Personalised Action Plans (PAPs) are a key element to provide the needed holistic care for comprehensive health plans designed to tackle the most relevant health problems in the region by the Andalusian Health Service (SAS-Servicio Andaluz de Salud). The PAPs are implemented in primary healthcare centres in collaboration with other levels of care, based on a comprehensive assessment of key aspects of patient status; including targeting symptoms, functionality and quality of life, and their preferred desired outcomes. These plans have been designed by multidisciplinary teams; family physicians, nurses, internists, case manager nurses, pharmacists, social workers, among others, with the consultation of each patient and/or caregivers. PAPs are regularly reviewed and revised depending on patient status and needs which are recorded and stored on the electronic health record facilitating coordination throughout the healthcare system. There was an overall reduction in the expected healthcare services utilisation compared to previous year, resulting in a 23.5% reduction in economic impact costs compared to expected trajectory. Moreover, there was improvement in health status perceived by patients. The lessons learnt from this practice include 1) Guidelines and online training course availability is key for HCPs 2) A corporate information system for electronic health records in important for PAPs implementation 3) HCPs’ agendas need to be adapted for performing PAPs 4) the support of key leaders is vital for the practice’s success.