Eligibility CriteriaPotential participants are selected by screening electronic healthcare and social care records or/and the hospital / national databases and/or during long term condition annual reviews in the community setting. If necessary, candidates are informed about the nature and the objectives of the evaluation. If a candidate passes the inclusion/exclusion criteria and signs the informed consent form, if necessary, they participate in the evaluation.
Inclusion Criteria- Age ≥65 years.
- Presence of health needs specified as: Presence of heart failure, stroke, COPD or diabetes (diagnosed at hospital or at specialist visit) plus at least one additional chronic disease / condition included in the Charlson Comorbidity Index (CCI).
- Presence of social needs based on Barthel Index of Activities of Daily Living and Instrumental Activities of Daily Living (IADL).
- Reasonable expectation of permanence in the BeyondSilos project for the whole data collection period (18 months).
- Informed consent, signed if necessary (by the subject or his/her delegate).
- Capability to handle ICT equipment / devices alone, or with the help from a delegate.
- Presence of good/reliable communication connection at home (internet, telephone or what is needed for the ICT connection).
Exclusion CriteriaSubjects who have been registered with an active cancer diagnosis and undergoing treatment, has undergone an organ transplant, or is undergoing dialysis prior to enrolment.
- Subjects in a terminal state
- People with an AIDS diagnose.