Beyond Single-Disease Care: Multimorbidity, Treatment Burden and Prioritizing Care Around What Matters to Older People in Viet Nam
AGE-FRIENDLY CARE QUALITYINTEGRATED CARE & CARE TRANSITIONS
Beyond Single-Disease Care: Multimorbidity, Treatment Burden and Prioritizing Care Around What Matters to Older People in Viet Nam
AGE-FRIENDLY CARE QUALITY, INTEGRATED CARE & CARE TRANSITIONS
Last reviewed: October 2026
An older person may see one clinician for diabetes, another for heart failure, another for chronic kidney disease and another for osteoarthritis. Each condition may be treated appropriately according to its own clinical guidance. The person may leave with several medicines, laboratory tests, dietary instructions, monitoring tasks and follow-up appointments, each individually reasonable.
But the person has to live with all of them at once.
For an older adult with several chronic conditions, the central quality question is therefore not simply whether each disease is being treated correctly. It is whether the combined plan remains safe, beneficial, manageable and aligned with what matters most to the person.
Multimorbidity is commonly defined as the coexistence of two or more chronic conditions in the same person. Yet that definition alone tells us relatively little about how difficult care will be. Two people may both have four chronic conditions, while one remains active with a relatively simple treatment plan and the other lives with frailty, pain, multiple medicines, frequent appointments, functional limitations and a family struggling to coordinate care.
For healthcare organizations in Viet Nam, the challenge is therefore larger than managing individual diseases well. It is learning how to see and manage the whole person when disease-specific plans begin to interact.
Multimorbidity is more than a count of diagnoses
Counting chronic conditions is useful for research and population monitoring, but clinical care needs a richer picture. A person living with hypertension, well-controlled diabetes and stable osteoarthritis may have very different needs from someone living with heart failure, chronic kidney disease and dementia, even if both technically meet the definition of multimorbidity. Severity, functional impact, prognosis, treatment interactions, cognition, frailty, social circumstances and the person’s own priorities all matter.
WHO’s healthy-ageing work increasingly places this complexity within a broader person-centred framework. The 2024 WHO Clinical Consortium on Healthy Ageing included specific work on multimorbidity and its implications for care and identified a need to position multimorbidity more clearly within healthy ageing, including its relationship with intrinsic capacity and functional ability.
The difficulty becomes particularly visible when several disease-specific guidelines are applied at the same time. An older person may be asked to take medicines at several times of day, monitor blood glucose and blood pressure, follow dietary advice, attend multiple specialty clinics, complete laboratory tests, perform rehabilitation exercises and recognize different warning signs. One clinician may adjust a medicine prescribed by another, while recommendations that are appropriate for one disease can become more complicated in the presence of renal impairment, frailty or another treatment.
The problem is not that the individual guidelines are necessarily wrong. The problem is that the person has to implement the combined plan in one life.
A major review in Nature Reviews Disease Primers highlighted this structural problem: healthcare education, organization and clinical guidance remain heavily oriented toward individual diseases, while people living with multimorbidity need coordinated, person-centred and minimally disruptive care.
Recent evidence suggests that current guidance still does not address the problem consistently. A 2026 systematic review evaluated 21 guidelines and consensus documents addressing multimorbidity or polypharmacy in older adults. Methodological rigor and applicability were among the weaker domains. Fifteen documents addressed interactions, but only nine incorporated patient preferences and nine addressed monitoring strategies; only three fully followed all five steps of the Ariadne principles used by the authors to assess multimorbidity care. Overall, recommendations remained weighted toward medication safety rather than broader person-centred and longitudinal management.
Medication safety is essential. It is simply not the whole problem.
Treatment burden makes the combined workload visible
The concept of treatment burden helps explain what happens when multiple reasonable recommendations accumulate.
Treatment burden refers to the workload imposed on people by healthcare-related tasks involved in managing chronic conditions. It can include taking and organizing medicines, attending appointments, undergoing investigations, monitoring symptoms or physiological measurements, following dietary or physical-activity recommendations, coordinating between clinicians, arranging transport and dealing with administrative requirements.
The impact of this burden is shaped by both the healthcare workload and the person’s capacity to manage it. A four-medicine regimen may be straightforward for an independent older person with good cognition, vision and family support. The same regimen can become difficult for someone with memory problems, visual impairment, limited health literacy or reduced hand function. One additional hospital appointment may be minor for someone living nearby and a major undertaking for an older person who depends on a working family member to travel several hours with them.
Families can carry a substantial part of this workload as well. They may organize medicines, schedule appointments, accompany the older person between facilities, communicate with different clinicians and monitor symptoms at home. A treatment plan that looks manageable on paper may only be manageable because an unpaid caregiver is quietly doing much of the work.
When a plan becomes difficult to follow, the review should therefore consider not only the person’s circumstances but also whether the plan itself has become unnecessarily complex.
The evidence base for reducing treatment burden specifically among older people with multimorbidity remains limited. A scoping review published in August 2026 found only six eligible studies, all observational. The authors identified 11 potential strategies across healthcare-system and access factors, therapeutic regimens, and patient or psychosocial factors, but those strategies were derived from observed associations rather than tested as treatment-burden-reduction interventions.
It would therefore be premature to present any one treatment-burden framework as a proven solution. The more defensible approach is to recognize treatment burden as an important dimension of care, ask about it explicitly and test practical ways to reduce avoidable workload without removing beneficial treatment.
Prioritizing care means organizing the plan around what matters to the person
Prioritization can easily be misunderstood. It does not mean deciding that one disease deserves care while another should be ignored, nor does it mean rationing treatment simply because someone is older.
Person-centred prioritization asks a different question: given everything this person is living with, what should the overall care plan be trying to achieve now?
For one person, preventing another heart-failure admission may be the immediate priority. For another, maintaining mobility may matter most because losing the ability to walk would threaten independence. For some people living with advanced dementia, depending on prognosis, clinical circumstances and their goals of care, simplifying parts of treatment and emphasizing comfort or function may be more appropriate than adding another preventive intervention with a long time to benefit. Another older person may strongly prioritize longevity and willingly accept a demanding treatment regimen.
The answer cannot come from diagnosis alone. Prioritization needs to consider likely benefits and harms, urgency, prognosis where relevant, function, frailty, treatment workload, caregiver capacity and, critically, the older person’s preferences.
Person-centred care therefore becomes an operational necessity rather than an abstract value. Imagine an older person living with diabetes, osteoarthritis and heart failure whose main goal is to continue walking to a nearby café each morning. Diabetes and heart failure still need appropriate treatment, but knowing that independent walking matters creates a shared outcome around which pain control, mobility, cardiovascular stability, medicines and rehabilitation can be organized.
WHO’s second edition of Integrated Care for Older People (ICOPE), published in September 2025, moves care in this direction. Its pathway combines assessment of intrinsic capacity and social-care and support needs with development of a personalized care plan rather than treating individual problems as unrelated episodes.
Viet Nam has incorporated this approach into Ministry of Health Decision No. 1976/QĐ-BYT of 1 July 2026. The guidance includes assessment of cognition, mobility, vitality, vision, hearing and psychological capacity, together with relevant health, personal-care and social-support needs, before moving toward a person-centred care plan with goals identified with the older person.
This provides an important foundation for multimorbidity care: different disease-specific actions can be considered against a shared person-level goal.
Medication review matters, but treatment burden extends beyond polypharmacy
Multimorbidity and polypharmacy frequently coexist, particularly in older populations, but they are not the same thing. Polypharmacy broadly refers to the concurrent use of multiple medicines. There is no single universally accepted numerical definition, although five or more medicines is the most commonly used operational threshold in research.
Treatment burden is broader. Someone can experience considerable burden with relatively few medicines if care involves frequent appointments, difficult monitoring, complex dietary instructions, rehabilitation exercises or repeated travel between healthcare facilities.
A 2026 study from the family physician clinic at Le Van Thinh Hospital provides a useful local illustration. The retrospective cross-sectional study reviewed 351 medical records of patients aged 60 years or older attending the clinic between October and December 2022. The investigators defined multimorbidity as three or more chronic conditions and polypharmacy as five or more medicines; by those definitions, 94.9% of the study population had multimorbidity and 54.1% had polypharmacy.
These figures should not be treated as national prevalence estimates. The study involved one hospital-based family physician clinic, used a three-condition definition of multimorbidity rather than the more commonly used threshold of two and examined a selected clinical population. It nevertheless illustrates the complexity that clinicians may encounter in routine older-person care in Viet Nam.
Decision 1976 is relevant here as well. Its guidance addresses concurrent use of multiple medicines and recognizes that medication-related problems can contribute to declines in intrinsic capacity. Review of unnecessary, duplicative or potentially harmful treatment requires appropriate clinical judgment rather than simply reducing the number of medicines.
The quality objective is therefore not “fewer medicines.” It is the right medicines, for the right reasons, within an overall plan the person can realistically manage.
Coordination and care transitions are where fragmentation becomes visible
Multimorbidity exposes a fundamental limitation of fragmented healthcare: no individual clinician may be doing anything obviously wrong, yet the combined experience can still be poorly coordinated.
A cardiologist may optimize heart-failure therapy. An endocrinologist may manage diabetes. An orthopedic clinician may address joint pain. A primary-care clinician may renew several prescriptions. If these plans are not reconciled, the older person or family can become the only place where the whole treatment plan comes together.
That is a fragile form of coordination.
WHO’s integrated-care work emphasizes organizing services around the person rather than around isolated disease-based encounters. ICOPE similarly supports shared goals, personalized care planning and greater coordination across providers and settings.
This does not mean every older person with multimorbidity needs a formal case manager. It does mean the system should be able to answer basic questions: Who has the most complete view of the care plan? Who reconciles conflicting recommendations? Who reviews the full medication list? Who notices when the workload has become unrealistic? Who ensures that important specialist decisions are visible to the next clinician?
These questions become particularly important during care transitions. An older person may enter hospital taking six medicines and leave with nine, several dose changes, new monitoring instructions, rehabilitation exercises and appointments with multiple departments. At the same time, the person may be weaker, more cognitively vulnerable or more dependent on family than before admission.
A discharge plan can therefore be medically complete while still being practically unmanageable.
Good transition planning for multimorbidity needs to consider the combined post-discharge workload. Which appointments are genuinely time-sensitive? Can investigations be coordinated? Have medicines been reconciled? Does the person know which changes are temporary and which are intended to continue? Can the family realistically carry out the plan? Does primary care know what specialists changed? Has functional recovery been incorporated into the same plan?
Several individually reasonable recommendations can become one unsafe plan if nobody looks at them together.
Viet Nam already has building blocks for more integrated multimorbidity care
Viet Nam does not need to build integrated older-person care from zero.
Decision No. 1116/QĐ-TTg of 22 June 2026, which amends the Older People Health Care Program to 2030, provides that from 2026 older people are to receive a free periodic health examination or screening at least once each year and have health-monitoring and management records established. By 2030, the program also targets at least 90% of older people being detected, treated and managed for major noncommunicable diseases including cancer, cardiovascular disease, hypertension, diabetes, chronic obstructive pulmonary disease and dementia.
These measures are important because regular examination or screening and longitudinal health records can make multiple chronic conditions more visible. But detecting and managing each condition is only the beginning of multimorbidity care.
Decision 1976/QĐ-BYT adds another layer through ICOPE-based assessment of intrinsic capacity, medication-related issues, personal-care and social-support needs, and person-centred care planning in home and community settings.
Implementation has moved further through Circular No. 34/2026/TT-BYT of 8 September 2026. Under the National Target Program on Health, Population and Development, the Circular requires training and community older-person care activities to follow the professional guidance in Decision 1976.
Taken together, these instruments provide useful building blocks:
health monitoring + NCD management + intrinsic-capacity assessment + medication review + community care + personalized care planning.
The specific national instruments reviewed for this article do not, however, set out a dedicated older-person multimorbidity pathway for systematically reconciling multiple disease-specific plans, assessing treatment burden and jointly prioritizing care around shared person-level goals across providers and settings.
That should be understood as an implementation opportunity rather than a reason to create another disease-specific program.
A practical multimorbidity review can remain relatively simple
Healthcare organizations do not need an elaborate new assessment for every older person who happens to have two diagnoses. A more intensive review is most useful when the interaction among conditions, treatment and the person’s capacity becomes clinically important—for example, when there are multiple specialist teams, polypharmacy, recurrent admissions, frailty, cognitive impairment, functional decline, frequent appointments, conflicting recommendations, suspected medication-related harm or a patient or caregiver who says the care plan has become too difficult.
The review should first clarify what matters most to the person now and which problems currently have the greatest impact on safety, symptoms, function or prognosis. Not every condition needs the same degree of attention at every moment.
It should then consider which treatments offer meaningful expected benefit relative to burden and risk. Are recommendations duplicative, conflicting or no longer relevant? Could monitoring or appointments be coordinated? Medication review is part of this process, but so are investigations, lifestyle advice, rehabilitation tasks and administrative workload.
The review also needs to ask what the person and family can realistically manage. Cognition, mobility, health literacy, transport, finances and caregiver availability can all affect what is feasible. Finally, someone needs responsibility for coordinating the resulting plan so that the older person, family, primary-care team and specialists are working from the same priorities.
The output should not be another longer list of diseases. It should be one coherent care plan for one person.
Simplification may be part of that plan, but it should not be confused with simply doing less. Combining appointments may reduce travel. Removing duplicated investigations may reduce cost and inconvenience. Deprescribing an inappropriate medicine may improve safety. But necessary treatment does not become unnecessary because someone is older or has several conditions.
The more useful question is:
“What parts of this care provide meaningful benefit, and how can we deliver them with the least avoidable burden?”
That distinction is particularly important because the 2026 treatment-burden review does not establish one proven intervention package for reducing burden in older people with multimorbidity. Its proposed strategies emerged from observational evidence and should be regarded as directions for future implementation and research rather than established standards of care.
Measurement should capture whether the overall plan remains coherent
Traditional quality measures often ask whether a disease-specific target has been achieved: blood pressure controlled, HbA1c monitored, appropriate medication prescribed or follow-up completed. Those measures remain useful, but multimorbidity introduces additional questions.
Was there one reconciled medication list? Were the person’s priorities documented? Were conflicting recommendations identified? Was function considered? Did the older person or caregiver report difficulty managing the treatment workload? Were duplicated appointments or investigations reduced where appropriate? Did primary care receive relevant information after specialist or hospital treatment? Was the overall plan reviewed after a significant change in health?
Organizations might also examine emergency visits, readmissions, medication-related harm and functional deterioration, although these outcomes need careful interpretation because people living with more complex multimorbidity naturally carry greater clinical risk.
Treatment burden itself can also be measured, but Viet Nam should not assume that an international questionnaire can simply be translated and treated as a validated local instrument without appropriate cultural adaptation and psychometric evaluation.
These are illustrative quality measures, not a proposed national multimorbidity indicator set for Viet Nam. Good performance should mean more than controlling several diseases separately. It should also mean that the combined care remains coherent, safe and manageable.
Viet Nam can initially learn through focused pilots. Geriatric services, family-medicine clinics, outpatient departments, selected hospitals and commune health stations all offer potential settings. A pilot could begin with older people who have several chronic conditions plus one marker of complexity—such as polypharmacy, frailty, functional decline, recurrent hospitalization or frequent specialist use—and test a structured review combining medication reconciliation, function and cognition, treatment workload, the person’s priorities and one coordinated care plan.
The questions should be practical. Can different clinicians agree on priorities? Does the older person understand the plan? Can appointments or monitoring be coordinated? Are family caregivers carrying tasks that professionals do not know about? Does primary care receive an understandable summary? Can workload be reduced without compromising important clinical care?
International evidence should inform these pilots, but it does not provide all the answers. The 2026 guideline review found important limitations in methodological rigor and applicability, while the treatment-burden review found only a small observational evidence base.
That is a reason to test and measure carefully, not a reason to ignore the problem.
The goal is not perfect disease control at the cost of an unmanageable life
An older person does not experience hypertension on Monday, diabetes on Tuesday and arthritis on Wednesday. They experience one life in which all of those conditions, treatments, symptoms, limitations, responsibilities and goals coexist.
Good multimorbidity care therefore requires a change in perspective. Disease-specific expertise remains essential, but it needs to sit within a person-centred plan that considers function, treatment burden, competing risks, caregiver capacity and what the older person is trying to preserve or achieve.
Viet Nam’s 2026 reforms provide useful foundations through free periodic health examination or screening at least annually, health-management records, stronger detection and management of noncommunicable diseases, and ICOPE-based person-centred care in home and community settings. Decision 1976 is now also being carried into community implementation through Circular 34/2026/TT-BYT.
The next challenge is to connect those components so that detecting and treating more diseases does not simply create more fragmented care.
For healthcare organizations, the most useful question is therefore not simply “Are all of this person’s diseases being treated according to guideline?” It is:
“Taken together, is this care safe, beneficial and manageable—and does it help this older person achieve what matters most to them?”
When healthcare organizations can answer that question consistently, multimorbidity care becomes more than the simultaneous management of several diseases. It becomes part of the infrastructure for safe, age-friendly, person-centred and integrated older-person care.
References
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World Health Organization. Integrated care for older people (ICOPE): realigning primary health care to respond to population ageing. Technical Series on Primary Health Care. Geneva: World Health Organization; 2018. WHO/HIS/SDS/2018.44.
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