Category	Item	Factors
Physiological functioning
Medical parameters	Treatment of risk factors CVD	Treat risk factors CVD according to CVD guideline
		Optimize cardiovascular risk profile
	Treatment of elevated cholesterol	Reduce elevated cholesterol
	Treatment of elevated blood glucose	Treatment of elevated blood glucose/reach target value blood glucose
		Reach target value blood glucose with education and information
		Education on influence of physical activity on blood glucose
		Improve self-management by education on self-check of blood glucose
	Treatment of elevated blood pressure	Reduce elevated blood pressure
Lifestyle	Promote healthy body weight	Advise balance for persons with healthy body weight
		Promote reduction of waist circumference for overweight or obese persons
		Promote weight loss for overweight or obese persons
		Reduce body weight
		Improve self-management with healthy diet and physical activity
	Promote healthy diet	History taking diet
		Promote healthy alcohol use
		Promote healthy diet
		Give dietary advice
	Promote physical activity	Attention for inactivity
		Advise to prevent excessive sitting
		Advise strengthening exercises for muscles and bones
		Promote physical activity
		Coaching on physical activity
		Improve endurance
	Promote quitting tobacco use	Advise or give coaching to quit tobacco use
		Advise strongly to quit tobacco use
		Advise to prevent inhaling smoke from others
		Treatment to improve motivation to quit tobacco use
Medication	Promote correct use of medication	Pay attention to correct use of medication
		Counselling for oxygen therapy
		Evaluate use of inhalation medication
		Deliver adequate pharmaceutical care through patient counselling
		Detect suboptimal medication use
		Education on goal and pharmacology of medication
		Education on use of inhalation medication aids
		Education on oxygen therapy
		Improve self-management by education on correct use of medication
	Improve therapy compliance	Discuss therapy compliance
	Improve medication safety	Deliver adequate pharmaceutical care by reviewing pharmacotherapy
		Deliver adequate pharmaceutical care by medication surveillance
		Discuss medication safety
		Medication review when prescribing new medication
		Periodical medication review by pharmacy and physician
Physical functioning
Prevention	Attention for oral care	Attention for oral care
	Attention for foot care	Advise patients on foot care and shoes
		Improve self-management with foot checks
	Attention for flu vaccinations	Yearly invitation for flu vaccination
		Education on flu vaccinations
Actual complaints	Reduce burden of cough	Reduce burden of cough by advising physical activity
		Reduce burden of cough by education on clearing sputum
		Reduce burden of cough by breathing and relaxation exercises
	Reduce dyspnoea	Reduce fear for dyspnoea by psychological counselling
		Reduce dyspnoea by breathing and relaxation exercises
		Reduce dyspnoea by adapting pace
		Reduce dyspnoea with medication
		Reduce dyspnoea by improving respiratory muscles
	Attention for self-management of exacerbations	Attention for exacerbation management
		Reduce disease burden in future: prevent exacerbations
		Education on reducing chances of exacerbations
		Education on early detection of exacerbations
		Improve self-management by composing an action plan for exacerbations
Functional (dis)abilities
Mobility	Attention for mobility	Education on possible limitations of fitness to drive
Functioning at home	Functioning at home	Advise aids
Quality of Life
Treatment burden	Reduce treatment burden	Reduce treatment burden
		Identify treatments with limited effects
		Identify medication with elevated chance of side effects
		Identify non-pharmaceutical interventions as alternatives to medication
		Identify alternative planning of appointments
		Identify ways to maximalise effect of current treatments
		Identify causes of high treatment burden
Emotional well-being	Learn coping with condition through psychological counselling	Advise contact with peers
		Treatment of adaptation problems
		Use psychosocial interventions (training for coping skills, relaxation exercises, stress-management)
		Psychosocial counselling to learn coping strategies
		Education on the condition
		Education on coping with the (consequences of) chronic condition
		Pay attention to psychosocial factors (fear of dyspnoea, shame, sexual problems, social isolation, depression) A
	Support for psychological problems	Support for psychological problems
		Reduce stress, fear, sadness, and depression
Social functioning
Social relationships	Attention for social relationships	Discuss important themes in partner relationship
		Discuss communication to others
		Pay attention to social context of patient
Labour participation	Improve labour participation	Advise occupation physician for work related problems
		Discuss communication at work
		Support for reintegration: reduce burden, improve capacity
		Reduce disease burden in future: prevent invalidity and incapacity for work
		Education on the possible limitations for work

CVD: cardiovascular disease.