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Coordinated Care for Patients With Multiple Chronic Conditions

Bring medications, diagnoses, specialists, behavioral health needs, and social barriers into one more connected care strategy.

Doctor showing a digital tablet to a senior woman during a healthcare consultation

Complex Patients Need More Than Separate Disease Programs

Many Medicare beneficiaries live with two or more chronic conditions. A single patient may be managing diabetes, heart failure, chronic kidney disease, COPD, hypertension, depression, pain, and other diagnoses while taking medications prescribed by several clinicians.

Each specialist may provide excellent condition-specific care, but patients can still experience fragmented instructions, overlapping medications, competing priorities, and gaps between visits. Social barriers and behavioral health needs can make an already complex plan even harder to follow.

PharmD Live’s Multi-Condition Chronic Disease Management Program helps connect these moving parts through a multidisciplinary clinical team with clinical pharmacist-led medication management at its center.

Doctor discussing a healthcare treatment plan with a senior couple using a laptop

One Coordinated Model, Three Core Capabilities

Doctor checking the blood pressure of a senior woman during a home healthcare visit

Multi-Condition Disease Management

The team supports a unified, patient-centered view of the care plan. Activities may include symptom and monitoring follow-up, care-gap identification, preventive care support, post-discharge coordination, patient education, and communication across authorized treating clinicians.

The program is risk-aligned. Patients with recent hospitalization, high medication burden, poor disease control, or significant access barriers can receive a level of support appropriate to program design and clinical need.

Clinical Pharmacist-Led Medication Management

The clinical pharmacist reviews prescription medications, over-the-counter products, and supplements across the patient’s diagnoses, laboratory information, allergies, and documented treatment plans. The review can identify:

Drug interactions and therapeutic duplication
Potential dose or monitoring concerns
Medication-related adverse effects
Adherence and affordability barriers
Regimen complexity and treatment burden
Potentially inappropriate medication use in older adults
Opportunities for deprescribing discussion
Conflicts or competing priorities across conditions
Situations in which pharmacogenomic information may be clinically relevant

The pharmacist sends informed, evidence- and guideline-driven recommendations to the prescriber. The prescriber makes all therapy decisions.

Older adult organizing multiple prescription medications at home
Caregiver helping a senior woman use a digital tablet during a home healthcare visit

Program Capabilities

Comprehensive medication review and reconciliation
Multi-condition care-plan support
Polypharmacy and medication-risk review
Adherence and access support
Coordination across primary care and specialists
Post-discharge transitional care
Remote monitoring support when ordered and appropriate
Behavioral health screening and coordination
Preventive and quality care-gap follow-up
SDOH screening and resource coordination
Targeted pharmacogenomic review when clinically appropriate

Outcomes the Program Is Designed to Support

Smiling senior patient during a healthcare consultation
Improved medication safety and understanding
Better adherence across multiple conditions
Reduced fragmentation across treating clinicians
Earlier identification of clinical and medication concerns
Fewer potentially avoidable hospital and emergency visits
Improved patient engagement and confidence
Stronger HEDIS, Stars, MIPS, and value-based performance
Better visibility into social and behavioral barriers
Lower avoidable total cost of care among high-risk populations
Senior woman greeting a healthcare worker at a medical facility

Who the Program Serves

Primary care and geriatric practices
ACOs and IDNs managing high-risk attributed populations
Hospitals and health systems focused on complex transitions
Medicare Advantage plans and other payers
FQHCs and rural health clinics
Specialty organizations seeking better cross-condition coordination

Frequently Asked Questions

How does PharmD Live coordinate among multiple clinicians?

Implementation establishes authorized communication and documentation workflows. Relevant findings and recommendations are directed to the appropriate treating clinician while the patient’s primary coordinating provider maintains oversight of the care plan.

How is polypharmacy addressed?

Clinical pharmacists review the complete regimen for duplication, interactions, adverse effects, adherence barriers, monitoring needs, treatment burden, and potential deprescribing opportunities. Recommendations are sent to the prescriber, who determines whether medication changes are appropriate.

Is behavioral health included?

Behavioral health screening, follow-up, and coordination can be included based on the client’s program design and the patient’s needs. Behavioral health services are integrated with the broader chronic disease plan when appropriate.

Can social-needs support be incorporated across all conditions?

Yes. SDOH assessment and resource coordination can be embedded throughout the program because transportation, food access, affordability, housing, health literacy, and caregiver support frequently influence multiple conditions at once.

Give Complex Patients a More Connected Care Experience

Align disease management, medication expertise, behavioral support, and social-needs coordination around the whole patient.

Discuss Your High-Risk Population