The aim of this study is to assess the effectiveness of proactive and integrated healthcare program for chronic complex patients (CCP). This program are based in coordination the primary level of attention with and speciality level. The objective is reducing hospital readmissions and know the benefit in total cost of care in 4 month before and 4 after intervention.

Quasi-experimental study with single-arm (pre-post study design without control group). The investigators checking pre and post intervention the effectiveness of a healthcare program for CCP. The interventions consist:

1. - Help the nurse in the hospital to carry out the care plans and the continuity care report.
2. - Refer patients to the social workers.
3. - Collaborate with the social worker to refer to centers of media, long stay and reference hospital.
4. - Ensure the follow-up appointments for the CCP.
5. - Make proactive calls to the CCP and/or their caregiver after discharge
6. - Plan the hospital discharge 48 hours in advance, so that the family and the patient can be organized.

The investigator analysed if with this program, the CCP reducing hospital readmission and reducing the Hospital expenditure.

Inclusion Criteria:

• Patient ≥ 75 years.
• Having attended 5 or more emergency visits or having had more than 3 hospital admissions in the last 12 months.
• Identified with social risk alert.

Exclusion Criteria:

• Participate in other health programs (AHT, diabetes mellitus,...).
• Terminal patient.