Need to target the appropriate patients        Consider risk factors and risk stratification Consider interacting conditions and treatments        Clinical assessment, consideration of illness and treatment burden, frailty, communication from other care givers and medication review Consider co-existing depression which is more prevalent in multimorbidity and creates challenges for self-management and may impede effectiveness of other interventions Incorporate patient preferences and priorities and take account of factors affecting capacity to adhere to management plans        Clearly identify patient needs, priorities and values, consider goal setting, elicit views of family and carers where appropriate Individualised management        Consider shared decision making, effective communication of care plans, balancing benefits with harms of treatment and optimal medicines management Monitoring and follow up        Planned reviews built into care plans, support for ongoing self-management and optimal medicines management