Transparent continuous communications with seamless transitions of care have been elusive yet are critical elements managing patients’ conditions. Patient care is typically managed by multiple health care providers (MDs, hospitals, visiting nurses, skilled nursing facilities, social services, ambulance EMS, and community care managers). Knowledge of the patient, their medical care, and their care goals are vital components to provide continuous stability of chronic condition sufferers. Knowledge needs to be accessible anytime and anywhere securely with ease and transparency. Chronic condition sufferers experience disruptions in care when outside their healthcare communities. Our community offering provides practical solutions supplying care team coordination while offering high quality of care delivered regardless of patient physical locale to their healthcare providers. Our model produces no service disruptions yielding measured reduced readmissions, lower length of stays, reduced skilled nursing home use and improved Hospice use.