Telemedicine for Home-based Management of Patients With Chronic Kidney Diseases and Comorbidities (NET-2018-12367206)

The investigators will design, test and evaluate innovative models for applying TM to the management of pts with chronic kidney diseases . New models will be characterized by the followings: * flexible adaptation to pts subgroups/ individual pts characteristics, including pts (and caregivers) expectation and willingness to participate actively in the process of care * identification of technical components which are essential, accessory, useful or futile for different pts subgroups, including evaluation of pts abilities and preferences. * definition of the team of care and the roles and responsibilities of each components: case manager, clinical manager etc * pre-definition of outcome measures, that should include at least the evaluation of quality of life, perceived quality of care by the pts and caregivers, number and duration of hospitalizations. * definition of Quality Assurance (QA) derived indicators related to risk and performance of TM implementation where needed Finally, the investigators will collect a set of data allowing to analyse and validate the care model and to measure the patient adherence to the care plan as well as measure the performance of the predictive models based on this data.