MICA · FIRST-LINE LEARNING NOTES
Understand, prioritise and organise follow-up
Long-term care coordinates conditions around the patient's life goals. It seeks clinical control, treatment safety and a manageable care burden with clearly assigned responsibility.
Prepare a priorities-based review
Gather new symptoms, results, admissions, specialist reviews and the actual medication list. Ask what matters most: pain, breathlessness, fatigue, independence or care organisation. A repeat-prescription visit may uncover deterioration or adherence problems. Multimorbidity requires more than mechanically adding guidelines developed for individual conditions.
[1]Review benefits, risks and treatment burden
For each medicine, assess current indication, response, adverse effects, administration and monitoring. Compare prescriptions, reported use and discharge information to find omissions, duplication and misunderstood changes. Explore cost, access, device use and available support. Any simplification or deprescribing is agreed with the patient and prescribers and includes follow-up.
[2]Prepare follow-up around patient priorities and the practical burden of care. Combining separate disease guidelines can create conflicting targets and difficult polypharmacy. Review function, fatigue, pain, mental health and available support. Distinguish a laboratory target from benefits in symptoms, functioning or prevention of complications.
[1][2]Build a shared care plan
Explain options, benefits, drawbacks and uncertainty, considering preferences and the ability to act. Use absolute risks when suitable data are available and check understanding through teach-back. Define goals, necessary tests, responsible professionals and review timing. Specify how to obtain advice between appointments and how information will be shared.
[3][1]Maintain continuity and anticipate change
At review, assess progress towards goals and adverse effects, not only numerical targets. After admission or treatment change, bring reconciliation and monitoring forward where needed. Provide condition-specific warning signs and relevant written illness plans. Record who follows results and when the care plan will be revised, with explicit communication to other clinicians.
[1][2]A learning situation
FICTIONAL CASE · SELF-REFLECTION WITHOUT A SCORE
After hospital discharge, a patient with diabetes, hypertension and kidney disease brings three different prescriptions. They take every available tablet and report dizziness, but assume they must wait for the next specialist appointment.
What should precede prescription renewal?
References and scope
- Multimorbidity: clinical assessment and management — Recommendations ↗
- Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes — Recommendations ↗
- Shared decision making — Recommendations ↗
Original educational synthesis for adult first-line practice. International references must be interpreted with the clinical setting and local care pathways. Independent human scientific review remains to be confirmed.