This paper presents a co-designed solution aimed at improving community healthcare assistance management. To enhance patients’ self-awareness of their health status, encouraging active participation in care process, and to support nurses in delivering patient-centered care, we have developed an innovative platform with a highly customized app. This platform was designed using a multi-disciplinary, bottom-up approach. Patient data collection and processing facilitate the automation of care timeline planning, based on real-time patients’ needs and the available resources. To achieve this goal, different components have been considered: real-time health data collection and processing, patient care planning, decision support for nurses, secure communication for data transmission, and user-friendly interfaces to ensure easy access to platform functionalities.