Model for the Integral Assessment of Chronic Disease Management Supported in Information Technology and Communication.

Inclusion Criteria: * Age ≥18 years old. * High complexity: according to a combined criteria a) predictive model of Valencia La Fe Health department for hospital resources consumption in next 12 months (probability \>95%) and b) risk confirmation by a clinical team with experience on chronic patients management. * Participants that accept to participate in the study by the informed consent signature * Participants that don't meet any of the exclusion criteria Exclusion Criteria: * Age \<18 años. * Participants with cognitive or sensorial difficulties or with insufficient knowledge of one of the 2 official languages of Valencian Community that, according to the healthcare professional, may affect their study participation. * No residents or temporary residents in the Health Department * Homeless or participants with high-risk of social exclusion. * Terminal patients or in palliative care according to the SECPAL (Spanish Society of Palliative Care) criteria . * Community-dwelling patients * Inability for mobile phone management if there is a caregiver with this capability. * Participants without a phone line * Non high-complexity chronic patients according to the recruitment healthcare professional. * Members of the research team, workers related to the centers implied in the study or any other person directly involved in the study - * First degree consanguinity or similar affinity with the team members. * Participants already involved in case management. * Participants already participating in clinical trials or experimental trials. * Participants that don't accept to participate in the study or not signing the informed consent * Participants with a main diagnostic of mental diseases * Participants with active oncological diagnosis * Participants already following specific interventions for hemodialysis, organ transplanting, day hospital * Participants with an infectious chronic disease as unique chronic disease (HIV, BHV (Hepatitis B Virus)…)