- To improve the Quality of life of those living with chronic disease.

- To decrease the complications experienced by chronic disease suffers.

- To reduce the time lag between a new diagnosis and follow-up for lifestyle changes.

- To reach out proactively to patients with evaluated risk factors.

- To empower patients with the responsibility for their progress through a “patient with provider” care model.

- Improve efficiency.

- Integrate communication & care.

- Enhance care managementthrough self ‐ management.

- Encourage improvement in metrics like blood pressure and cholesterol.

- Assess quality of care over time through closer monitoring.

- Patients take charge of their own health care immediately.

- Patients interact with health care providers in a manner that works for everyone.

- Patients proactively track their activities and progress.

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