The management of chronic and out-patients is a complex process which requires the cooperation of different agents belonging to several organizational units. Patients have to move to different locations to access the necessary services and to communicate their health status data. From their point of view there should be only one organization (Virtual Health-Care Organization) which provides both virtual and face-to-face encounters. In this paper we propose the Serviceflow Management System as a solution to handle these information and the communication requirements. The system consists of: (a) the model of the care process represented as a Serviceflow and developed using the Workflow Management System YAWL; (b) an organizational ontology representing the VHCO; and (c) agreements and commitments between the parties defined in a contract (represented as an XML document). On the basis of a general architecture we present an implementation in the area of Diabetes management.