Integral Clinical Plan Shared With or Without Telemonitoring of Constants in Patient With Chronic Diseases

Inclusion Criteria: * Majority legal age (18 years of age or older) * Present any of the following shortcomings: Heart failure with baseline dyspnea ≥III of New York Heart Association (NYHA) Chronic respiratory insufficiency with basal dyspnea ≥III of Medical Research Council (MRC) Scale and / or oxygen saturation \<90% and / or home oxygen therapy. * Present Heart Failure or Respiratory Insufficiency with basal dyspnea grade \<III (according to NYHA and MRC respectively) but have presented 2 or more income in the last year. * Score of Patients with terminal or palliative medical diseases (score PALIAR) index between 0 and 7 points. * To present one of the following assistance situations: hospital admission, follow-up in Home Hospitalization or Palliative Care Teams, specialized outpatient follow-up. * Speak, understand, read and write Spanish, either the patient or the primary caregiver. * Have basic knowledge of the use of mobile phones and applications of computer tablets (such knowledge will be confirmed by personal interview, with test of the device). * Informed consent to participate in the study Exclusion Criteria: * Presence of malignant neoplastic disease ACTIVE except localized adenocarcinoma of prostate in hormonal treatment, and / or cutaneous basocellular-squamous cell carcinoma. * In the case of Chronic Renal Disease if there is the possibility of entry into Substitutive Therapies (hemodialysis or transplantation) * In the case of chronic liver disease, if there is a possibility of liver transplantation. * Chronic neurological disease with established cognitive impairment (E. Pfeiffer with 7 or more errors and / or Mild cognitive evaluated (ECM with ≤18 points). * Clinical situation of agony. * Surprise question ("Would you be surprised if your patient died in the next 6 months?") With the result "I would not be surprised" + PALIAR Score Score ≥7.5 points. * Participate in another tele-health initiative. * Go simultaneously to a private health service and / or be institutionalized