The greatest challenge we face over the next 20 years is the management of chronic diseases in an elderly population. Older adults in poor health are at risk of negative outcomes and are the major consumers of health resources in hospital or in community settings. As a consequence, the medical, social and organizational solutions for frail people with chronic disease must resolve a complex situation. The caregiver is a key to the care of the frail patient with chronic diseases, acting both as point of reference and support giver. The caregiver inside the family is becoming increasingly both the supplier of care as well as the subject of that care with its matrix of important physical, psychological, relational and working consequences. The aim of the present article is to focus on the cultural and organizational pillars of guaranteeing care and assistance as well as to consider as a whole both the frail patient and their caregiver. The chronic patient almost always has some disability because of his or her history of clinical complexity, with several comorbidities and social fragility. Such a patient requires a multidisciplinary approach and at the same time needs an individualized of care in order to optimize his or her physical and clinic condition, quality of life and social involvement. Therefore, the patient’s need is not only clinical but also social and multifaceted. Continuity of care is inevitably the solution for the frail patient. This would be based on an integrated net of services including hospitals for acute admissions, intermediary structures, centers of rehabilitation and long-term admission, homecare and primary care services all working with real dialogue, communication and integration. A general consensus on which follow-up program can be most effective for chronic patients is still lacking. The most important function for good continuity of care is what is technically called “case management”, which is the ability to activate all the necessary resources to deal with the various different needs of the individual patient. Continuity is founded on two poles: on the one hand patient care from local general practitioners and home-care services and on the other hand hospital admission or out-patient services for specific diseases. To ‘network’ means to think of the projects in terms of “Hub and Spokes” with centralized expertise that spreads and branches to the regions. To ‘guarantee continuity’ means to integrate social services in local areas and other relevant competent authorities using methodologies of empowerment and development of expertise. In preparing the guidelines, it is essential to think about the whole process of patient care as a virtuous circle of listening, planning, programming and verification in the field. Guarantee of continuity of care should be a fundamental contractual principle both for the one who pays and for the one who disburses the service. However, it is not enough to only treat the specific illness; there is a need to take into account not only the symptoms of this illness but also the medical complexity of other factors involving the whole person. An organizational answer is not enough to bridge this gap; formative education both in university and school is needed. Indeed, a culture is needed that changes the physicians’ focus on patients as individual person within the population that focuses on his holistic care. The future of chronic and frailty care follow-up systems depends on: (1) human factors, (2) economics and (3) technology. The real “technology” is the human resource available in hospitals, homes and health and social care organizations. New care models need to respond to criteria of equity, simplicity, efficiency, efficacy, safety and patient-centeredness.