Case identification. Identification of candidates for inclusion into the program following the pre-defined inclusion/exclusion Case evaluation. During hospital admission or home hospitalization. A holistic characterization should be performed covering a threefold aim: i) Comprehensive assessment of each individual's need for health and social support; ii) Individualized pharmacological and non-pharmacological treatment, including adherence and self-management interventions needs; iii) Identification of short and long-term clinical requirements; and, iv) Assessment of barriers that may limit fulfilment of the program.