Eligibility criteria
CHRONIC DISEASES
Patients (or a legal representative) must provide written informed consent before any study procedures occur. The inclusion criteria are as follows: at least 18 years of age; medical diagnosis of at least three chronic diseases that have led to GP treatment in at least three out of four quarters in the last twelve months; and insured by statutory health insurance. The exclusion criterion is a life expectancy less than 12 months as assessed by the treating physician.