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In India, high prevalence of chronic kidney disease of unknown origin reported in uddhanam region of Srikakulam District, Andhra Pradesh. The Uddhanam region is a cluster of 175 villages has been consistently reporting a high burden of non-communicable diseases including chronic kidney disease. Since 2018, the George Institute for Global Health India, in collaboration with the Government of Andhra Pradesh, has been working in these communities to assess disease burden and strengthen primary health care service delivery through the STOP CKDu project. Current project “The Uddhanam Homecare” is funded by the GIVE2ASIA. This program aims to provide home based follow up of those recovering or recovered from COVID and especially those with comorbidities. This is a program conducted in three-phase. During the first phase, qualified trained health workers went door to door and screened 1097 people who tested positive for COVID and identified 467 people with post-COVID 19 manifestations. The project staff also collected demographic information such as height, weight, temperature, oxygen saturation levels, blood pressure, lung functional status. In Second phase small sample of blood is drawn from 285 high risk participants and send to NABL accredited lab for analysis for various POST COVID biomarkers such as; C-reactive protein, complete blood picture, haemoglobin and also hbA1C and serum creatinine. In third phase, we had undertaken community based participatory workshops to understand the common challenges faced by the population in post COVID recovery phase. A thematic flip charts were designed especially for these program and we conducted 15 awareness sessions. After the session, the medical staff conducted a evaluation of the participants to determine who had long COVID symptoms that persisted and referred them for the necessary medical care. Referral and Continuum care: We trained frontline healthcare workers and primary health care personnel in recognition and management of Post COVID complications and co-morbidities. Physician at community health centre, identified complications and on further instructions, facilitate referrals to a higher-level facility. As part of home based pulmonary rehabilitation, 250 invasive spirometers were distributed to people who having poor lung functions.