--- module: 071-03 language: en chapter: 71 title: "Primary Care, Prevention, Multimorbidity, and Continuity" module_title: "Management, monitoring, prevention, safety, ethics, systems issues, and longitudinal care" source_sha256: deec283c5ec893295baea398944b7bd404e0e6c5b3e0d78cbf882ba8274678b0 --- # Longitudinal management in primary care ## Goals before disease targets ### Reduce harm without overwhelming the person #### Each addition needs purpose, review, stopping rule ### Start from what matters most to the person #### Translate values into measurable goals ### Shared decisions still include clear advice ### Relax targets when harm outweighs benefit #### Age alone does not exclude effective therapy ### One integrated plan with named owners #### Patient is not the only information conduit ## Polypharmacy as dynamic exposure ### Verify what is actually taken #### Ask how medicines are organised and missed ### Prescribing cascade #### Adverse effect treated as a new condition #### Time new symptoms against medication changes ### Deprescribing when harm exceeds benefit #### No indication, duplication, high-risk combinations #### Taper some, change few, monitor outcome ### Transitions are high risk #### Reconcile what stopped, started, changed #### Dosing aids do not solve intentional non-use ## Monitoring that answers questions ### Control, toxicity, adherence, progression ### Interval from kinetics, stability, actionability #### Too often detects noise, too rarely misses decline ### Condition reviews beyond refills ### Home monitoring: agency versus anxiety #### Validated devices and response pathway #### Wearables give false alarms ## Prevention by absolute benefit ### Life-course review of preventive care #### Bundle, but do not displace the concern ### Smoking cessation benefits at every age ### Weight counselling without stigma ### Specific physical activity prescriptions ### Screening weighs life expectancy, overdiagnosis #### Stopping must not imply life matters less ## Adherence by reducing friction ### Intentional, unintentional, structural #### Diagnose the barrier, not moral failure ### Simplify dosing, align refills, involve pharmacists ### Teach-back and motivational interviewing ### Written action plans for episodic conditions #### Baseline, warning signs, steps, when to seek help ## Referrals and transitions ### Referral states question, urgency, goals ### Referrer responsible until transfer accepted #### Bridging care and escalation criteria ### Reconcile advice with whole-person plan ### Early post-discharge period is high risk #### Early contact checks symptoms, medicines, support ### Multidisciplinary care needs explicit roles ## Digital care and access ### Telehealth cannot replace every examination #### Confirm identity, location, privacy ### Portals may exclude some patients #### Urgent symptoms not via asynchronous messages ### Automated summaries need verification ### Missed appointments are clinical information #### Proportionate outreach ## Relational ethics ### Warmth within professional limits ### Confidentiality in family and community ### Honest disclosure of errors and delays #### Second opinion or complaint without fear ### Carer involvement with consent #### Assess carer health separately ### Changed capacity: legal pathway, prior values ## Success through function and experience ### Outcomes beyond biomarkers #### Lower value is not success if patient falls ### Periodic whole-plan reviews #### Ask what could be stopped ### Anticipatory and advance care planning ### Cycle: prioritise, act, measure, simplify, revise