Table 3.

Barriers Regarding the Healthcare Systems That Were Primarily Designed to Address Individual Health Conditions from the Perspective of Stakeholders

Stakeholders	Barriers
Patients	Disease and treatment burdens
	Lack of communication skills with healthcare professionals
	Lack of knowledge, skills, and confidence in self-management
	Conflicting information from healthcare professionals of different disciplines and settings
	Insufficient information adaptation of healthcare professionals based on patients’ needs and capacities
	Insufficient social support
	Preferring a passive role in the process of healthcare
Informal caregivers	Lack of knowledge, skills, and confidence in providing informal care
Healthcare professionals	Insufficient evidence base
	Insufficient awareness of shared decision-making with patients and informal caregivers
	Lack of knowledge, skills, and confidence in addressing multimorbidity
	Lack of communication skills with patients, informal caregivers, and other professionals
	Low medical adherence of patients
	Conflicting priorities, preferences, and goals on decision-making among two or more informal caregivers
	Heavy workloads
Healthcare managers	Fragmented and poorly coordinated healthcare system
	Insufficient human resources
	Insufficient information and communication technology support
	Lack of appropriate quality metrics designed for patient-centered, coordinated, and continuous healthcare
Policymakers	Lack of efficient and sustainable reimbursement and payment mechanisms
	Insufficient chronic care resources and health inequality