With almost 10 million inhabitants, regione Lombardia represents 1/6 of the Italian population, with over 4.6 million chronic patients, most of them over 65 years and affected by 3 or more pathologies. Chronic diseases are a growing burden for the regional health and social economy and this, in 2011, prompted the regional government to launch an innovative program, called CReG (chronic related groups) with the objective to promote continuity of care for chronic patients. The CReG is like a territorial diagnosis related group (DRG): a group of predefined economic resources assigned to an institutional subject (CReG provider), to guarantee the delivery of an established treatment plan to the chronic patients it has in charge, in order to provide them with a comprehensive care outside of the hospital. The main pathologies involved are BPCO, hypertension, heart diseases and diabetes. The CReG pilot involved more than 60,000 patients, and several CReG providers were selected to manage this population. Many of the providers (for a total of more than 300 GPs involved) selected the same technological partner, having 60% of this population (approx. 37,000 patients) managed through the same IT platform, thus making this one of the largest European pilots for the care coordination and telemonitoring of chronic patients. The paper will describe this experience, the background, the new model for managing chronic patients proposed by the Lombardia region, the enabling technological platform, the services provided through the platform, and the population stratification method for the identification of the highest risk patients.