a select number of their patients (who have consented to be part of the study, are patients of the practice and are living with multimorbidities and prescribed 10 or more medications). After the review, a treatment plan is drafted in agreement with the relevant patient.

Responding to growing needs for chronic disease management has been a HSE priority for several years. Accordingly, the Integrated Care Programmes for Chronic Disease Management Programme for medical card patients was scheduled to commence in early 2020, rolling-out to all adults over a four-year period.

An update of this programme incorporating implications of Covid-19 for chronic disease management is being processed. Community hubs were opened around the Republic of Ireland in April 2020, dedicated to the assessment of possible Covid-19 patients. This measure is anticipated to increase capacity in primary care for the re-engagement of people with non-Covid-related health concerns to attend their GP. Furthermore, an agreement has been reached between the HSE and the IMO by which GPs will be remunerated for provision of remote consultations to support and maintain regular essential healthcare consultations, as well as to assist in the efforts to combat Covid-19 (HSE, 2020).

It is potentially feasible that the MyComrade intervention could be adapted to accommodate medication reviews for the most at risk, which are communicated virtually as part of a proactive remote consultation.

Furthermore, GPs registered with the chronic disease management programme advocated by the HSE would have generated a list of their vulnerable patients. Proactive remote consultations, supported by the HSE, could increase primary care engagement with patients known to have multimorbidities. A remote consultation also removes the infection risk and worry that a practice-based consultation would involve.

In summary, is the current reported drop in patients seeking GP consultation an opportunity for GPs, using similar processes as MyComrade, to proactively identify, conduct medical reviews and remote consultations with persons who are at high risk? And in doing so, can they utilise and expand on methodologies to help address chronic care management during or after a national health crisis, such as the current Covid-19 pandemic?

References on request