The project has developed and defined new models and technologies to support fragile citizens through the involvement of social and health service operators (doctors, nurses, social and health facilities), by designing and prototyping an integrated technological infrastructure, based on an information model inspired by the principles of Population Health Management (PHM). This model is able to implement, manage and continuously to evaluate an integrated care System. The implemented solution was tested in real scenarios, in order to validate both the validity of the care models and the capacity of the technological infrastructure to effectively support the implementation of these models.