Objectives - To assess the impact of ICT-supported ACM on: i) reduction of early hospital-related events including hospital re-admissions, visits to emergency department and mortality; and, ii) Health value generation of the long-term intervention, defined as target outcomes achieved relative to their costs.Detailed outcomes include the eleven indicators recommended by the Spanish Health System covering the following dimensions: i) Characteristics of the study groups and health status (i.e, Users attended in primary care and, Health-related quality of life of patients and caregivers); ii) Intermediate outcomes (Emergency Department visits; General Practitioner visits; Cumulative days per year admitted in hospital; Poli-medication; Potentially avoidable hospitalizations; Hospital readmissions; Needs for social support); iii) Empowerment (Unhealthy life styles); and, iv) Structure (Access to ICT-supported integrated care). Moreover, through the program lifespan progresses consolidated by the International Consortium for Health Outcomes Measurement (ICHOM) will be incorporated.