Comparing different strategies for chronic patients self-control in dependent patients living at home

INTERVENTION: Five Primary Health‐Care Centers (PHCs) from the OSI Donostialdea are randomised to the experimental group and five PHCs to the control group. Within the experimental group (five PHCs), individuals will be randomized to telephone follow‐up or follow‐up using the mobile phone application. The control group receive usual care. Phone group: Phone call every 2 weeks from the patient to the case nurse or any time the patient has any of the alarm signs or symptoms established App group: The patient answers a short questionnaire every morning. The app compares the situation with the previous one to see if the patient has worsened or remains at the basal situation. Then suggest an action: change in treatment (send to the doctor to confirm it) or stick to the previous treatment Mortality, emergency department visits and physical consultations in relation to the chronic process, telephone calls, number of visits and quality of life (EuroQol) and the quality of care are collected via questionnaire. The total intervention duration is 1 year, the same as the follow‐up. CONDITION: Chronic diseases in frail patients (at‐home dependent patients) ; Not Applicable PRIMARY OUTCOME: 1. Number of physical consultations, taken from information systems during the 1‐year follow up; 2. Number of visits to ED, taken from information systems during the 1‐year follow up; 3. Mortality, taken from mortality registry at the end of the 1‐year follow‐up SECONDARY OUTCOME: 1. Number of admissions, registered by information systems during the 1‐year follow up; 2. Length of stay, the mean number of days if the patients suffers more than one admission, registered by information systems during the 1‐year follow up; 3. Perceived quality of care, measured using standard questionnaire at the end of the 1‐year follow‐up INCLUSION CRITERIA: 1. Frail patients 2. Living at home 3. Barthel Index score lower than 60 4. Agree to participate 5. No age limits