This document summarizes a project that coordinated telemonitoring and telecare for chronic patients in the Basque region of Spain. The project integrated health and social care to customize support for each patient's needs and improved health outcomes, quality of life, and satisfaction for patients, families, and caregivers. It also increased efficiency by standardizing services and reducing healthcare resource use and professionals' workloads. The conclusions were that coordinating health and social care not only improved patient health but also increased satisfaction while achieving less use of health resources and a streamlined workload for health workers.