Anticipated strengths and weaknesses of the care program in comparison to usual care * Integral health status Digital questionnaire Conversation with practice nurse Setting goals Care plan Communication with other healthcare professionals Time investment for patients Potential points of improvement of the care program in comparison to usual care * Integral health status Digital questionnaire Conversation with practice nurse Setting goals Care plan Communication with other healthcare professionals Time investment for patients

* The regular chronic disease management programs (DMPs) focusing on management of a single chronic disease in which a patient was included, as described in the Introduction.