When Multimorbidity Meets System Fragmentation

SCENARIO

A 52-year-old woman is living in temporary shelter accommodation. She presents with:

• Poorly controlled type 2 diabetes

• Chronic obstructive pulmonary disease (COPD)

• Hepatitis C

• History of injection drug use

• Major depressive disorder

She has visited the emergency department five times in the last six months for hyperglycaemia and respiratory exacerbations. She has missed multiple outpatient appointments with endocrinology and hepatology. Shelter staff report increasing withdrawal and irregular medication use.

She reports feeling “tired of repeating her story.”

ANNA

Health perspective

“Clinically, this is advanced multimorbidity. Diabetes alone requires stable routines, diet consistency, glucose monitoring and medication storage. COPD requires inhaler adherence and environmental stability. Hepatitis C requires long-term antiviral treatment and follow-up.

Her emergency visits are predictable outcomes of poor chronic disease control. But the question is: is this medical non-adherence — or structural impossibility?”

She pauses.

“Insulin requires refrigeration. COPD inhalers require consistency. Antiviral therapy requires continuity. Without stable housing, disease management is structurally compromised.”

PAUSE AND REFLECT

What parts of her treatment plan assume stability?

Is the care plan realistic given her living conditions?

At what point does repeated emergency admission become a system failure?

MAREK

Social care perspective

“She is living in a shared shelter with limited privacy. Medication can be stolen. Storage is unsafe. Curfews restrict flexibility. Transport to outpatient clinics requires multiple transfers. Appointments are scheduled weeks apart in different locations.”

He continues:

“She must manage diabetes, respiratory care, hepatitis treatment, and depression while also securing food, navigating shelter rules, and dealing with stigma. Administrative systems require identification, scheduling and punctuality — all of which assume stability.”

PAUSE AND REFLECT

Which barriers are logistical?

Which are administrative?

Which are embedded in system design?

What would happen if housing stability were introduced first?

EVA

Lived experience perspective

“When you're constantly uncertain about where you'll be next month, long-term health feels abstract. Depression makes planning difficult. If you've been treated as 'non-compliant,' you stop explaining yourself.”

She adds:

“Emergency departments feel more accessible. No appointment needed. Immediate attention. Then discharge — back to the same instability.”

PAUSE AND REFLECT

How does depression alter executive functioning?

How does stigma reduce engagement?

Is emergency use irrational — or adaptive within the system?

Deep Analytical Layer

This case demonstrates trimorbidity:

Physical illness (diabetes, COPD)

Infectious disease (hepatitis C)

Mental illness (major depression)

Substance use history

Each condition worsens the others:

Diabetes increases infection vulnerability.

Depression reduces medication adherence.

COPD worsens with smoking and environmental exposure.

Hepatitis C complicates medication choices.

Substance use history influences provider bias.

The system responds episodically, but her conditions require continuity.

Ethical Tensions

ANNA

reflects:

“Repeated discharge into unstable housing raises ethical concerns. Are we fulfilling beneficence if we treat acute symptoms but ignore structural triggers?”

MAREK

asks:

“Is it ethical to require appointment adherence in a system designed for housed patients?”

EVA

adds:

“When you're labelled 'complex,' it often means the system isn't designed for you.”

Reflect:

Where does responsibility lie?

Does equity require disproportionate resource allocation?

When does system design become ethically problematic?

Intervention Analysis

Consider potential responses:

STAIRCASE MODEL

Would requiring abstinence and staged progression stabilise her diabetes and COPD?

Likely outcome:

Delayed permanent housing

Continued instability

Recurrent emergency use

HOUSING FIRST APPROACH

Immediate permanent housing combined with:

Integrated primary care follow-up

On-site medication support

Hepatitis C treatment coordination

Mental health outreach

Harm reduction services

Likely outcome:

Improved medication adherence

Reduced emergency visits

Stabilised chronic disease management

SYSTEMS INSIGHT

Her repeated hospitalisations are not simply clinical deterioration.

They are signals of:

Fragmented care pathways

Housing instability

Administrative barriers

Lack of coordinated follow-up

Complex patients are often reflections of complex systems.

Guided Integration Reflection

Consider the following questions:

Which social determinant most directly undermines her health management?

How does multimorbidity increase emergency dependence?

Which barrier is most modifiable in the short term?

What would integrated discharge planning include?

How would a trauma-informed approach alter engagement?

Take a moment to synthesise your thinking.

CLOSING SPARRING INSIGHT

Multimorbidity in homelessness is not only medical complexity. It is systemic complexity.

Integrated care reduces that complexity not by simplifying patients — but by redesigning systems around real-life conditions.