Table 1

Multiple Levels and Examples of Key Contextual Factors

Contextual CategorySubcategoryExamples
BiologicalOrgan system
Cellular mechanisms
Genetic and physiological mechanisms that create interaction effects between diseases and treatments
Basic understanding of multimorbidity
PersonPersonal goals and preferencesGoals and preferences for process and outcomes of care
Personal hopes and expectations and life goals (short and long term)
Concerns about care
Medical characteristicsFunctional status
Degree of symptom distress—especially pain
Mental health, cognition, mood
Complexity of conditions and care regimen
Specific dominant conditions
Capacity for self-care
Cultural factorsLanguage
Race, ethnicity, cultural background
Personal preferences (eg, religiosity, privacy)
Ability to advocate for self
ResourcesFinancial resources
Insurance benefits
Housing, living situation
Transportation and access to care
Educational attainment, literacy
Health literacy and numeracy
Social isolation, connectedness to others, communication
Presence of family, unpaid caregiver
Peer support
FamilyCapacity of family to provide careAbility to provide care and personal services
Emotional support
Proximity and availability
Financial resources
Ability to advocate for patient within health care system
Legal considerations
Social and cultural context of familyFamily dynamics (including potential for abuse, neglect)
Cohesion and ability to make decisions as a unit
Family’s connection to the community and health care system
Preferences for care and caregiving, including location for caregiving
CommunityPhysical characteristics of the communityClimate
Urban, rural, suburban
Connectivity of community—eg, broadband, telephone, other resources
Transportation system (including accessibility)
Safety of community
Potential for recreation
Physical infrastructure and built environment
Healthy food, air, and water quality
Health care infrastructureLink between community resources and the health care system
Health care marketplace
Available clinicians
Implementation of health care policy
Availability and skills of community health workers
DemographicsSocioeconomic status of community
Diversity (race, ethnicity, sex, age, culture)
Social cultureCivic culture (eg, organized volunteer groups)
Employment for individuals with multiple chronic conditions
Acceptance of diversity, openness to interventions etc
Social networking, social norms
Health care systemDeliveryContinuity of care
Access to mental health care
What is measured and incentivized
Accessibility of system: responsiveness, ease of communication, patient centeredness
Integration, fragmentation, structure of health care system
ResourcesFinancing, sources of revenue, reimbursement structure
Physical infrastructure
Extent of and allocation of resources
Communications and information technologyInformation systems
Patient and caregiver access to information systems and information
Information flow—between whom?
WorkforceSupply—professional and nonprofessional
Abilities and skills
How systems use care teams and who is on them
Education and trainingScope of practice
Match between training and needs
Ongoing workforce education and training
PolicyFinancialWhat is paid for, and what is not paid for?
By whom? To whom? For what? Who is eligible?
Benefit design
QualityWhat is measured? What are the outcomes that matter?
Which measures are imposed in which settings?
Legal, regulatoryScope of practice, licensing laws
Privacy protection
Health care workforce protections, labor laws
Political environmentLocal and policy effects
Economic environmentEffects on community, health care system
Media environmentWhat is communicated? To whom?