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An introduction: The Strategy of Care for People with Chronic Diseases (SCPCD) is one of the main strategies in the Madrid Region. This strategy proposes some key elements for its application in each territory in order to achieve a better integrated-care, elements that include interventions that have proven to be effective and efficient as well as the adaptation of the care model to the needs of the patients.The Westernarea of Madrid, in particular, the area of influence of "Rey Juan Carlos" Hospital, is a territory where continuity of care and the integration of services has become a priority.It is the Madrid areawith the highest percentage of patients with high level of risk. The institutionalized population in nursing homes constitutes 2.5% of the total population and it is estimated that 4% of the population has complex chronic diseases. It is considered as one of the most advanced area in the application of new care routes and tools and also with initiatives such as a social and health plan for the integration between the hospital and social services and nursing homes.