ICT- Support - The three main actors, namely: i) the healthcare professionals with access to an adaptive case management system for work plan prescription, follow-up, coaching, and care-coordination across healthcare tiers; ii) the adaptive case management system supporting execution of the patient work plan and providing a bridge of interoperability and collaborative tools among the patient (through the PHF), the case manager and the electronic medical record; and, iii) the patient, with access to the PHF wherein she/he can answer questionnaires, perform monitoring through mHealth apps, and have access to a follow-up reports and tailored educational information.