Multimorbidity in Australia

Self-management is an important aspect of the treatment and management of many chronic conditions. This may involve taking medication as prescribed or completing exercises prescribed by a physiotherapist.

People living with multimorbidity have more frequent and longer medical appointments and more medications to manage than those without multimorbidity (RACGP 2023).

Most care for chronic conditions is provided in the primary health care setting by general practitioners (GPs), nurses and allied health practitioners (RACGP 2023), with the number of GP visits increasing with the number of chronic conditions a person experiences (Dobson et al. 2020).

People aged 45 and over with multimorbidity also have higher acute care service use (including hospital and emergency department visits) than people without multimorbidity (Kabir et al. 2024).

This increases the complexity of patient care and can require ongoing management and co-ordination of care across multiple parts of the health system by both patients and practitioners. Supporting co-ordinated care for people living with chronic conditions and multimorbidity is an important priority.

Supporting co-ordinated care

In Australia, co‑ordinated care for people with chronic and complex health conditions and multimorbidity is supported by various programs.

• Medicare-subsidised chronic disease management services support co-ordinated care for people with chronic and complex health conditions, including those with multimorbidity. In 2022–23, 16% of the Australian population (4.1 million people) accessed co-ordinated care through a GP chronic disease management plan (AIHW 2024).
• Home medicines reviews (also known as medication management reviews) involve a patient’s GP working with a pharmacist to thoroughly check the patient’s medications, with the aim of maximising therapeutic benefits and reducing the risk of medication-related problems. In 2023–24, there were almost 167,000 medication management review services provided – 91,200 for people living in the community (MBS items 245 and 900) and 75,300 for people living permanently in residential aged care (MBS items 249 and 903) (Services Australia 2025).
• The MyMedicare voluntary patient registration model that gives patients access to greater continuity of care by providing additional funding to their nominated regular care team to manage their care. As at 10 April 2024 there were over 1.0 million patients (3.9% of all patients) and 5,800 practices (91% of all practices) registered with MyMedicare (Department of Health and Aged Care, personal communication, 17 April 2024).
• The Fast Healthcare Interoperability Resources (FHIR) Accelerator Program Sparked supports multidisciplinary care and improves co-ordination and continuity for individuals living with chronic and complex conditions by focusing on enabling consistent, reuseable and interoperable data capture across healthcare settings. This supports co-ordinated care through the digitisation of chronic condition management forms and the standardisation of digital health data.