1 Isabel Taveira, MD, is Internal Medicine Resident since 2016 at Litoral Alentejano Hospital where she continues to work. She studied medicine at the University of Santiago de Compostela, Spain, and started practicing Medicine in Portugal in 2015. Dr. Taveira has been a member of the case management program since it started, the first Portuguese program dedicated to chronic care patients with multiple comorbidities. Adelaide Belo, MD, is a Medical Doctor, and the Internal Medicine Senior Specialist from the Lisbon Faculty of Medicine in Internal Medicine, and has been an attending physician since 1984. She is the Service Coordinator of Integration of Care process in Litoral Alentejano since 2016, and is the founder, promoter, and coordinator of the case management program. Dr. Belo is responsible for selecting all team members, including physicians, nurses, case managers, and social workers, as well as gathering the team and organizing and leading team meetings. Marta Cristino, is a licensed social worker, Litoral Alentejano Hospital. Ana Goes, MD, is an Internal Medicine Resident, Internal Medicine Department, Litoral Alentejano Hospital. Vitor Gomes, is a Family Nurse, specialized in Rehabilitation, Odemira Community Centre. Carla Macieira, is the Internal Medicine Ward Chief Nurse, specialized in Medicine and Surgery, Litoral Alentejano Hospital. Susana Matos, is a Family Nurse, post-graduate in Rehabilitation, Santiago do Cacém, Community Centre. Hugo Mendonça, is a Family Nurse, post-graduate in Healthcare management, Odemira Community Centre. Teresa Silva, MD, is a Family Physician, Family Medicine Department, Santiago do Cacém, Community Centre. Sofia Sobral, MD, is an Internal Medicine Resident, Internal Medicine Department, Litoral Alentejano Hospital. Cláudia Vicente, MD, is an Internal Medicine Specialist, Hospital Coordinator of the Case Management Project, Internal Medicine Department, Litoral Alentejano Hospital.