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This project was born out of the common concern of the primary care professionals from the CAP and the municipal social services, both from Amposta, with the intention to provide integrated, efficient and high-quality attention to patients with the need for complex social and medical care: complex chronic patients (CCP), advanced chronic disease (ACD), home health care (HHC), patients with a 2nd or 3rd dependence degree or with home care services (HCS).

It gives integrated health and social care to chronic patients and those with dementia based on a communication tool created by the IT services of the Terres de l'Ebre ICS. This system makes it possible to implement an agile, fluid and guaranteed communication system between the health services and the social services of the territory.