Impact of a Health Intervention on Some Indicators in the Care of Chronic Complex Patient (CCP).

Quasi-experimental study with single-arm (pre-post study design without control group). The investigators checking pre and post intervention the effectiveness of a healthcare program for CCP. The interventions consist: 1. \- Help the nurse in the hospital to carry out the care plans and the continuity care report. 2. \- Refer patients to the social workers. 3. \- Collaborate with the social worker to refer to centers of media, long stay and reference hospital. 4. \- Ensure the follow-up appointments for the CCP. 5. \- Make proactive calls to the CCP and/or their caregiver after discharge 6. \- Plan the hospital discharge 48 hours in advance, so that the family and the patient can be organized. The investigator analysed if with this program, the CCP reducing hospital readmission and reducing the Hospital expenditure.