Designing Integrated Approaches to Support People with Multimorbidity: Key Messages from Systematic Reviews, Health System Leaders and Citizens

Background: Living with multiple chronic conditions (multimorbidity) – and facing complex, uncoordinated and fragmented care – is part of the daily life of a growing number of Canadians. Methods: We undertook: a knowledge synthesis; a “gap analysis” of existing systematic reviews; an issue brief that synthesized the available evidence about the problem, three options for addressing it and implementation considerations; a stakeholder dialogue involving key health-system leaders; and a citizen panel. Results: We identified several recommendations for actions that can be taken, including: developing evidence-based guidance that providers can use to help achieve goals set by patients; embracing approaches to supporting self-management; supporting greater communication and collaboration across healthcare providers as well as between healthcare providers and patients; and investing more efforts in health promotion and disease prevention. Conclusions: Our results point to the need for health system decision-makers to support bottom-up, person-centred approaches to developing models of care that are tailored for people with multimorbidity and support a research agenda to address the identified priorities.