Fig. 2

Visualisation of the development process including one exploratory phase and four act-observe-reflect-adjust co-creation cycles. A To optimise diversity in the selection of persons with multimorbidity, GPs suggested to cluster certain chronic conditions, such as cardiovascular risks and diseases, asthma and COPD, and several osteoarthritis conditions. B GPs generated a patient list in which patients were grouped based on information extracted from the EMR by means of uniform queries developed for this project. C i.e. joint EPCC with GP and then independently with patients they already treat in DMPs. D GPs expected these patients to benefit from an EPCC, i.e. patients with polypharmacy, patients without any diagnosis eligible for a DMP, “frequent attenders” (i.e. patients with >31 face-to-face consultations, telephone consultations or home visits (CTV) in two years) and “low-attenders”(less than 10 CTV in two years). E SeeFig. 1 (Step 3)