Integrated multimorbidity management in primary care: why, what, how, and how to?

The epidemic of multimorbidityPolicymakers regard “the epidemic of multimorbidity” as the greatest threat to the sustainability of healthcare systems. They believe the solution is “integrated care”, “The search to connect the healthcare system (acute, primary medical and skilled) with other human service systems (e.g. long-term care, education and vocational and housing services) in order to improve outcomes (clinical, satisfaction, and efficiency)” [1]. This definition includes key characteristics of complex adaptive systems. People act as agents who evolve in their characteristics and behaviours over time. These agents constantly learn and adapt in real time to changing contexts. These systems display emergent dynamic non-linear behaviours resulting from ongoing iterative feedback amongst their agents.Emergent outcomes do not have linear “cause and effect” relationships and can best be understood in hindsight. Emergent behaviours are highly sensitive to context; consequently, the “same” approach used by different agents in different contexts will not produce the same outcomes. Agents navigate toward mutually agreed outcomes by constantly adapting to evolving changes within the context of local constraints [2].A complex adaptive system approach overcomes many of the dysfunctions in the current health systems, in particular the fragmentation of patient care [3]. Overcoming fragmentation requires continuous adaptation to changing circumstances – a constant challenge for patients, health professionals, community service providers, and policymakers.How can the already overburdened primary healthcare services achieve these goals?To address the complex challenge, we first must reflect on three key questions:What is health?What is disease?What is multimorbidity? Journal of Comorbidity 2016;6(2):114–11