Demographic change is a global trend which particularly affects the Alps. A rising number of elderly brings to a significant growth of patients with chronic co-morbidities and age-related conditions. Changing society calls for political actions able to answer to new needs coming from an ageing society to ensure its wellbeing. NATHCARE aims to design, consolidate and validate an healthcare local community model embracing all the players of the system for securing a sustainable and improved organisational adaptation of healthcare services. The proposed model, capitalising on the ALIAS project, will analyse the process for an hospital-territory integration addressing mainly, but not exclusively, chronic diseases in the perspective of continuity of care as dimension of the demographic change. The NATHCARE model will be offered to the attention of policy makers, as an example on which they can get inspired to adopt orchestrated policy strategies to mitigate demographic change impact on healthcare systems. Achievements: Within the model design activity, the main result achieved was the finalisation of the overall NATHCARE concept. As existing infrastructure, care processes and requirements can strongly vary between pilot sites and a multi-solution Model needed to be conceived. NATHCARE allows three different implementation scenarios while providing a common overarching architecture. Within the assessment activity, the methodology to assess healthcare models has been released identifying indicators for carrying out the evaluation of those models currently in use for the management of long care term conditions. Furthermore, the definition of the system architecture, finalisation of the development plan and the implementation of the development activities dedicated to the realisation of the first prototype have been performed. The legal/security NATHCARE framework has been defined and the security experts have closely followed the technical application development.