Disability from musculoskeletal diseases and co-morbidities may lead to the worsening of social and economic well-being through a multitude of paths. Moreover since in European Union (EU) Member States it is projected that those aged 65 and over will become a much larger share (rising from 17% to 30% of the population), and those aged 80 and over (rising from 5% to 12%) will almost become as numerous as the young population in 2060, there is a great potential for Information and Communication Technologies (ICT) solutions for addressing the present and future living arrangements in older people. The UPPERCARE system is meant to affect positively both the intergenerational and partners care since it contributes to decrease usability barriers and promote collaborative environments for informal and self-care. UPPERCARE is a new approach for integrated care supported by ICT systems and services, focusing on post-operative rehabilitation of musculoskeletal pathologies, having as a case study the knee post-operative scenarios of prosthetic care. This paper presents the UPPERCARE system, that provides an integrated care solution, supported ICT, for empowering self-care and adherence to rehabilitation plans through natural interfaces, gamification and cross-modal paths for community care collaboration. The system addresses current barriers from technological, clinical, social and organisational perspectives in a multidisciplinary environment. Special attention is given to the patients' needs and behaviours entailing the participation of a wide care community, including clinical and non-clinical people, associations, institutions and authorities) through an user driven interaction within the system.