Anna is a 3-year-old baby living with her parents in a mountain village 55km away from the urban area and the referring hospital. She was born at 29 weeks, weighting less than 500g. She was hospitalised for 14 months and then discharged with an Integrated Home-Based Care Program. Anna is affected by bronchopulmonary dysplasia, hypothyroidism, has cognitive delay and is recovering from stage 1 retinopathy of prematurity. Anna’s mother had to leave her job to provide care to her. Anna has invasive mechanical ventilation dependency, lasting at night-time and during limited day-time hours, due to a permanent tracheostomy. She also needs cough assist device four times a day to aid with clearance of secretions. Anna has neurocognitive disorders related to language and play activity issues, with generally poor socialisation and communication skills. She receives weekly medical home care assistance by the anaesthetist for patient-ventilator system and tracheostomy check, physiotherapist, and speech therapist. She periodically receives Day Hospital neurologic, nutritional, ophthalmologic, endocrinology and pneumological consultancy and she regularly practices capno-oximetry in short-term hospitalisation. Ordinary hospitalization is limited to acute events not manageable at home (at present, one hospitalisation for acute pulmonary superinfection).