The world of chronic non-communicable diseases is progressively growing epidemiologically, requiring a significant commitment of resources, continuity of care, and strong integration between healthcare professionals and care settings. The National Recovery and Resilience Plan, in the Ministerial Decree 77 of 23/5/2022, identifies Community Homes as the privileged location for providing integrated, multidisciplinary and multiprofessional interventions, involving specialists and nursing clinics, general practitioners and district structures, utilizing all the necessary technological equipment, including digital platforms for telemedicine. In this context, cardiology is facing a complicated challenge: cardiologists must take care of patients with cardiovascular diseases who have also complex comorbidities and are required to extend their knowledge beyond the specific, sometimes super-specialistic, cardiovascular field, to avoid fragmentation, redundancy, and potential conflicts in the diagnostic-therapeutic care pathways. The Territorial Specialist Department, recently created in the Azienda Sanitaria Universitaria Giuliano Isontina, aims to promote the so-called "value-based medicine", that is, an effective yet sustainable medicine in both economic and social terms, reconciling guidelines with the actual needs of the patient. The ultimate goal is to implement an initiative-based medicine program with systematic stratification of patients at greater risk/complexity for a more efficient, appropriate and sustainable clinical governance.