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Chronically ill patients living in the home present healthcare systems with financial and logistical challenges. The top 5% patients account for 50% of healthcare spending. Combining innovation, prototyping, design and research, thru a co-creation process, we designed a patient-centered, cost-effective, proactive health management system. Clinicians, business experts, analysts, developers, researchers and designers contributed from different perspectives using service blueprinting techniques and participatory design workshops. We detailed patient needs to develop monitoring devices with an engaging user experience, resulting in a tablet app.