Clinical Research Directory

PATIENTS: Inclusion Criteria: * ≥ 65 years; * With multimorbidity (diabetes or hypertension plus one of the following: arthritis (osteoarthritis and rheumatoid arthritis), asthma, atrial fibrillation, Alzheimer's disease and related dementia (not severe), cancer, chronic obstructive pulmonary disease, depression, heart disease, heart failure, hyperlipidemia, osteoporosis, kidney disease and stroke. Patients with diabetes plus hypertension are eligible. * Have had two or more clinic visits in the previous 12 months; * Plan on receiving ongoing care at the clinic with the enrolled clinician for the subsequent 6 months; * Do not have vision or hearing problems that cannot be corrected; and * Have not recorded a clinic visit for personal use in the past 6 months Exclusion Criteria: * With no capacity to consent to the project; * With schizophrenia and other psychotic disorders, current substance-use disorders, uncorrected hearing or visual impairment; * Living in skilled nursing homes or hospice, because they engage less in self-management; * With cognitive impairment as identified by a score of ≤3 on the six-item screener (SIS) * Lacking internet access; * Who do not speak English or Spanish; * Who (i) do not have access to a personal email, (ii) do not have an email address shared with a family member or patient-identified caregiver, and/or (iii) are not interested in creating a personal email as this would prevent them from engaging with the intervention(s); and * Who do not wish to create a patient portal account, if they do not already have one as this would prevent them from engaging with the intervention(s). CAREGIVERS: Inclusion criteria: * Agree to their identified role as a caregiver; * Speak English or Spanish; * Have capacity to consent to research participation; and * ≥ 18 years. Exclusion criteria: * No capacity to consent to the project; * Living in skilled nursing homes or hospice; * Lacking internet access; or * Do not speak English or Spanish