Table 1.

Clinical vignette of a multimorbid senior for the structured process observations

Sex	Male
Age	76 years
Health insurance	Statutory health insurancea
Chronic diseases	- Type 2 diabetes mellitus - Hypertension - Atrial fibrillation - Hashimoto
Participation in special care contracts	- GP-centered care - DMP type 2 diabetes mellitus
Prevention & functional testing	- Check-up (bi-yearly) - Skin cancer screening (bi-yearly) - Prostate cancer screening (yearly) - Geriatric assessment (yearly) - Diphtheria booster (every 10 years) - Tetanus booster (every 10 years) - Influenza immunization (yearly)
Follow-up examinations	- Repeat colonoscopy in 2019 is recommended (colonoscopy 2016: tubular adenoma) - Control of INR - DMP diabetes examinations (twice a year) - Diabetes feet check (yearly) - Referral for diabetic eye check (yearly) - Thyroid control
Lifestyle characteristics	Smoker
Characteristics/impairments	- Receives oral anticoagulants - Poor hearing and poor eyesight - Sometimes nagging - The patient’s advance health care directive is deposited in the practice
Persons involved in care processes	- Mobile nursing service that helps the patient to put on the compression stockings to prevent leg ulcer in venous insufficiency - Next of kin has to be involved in care decisions

^aNearly every person living in Germany has a health insurance, either private or statutory. About 90 % are members of the statutory health insurance (sickness funds), which is financed predominantly by contributions paid by employers and employees