Multimorbidity
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Multimorbidity

Multimorbidity means having two or more long-term health conditions, such as heart disease, dementia, or diabetes. It is common in older adults, especially those in aged care, and makes care more complex. Managing multiple conditions at once can lead to high treatment burdens, frequent medication use, and difficulty maintaining quality of life. For aged care nurses and care workers, understanding multimorbidity is essential to providing person-centred care, preventing unnecessary hospital visits, and ensuring that care decisions focus on comfort, dignity, and the person’s own preferences.

What I can do

People with multimorbidity often experience a fluctuating and heavy symptom burden. Instead of managing each condition separately and according to guidelines, a more effective approach focuses on:

  • Dealing with the most pressing problems the person is experiencing
  • Prioritising what matters most to the person, their family or carers
  • Ensuring care is well coordinated and not burdensome and disruptive to the person and their life.

To assess the impact of multimorbidity:

  • Ask: ‘How are your conditions affecting your quality of life?’ or ‘Have you noticed any recent changes in your wellbeing that you’d like to discuss?’
  • Use the Instrument for Patient Capacity Assessment (ICAN) (334kb pdf) assessment tool to evaluate how the person is coping with care and its coordination

If you notice signs of deteriorating health, use the Supportive and Palliative Care Indicators Tool (SPICT 315kb pdf or SPICT-4ALL 371kb pdf) to assess wellbeing.

What I can learn

People with multimorbidity often need to balance symptom management and medication side effects to maintain their ability to do what matters most to them. The Communicating benefits and harms modules by the Australian Commission on Safety and Quality in Health Care (ACSQHC) can help you support them in making these complex decisions.

For more detailed information on multimorbidity, read:

What I can give

If a family member or carer is struggling with the demands on supporting someone with multimorbidity, these self-assessment tools may be helpful in discussing their own needs with a GP:

What I can suggest

The aged care team plays an important role in managing multimorbidity by adopting a person-centred, coordinated, and proactive approach. Consider:

To improve care coordination for the person:

  • Hold regular case conferences with the person, their GP, specialists, and family/carers to review care plans and adjust treatment based on evolving needs
  • Use digital care plans that allow all healthcare providers to access up-to-date information on the person’s conditions, medications, and preferences.
  • Designate a key worker or care coordinator to help navigate services, appointments, and follow-ups, reducing the complexity for the older person and their family and carers.

Establish clear protocols on when and how to escalate care, reducing unnecessary hospital transfers by using virtual health consultations or palliative care support. Anticipatory prescribing and care planning can help.


Page updated 27 February 2025