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This work is motivated by the Patient-at-Home (PAH). He or she is an ambulatory patient who requires a greater level of attention, such as individuals with chronic conditions, elderly patients, those with trauma injuries, etc. Latest developments in US national-level health care standards and specifications have focused on needs of in-hospital scenarios and interoperability among diverse institutionally-situated software systems. This work provides a focus of bringing the Patient-at-Home into collaborative partnership with the emerging standards-based electronic health care support. To accomplish this, an approach involving collaborative elements was developed. These include interactions between the PAH and an agent-based software application named Patient-at-Home Supporting Software Agents (PAHSSA) and between the PAH and the Family Physician. The point of connection between the Patient-at-Home and the emerging electronic health care system involves the Family Physician's Electronic Health Record (EHR). In this work, we develop a set of scenario elements that pertain to the PAH. We then derive requirements that can be utilized as use case snippets in order to design meaningful collaboration between the PAH and the health care system. Finally, we present an initial agent system design for PAHSSA to support the collaboration.