The long term aim of the "chronic disease module" is to increase a community's capability to provide unbroken care to its chronically ill, especially where services are nonexistent or weak. This modular approach to continuing care seeks to strengthen the process whereby chronically ill persons enter the health care system, move across its boundaries, and receive continuous care. Incorporating new manpower, the program is designed to achieve objectives at moderate cost. The specific aims of this demonstration and evaluation program are 1) to establish modules in a number of communities as new units to add to the system of services for chronically ill people who live at home and 2) to conduct continuous evaluation of development, operation, and effects. Each "module" includes a part time physician, a part time nurse or social worker, and two full time health assistants. First stage training of health assistants is provided by a local community college and includes an introductory package of courses. Second stage training, conducted by the Cadre Training Module based at the Greater Lansing Area Rehabilitation Medical Center, includes field training (special focus on home care), training in assessment of comprehensive function, and use of a community's health and social services system. After orientation of professional and assembly of modules, they are introduced into facilities which have comprehensive services in various stages of development to permit comparisons in a broad range of service settings. Evaluation studies are both descriptive and compartive utilizing a control group design. Before, during and after implementing the module, the following major dimensions are being evaluated: 1) perceived needs and functional level of chronic disease patients, 2) effectiveness of module service, 3) utilization behavior, organizational dynamics, and barriers to care, 4) comparative costs, 5) recruitment and training of module teams, and 6) implementation and working of the "module".