Clinical assessment - Evaluation will be done by an independent team at baseline and after the 12-month follow-up. The questionnaires are those used by the integrated care team with additions designed to capture patient empowerment characteristics: mental status, activities of daily living, anxiety and depression, health-related quality of life; acute episodes requiring emergency department consultations and/or hospital admissions within the healthcare sector will be assessed using shared registries from the public health system. Moreover, core outcomes, will be assessed from public registries.