This chapter presents options countries have to adapt their health systems to an ageing population. It covers policies to better prepare the workforce for an increase in the number of older people with complex needs, discusses redirections of the delivery of care to primary health and outpatient care, and avenues to foster the integration of providers within healthcare system and with other sectors, such as social and long-term care. This chapter puts particular focus on measures to avoid, shorten or replace hospital stays for older people.
The Economic Benefit of Promoting Healthy Ageing and Community Care
Abstract
Older people have more, more complex, and different needs than younger people. In 2019, more than every second person aged 65 and above had at least two chronic conditions, and more than every fifth person had at least one limitation in (instrumental) activities in daily living, requiring care from different providers from the health, social and long-term care sector. This makes them vulnerable to health system deficiencies, such as a lack of primary care and care fragmentation.
Care provision to older people displays inefficiencies. More than 10% of long-term care spending is directed to hospitals, suggesting cost-efficiency gains by redirecting these flows to long-term care facilities and long-term care at home. Older people frequently experience avoidable hospital admissions. Expanding on high quality patient-centred care can help curb the rate of avoidable admissions and improve health outcomes of older people to support healthy ageing.
Policy options
Preparing the health workforce for a change in patient structures. New roles that are particularly designed to support older people, the expansion of already existing roles, and additional education and training help equipping the health workforce with the skills they need to take care for the needs of an ageing population. In 19 countries, geriatrics is now an independent specialisation, and Latvia, Lithuania, France and Germany have just expanded the roles of nurses to offer more care to older people.
Providing care in a person’s home. Outreach teams offer non-life‑threatening emergency care at a patient’s home or in a long-term care facility. Nurses and medical doctors are dispatched to offer assessments and simple interventions where the patient resides. First results from Australia, Canada, Denmark and Finland indicate a reduction in emergency admissions and suggest that they are perceived as less disruptive than hospital admissions. Hospitals at home offer hospital-type care in a patient’s home or long-term care facility to outright replace or shorten inpatient stays and are dominant in at least 22 OECD countries, such as Chile, France, Spain and the United Kingdom. First evidence shows 20‑30% lower costs than an inpatient stay and patients value remaining in their familiar surroundings, but it can an additional burden on caregivers, who need to be well-prepared and integrated in the programme.
Setting up new provider structures. New physical structures offer better people‑centred care by teaming up different health professionals within primary care, for example in Canada, Greece and Poland. Intermediate care structures function as a bridge between primary care and hospitals to help shorten hospital stays or to avoid them altogether, and a number of countries have introduced them, such as France, Hungary and Italy. These new structures offer better access to primary care, and can shift some care away from hospitals, but still operate on a small scale.
Formalising integrated care structures. Health workers regularly interact with other professions. Integrated care programmes aim to seamlessly co‑ordinate care from different professionals by teaming up different professions. New provider payments aim at incentivising co‑ordination and reform the way providers are paid to incentivise better continuity of care, as in France and Ireland. Some integrated care programmes like PRISMA/RSIPA in Canada (Québec) have been successful in achieving better health outcomes and cost-effectiveness, but integrated care programmes are conditional on having built a trustful and collaborative team climate, which takes time to implement.
4.1.1. Health systems are insufficiently tailored to the needs of older people
Older people often have more complex needs than the younger parts of the population, which pose challenges to healthcare systems and expose older people to greater risks of unmet need, care fragmentation and insufficient quality of care. They often have several co-morbidities, require support in their (instrumental) activities of daily living (see Chapter 2) and use a set of providers from the health, social and long-term care sector concurrently to meet their health and long-term care needs. Some symptoms and diseases, such as cognitive impairment and dementia, are particularly prevalent among older people: cognitive impairment and decline affect 20 to 50% of the older population and can progress into different forms of dementia, such as Alzheimer’s (Manly et al., 2022[1]; Yao et al., 2020[2]). A lack of access, short consultation times, insufficient training of health workers for their needs, fears of and experiences with ageism in the healthcare system, which encompasses prejudices against and discrimination of a person on the basis of their age, are only some of the barriers that older people are facing when seeking care (Federal/Provincial/Territorial Ministers Responsible for Seniors Forum, 2023[3]; Cabañero-Garcia et al., 2025[4]; Iyengar and Mitchell, 2023[5]).
Because health systems are not yet well adapted to ageing, older people receive insufficient, inappropriate or uncoordinated levels of care to meet their needs, and in a setting that is more costly, but poorly equipped to respond to the needs of older people, and to facilitate healthy ageing.
Firstly, some people do not sufficiently use primary care resources that allow for continuous monitoring of people’s health and prevent deterioration in health and increase in limitations where possible (OECD, 2020[6]). This results in emergency admissions, avoidable hospitalisations and an increase in the number and severity of limitations and diseases, which are costly to countries and consume financial and human resources that could better be directed elsewhere (OECD, 2020[6]; OECD, 2017[7]; OECD, 2024[8]).
Secondly, the provision of health and long-term care does not always take place in the appropriate setting. Older people represent the majority of hospital stays. A share of these hospitalisations is not necessary and care provision in hospitals is generally more expensive, resulting in an inefficient use of financial and human resources that are designed to treat urgent and acute rather than chronic and long-term care conditions. Separate funding channels and budgets hamper efficient spending. Budgets have historically evolved over time, and greater spending on primary and long-term care can reduce spending on hospital care, but gains are not transferred from the sector where cost savings materialised to the sector where higher costs occurred.
Thirdly, care is often poorly co‑ordinated among different providers within healthcare, and between health and long-term care providers (Barrenho et al., 2022[9]; OECD, 2023[10]). This problem becomes even more prevalent for an ageing population with multiple, chronic conditions that use services from a set of different providers. Poor co‑ordination and integration within health, and with long-term care, leads to disruptions in care, worse health outcomes, system inefficiencies and wasteful spending. Responses from the OECD’s Patient-Reported Indicator Surveys (PaRIS) show that only 47% of patients aged 65 and above perceive their primary care practice as well-prepared to co‑ordinate with long-term care providers (see Chapter 1).
4.1.2. Countries have recognised the need to better align their health systems with the needs of older people
Four policy areas prevail to accompany people in their ageing trajectory and to improve healthy ageing across OECD countries (Figure 4.1). Firstly, countries are taking measures to ensure that they have the right workforce in place to offer care to an ageing population. This includes the right roles, either by expanding the roles of already existing professions or by introducing new roles, and the right skills to ensure that health workers have the appropriate education and training to support their patients in their ageing process. Secondly, countries are exploring measures to ensure that older people receive the right, and sufficient services they need. Thirdly, countries are active in introducing policies to ensure that people are provided care in the setting that is best for their needs, which largely consists of measures to shift the delivery of care from the in- to the outpatient sector. Finally, countries are experimenting with new ways to link and team up health and long-term care providers to offer patient-centred, seamless care.
This chapter offers an overview of how these different system adaptations look like in closer detail, synthesises findings on the effect of these policies where available, highlights good practices across OECD countries and points to avenues to further adapt health systems to accommodate demographic change. It presents a summary of the experience with these policies, synthesises the evidence to date and formulates policy recommendations to support countries in further tailoring their healthcare systems to the needs of an ageing population.
A changing demographic and more complex and different needs of older people pose challenges for the health workforce. Countries respond to it by introducing new roles, by expanding the roles of health professionals, and by offering additional education and training to equip the health workforce with the necessary skills. More than a third of countries that responded to the OECD Questionnaire on Healthy Ageing and Community Care have expanded the roles of health professionals, for example by increasing the roles and competencies of already existing health workers (11 out of 29 countries), and/or introduced new professional roles (12 out of 29 countries).
4.2.1. The introduction of geriatricians is still in early stages
In half of all OECD countries (19/38), geriatrics now form an independent specialty, followed by 13 countries in which geriatrics is available as a subspecialty with one to three years of training required (Pitkala et al., 2018[11]) (Figure 4.2). Several countries discuss introducing geriatrics as a (sub-)specialty. Norway is currently investigating the introduction of a separate specialisation in gerontology and home care, which would augment its role from a subspeciality status to its own specialty (Norwegian Government, 2024[12]).
Note: Japan does not have a dedicated specialty scheme, but medical students can receive training in geriatrics and work as geriatricians afterwards.
Source: Based on Pitkala et al. (2018[11]), “Status of Geriatrics in 22 Countries”, https://doi.org/10.1007/s12603-018-1023-7 and additional compilation by the authors.
Geriatricians can play an important role in assessing and managing the role of older people and several OECD countries are promoting a geriatrician-led frailty assessment in the delivery of care to older people (Cesari et al., 2024[13]). Comprehensive geriatric assessments for frailty have been associated with improved health outcomes and have been piloted in different settings at different points of the patient’s care trajectory and for different conditions, for example in emergency departments, trauma centres and for oncology treatments. Geriatric assessments in oncology can be beneficial for better-tailored treatment and communication as well as a higher likelihood of treatment completion, better physical functioning and quality of life (Hamaker et al., 2022[14]). England has piloted a geriatrician assessment within 72 hours after admission to a trauma centre, which as associated with reduced risk of death (Braude et al., 2022[15]). This echoes findings from Ireland, where a frailty screening with a comprehensive geriatrician-led multidisciplinary assessment in an emergency department was associated with shorter length of stay in an emergency department, lower rates of admissions to long-term care facilities, better quality of life and a lower decrease in functional decline (Leahy et al., 2024[16]). Norway has also piloted the assessment and joint medication reviews by a geriatrician and general practitioner and found an increase in deprescribing of certain medicines, a reduce in dosages, an increase in new medication plans, and improvements in quality of life, but also an increase in hospital admissions which might have resulted from new medication plans (Romskaug et al., 2020[17]).
Geriatrics as a specialisation has been growing in relevance, but suffers from shortages and a lack of attractiveness (Rowe, 2021[18]; Cesari et al., 2024[13]). Geriatrics is insufficiently integrated in medical education and training, earnings are generally much lower than in other specialties, prestige is low, the workload is demanding and caring for older people is often deemed unattractive (Meiboom et al., 2015[19]).
4.2.2. More OECD countries are closing in on expanding the roles of nurses
Community health nurses and advanced practice nurses are already common in at least half of all OECD countries (Brownwood and Lafortune, 2024[20]). They play an integral part in improving access to primary care and continuity and quality of care, and in delivering care to older people. They have consistently shown that they can reduce the workload of medical doctors by taking over some of their tasks, such as prescribing medicine, and can have a more comprehensive overview of the care trajectory of people, which is particularly beneficial for older people with complex needs (Htay and Whitehead, 2021[21]; Lukewich et al., 2022[22]; Jakimowicz, Williams and Stankiewicz, 2017[23]; Maier, Aiken and Busse, 2017[24]). Additionally, nurse practitioners tend to spend more time than general practitioners on each patient, enabling them to address more concerns per visit and spend extra time on examinations, patient education and comprehensive, multidimensional care (Roots and MacDonald, 2014[25]). Several systematic reviews found higher patient satisfaction in nurse‑led compared to physician-led care, equal or better quality of care, and similar or lower resource use across age groups as well as for older people specifically (Maier, Aiken and Busse, 2017[24]; Brownwood and Lafortune, 2024[20]; Morilla-Herrera et al., 2016[26]; Woo, Lee and Tam, 2017[27]). Older people, for whom visiting a medical doctor may be difficult due to mobility restrictions, have been found to particularly benefit from home visits and care by advanced practice and community health nurses (Kasa et al., 2023[28]). Although the precise channels are unknown, research also suggests lower mortality rates among chronically-ill older adults under community-based nurse‑led care (Coburn et al., 2012[29]) and fewer hospital admissions for all older adults, especially with high-intensity team-based services and self-help education (Dunn, Bliss and Ryrie, 2021[30]). Rising demand for medical services due to population ageing and heightened medical complexity increases the need to expand the roles of community health nurses and advanced practice nurses. By monitoring patients long-term, they can identify risks, such as poor nutrition and dehydration, loneliness and isolation, detect changes in health, such as sudden weight loss, signs of depression and cognitive impairment, and perform medication reviews, for example for patients receiving several prescriptions concurrently and at risk of inappropriate prescriptions, as is the case for older people. Nurses also engage with informal carers and can help detect deficiencies in care provision at home.
OECD countries have continuously expanded the roles of nurses in the delivery of care (Maier, Aiken and Busse, 2017[24]; Maier, 2019[31]). For example, OECD countries have started allowing nurses to prescribe medicines, order diagnostic tests, and provide teleconsultations, either independently or under the supervision of a physician (Brownwood and Lafortune, 2024[20]). In 2022, Austria and Switzerland joined other OECD countries in introducing community health nurses. Austria introduced 116 pilot projects for people aged 75 and above who live at home and are care‑dependent and their caregivers. Programmes aim at enabling people to stay at home for as long as possible, at improving their health literacy and quality of life, and at connecting them with other regional offers of care. Community health nurses perform preventive home visits, inform and advise the care dependent and their carers on suitable offers and support, and connect them with other providers as needed. Latvia is also planning to introduce advanced nurse practitioners (paplašinātās kompetences māsa) in 2026 to offer better care to people with chronic diseases, which complements the introduction of general nurses with bachelor’s degrees in 2022 (Republic Latvia, 2024[32]). Luxembourg followed two years later with the introduction of a bachelor’s degree in general nursing (Bachelor en Sciences infirmières – Infirmier responsible de soins généraux). In 2023, France expanded the roles of advanced nurse practitioners (infirmières en pratique avancée) to also prescribe specific drugs, some of which patients can also access directly without referral now, as part of a set of efforts to improve care in underserved areas. In 2022, Germany expanded the roles of nurses by allowing them to recommend a prescription of care aids and make more important decisions independently (Brownwood and Lafortune, 2024[20]). Moreover, there is a legislative proposal to further expand the role of nurses and Germany is considering introducing advanced practice nurses, too. Lithuania also expanded the competencies of nurses by allowing them to perform vaccinations and renew prescriptions issued by a medical doctor (Ministry of Health of Lithuania, 2023[33]).
Despite the perceived benefits and expansion in some countries, the scale of community health nurses and advanced practice nurses remain limited in many OECD countries. The introduction of these roles and their increase can help improve the quality and effectiveness of care, but staff shortages and the time needed to integrate community health nurses and advanced practice nurses into the care pathway and to be accepted by the public limit their scale and scope. The nursing workforce is already facing challenges with overall shortages. Low salary levels, poor levels of recognition and difficult working conditions affect the nursing profession in general, leading to a low stock of people who could potentially become advanced practice nurses and community health nurses. Within healthcare systems, the community sector faces competition from the hospital sector, where nurses can enjoy much higher salaries than in other sectors (OECD, 2023[34]). The introduction and increase of advanced practice nurses can help improving the professional standing of nurses and offer a career path, which can positively affect the recruitment and retention of nurses. Community healthcare, however, faces low to moderate levels of attractiveness among nurses in education and training. Efforts to increase interest in community healthcare by increasing the exposure to community-related tasks have not yet led to significant improvements in interest (van Iersel et al., 2019[35]). Additionally, the successful integration of community health nurses depends on their acceptance by people in need of care, who might not recognise their needs or feel uncomfortable with a stranger entering their private sphere. While this is not unique to community health nurses, this is a particularly limiting factor for a profession that was introduced to offer people at home. Countries are invited to consider that the adaptation of community health nurses might require several years to familiarise older people with the concept and to experience the benefits. In addition, advanced practice nurses and community health nurses can be a great addition to the health workforce but require appropriate training in geriatric care and in the additional services that they are intended to provide to be able to perform them. The introduction of advanced practice nurses or community health nurses offers an opportunity for OECD countries to identify which skills are needed for these professions to perform additional tasks for an older population, to ensure that education and training allows them to perform these tasks, and incorporate additional training in, e.g. geriatrics, dementia care, and mental health support if needed.
Other professions, such as general practitioners, pharmacists, dental hygienists and dental therapists, have seen increases in their roles, as well, to improve access and reduce the workload of other professions. For example, Belgium increased the roles of so-called “reference pharmacists” of patients with chronic diseases in 2023, who can now review medication schemes of patients with polypharmacy and check for inappropriate medication, deprescribing and dangerous interactions with subsequent notification of the patient’s general practitioner (RIZIV-INAMI, 2022[36]). Czechia increased prescription rights of general practitioners in 2024, that are now also allowed to prescribe medicines that are often consumed by older people, such as diabetes-related medication and blood thinners, and were previously limited to specialists. The United States, several states expanded the roles of dental hygienists and dental therapists over the past years, for example by allowing direct access to prophylaxes performed by dental hygienists and by allowing them to administer local anaesthesia and to prescribe, administer and dispense fluoride, topical medications and chlorohexidine (Teekshana, Shirey and Surdu, 2025[37]). An increase in the autonomy of dental hygienists was associated with better outcomes in population oral health and found to be particularly helpful in areas with shortages of dentists and other dental health professionals (Chen, Meyerhoefer and Timmons, 2024[38]; Langelier et al., 2016[39]).
4.2.3. Equipping the health workforce with the right skills and tools
Countries offer additional education, training and technical support to the already practicing workforce to help them detect suboptimal care. For example, one common risk factor of older people is the prescription of several medications concurrently (polypharmacy), which increases the risk of adverse drug-related events. A total of 12 countries offers guidelines to reduce inappropriate polypharmacy to offer guidance to health workers and 10 countries provide additional training to health workers on reducing polypharmacy (voluntary in all countries except Iceland, where it is mandatory). Training aims at increasing awareness and improving appropriate prescribing patterns. Secondly, they offer tools to healthcare professionals to equip them with the necessary information to improve prescribing patterns, either through digital prescription tools (mandatory in Hungary, Iceland, Latvia, New Zealand, Portugal, Sweden and the United States, voluntary in Japan). For example, several countries, such as England, Finland and Sweden offer a screening tool for health workers to identify and potentially deprescribe fall-inducing drugs. The Screening Tool of Older Persons Prescriptions in older adults with high fall risk (STOPPFall) was developed by the European Geriatric Medicine Society (EuGMS) Task and the Finish Group on Fall-Risk-Increasing Drugs (Seppala et al., 2020[40]). This list currently covers 14 drug groups.
OECD countries have introduced a set of policies that aim at expanding access to and the supply of services for older people. Good levels of access to primary care services and to the right services aim at improving the management of their health conditions to reduce a worsening of care that results in adverse events, such as avoidable hospitalisations, which drive up healthcare expenditures and bind human resources. Policies that aim at increasing supply cover, for example, reducing co-payments for certain population groups to increase demand for certain services, increasing the payment of already existing services to incentivise the health workforce to reallocate their time towards these services by adding new services to the list of services provided, for example for the case management of older people. In most instances, these services are provided in a doctor’s practice. For example, Australia tripled financial incentive payments to doctors for treating, among others, older people above the pension age and below a certain income threshold without charging additional costs to the patient (triple bulk-billing), translating into an increase from AUD 6.85 to AUD 20.65 in metropolitan areas, or from AUD 13.15 in very remote areas to AUD 39.65 (Australian Department of Health and Aged Care, 2024[41]). In 2022, Czechia introduced payments for geriatric doctors for frailty assessment and the case management of geriatric patients on a pilot basis. In 2024, these payments were integrated as additional services in the fee schedule and are now reimbursed by health insurance funds. Latvia increased capitation payments for older people to doctors and reduced co-payments of people aged 65 and above for visits with general practitioners. Germany pays quarterly flat rates to physicians which differ by patient age and are higher for older patients to compensate for higher costs and more intensive care provision due to higher patient complexity. The quarterly flat rate for patients aged 76 and above for general practitioners was 75% higher than for patients aged 19 to 54. In 2025, Germany decided to replace quarterly flat rates to general practitioners by longer terms in case of one chronic disease, which has no need for an extensive treatment, to avoid unnecessary practitioner visits. Norway and Slovenia have just modified the adjustment of payment to physicians. In Norway, payments for general practitioners are now weighted by gender, age, service use, density of doctors and a socio‑economic factor, with age being a major factor in cost differences (Helfo, 2023[42]). Slovenia reduces the fee‑for-service part in favour of an increase in capitation, and introduces billing for people with multiple chronic diseases, but has been criticised for reducing the capitation payment for older people (Zdravniška zbornica Slovenije, 2024[43]).
Payment systems that incentivise physicians for providing volume and higher prices can increase the number of services provided (Quinn et al., 2020[44]). Policymakers can make use of these dynamics in a threefold way to improve the delivery of care to older people. Firstly, they can adjust the payment to physicians by complexity to ensure a fair compensation that accounts for the medical complexity of older people and that reduces the risk of physicians giving preference to younger, healthier patients over older, sicker ones. Secondly, they can operate with price changes to increase the delivery of care for certain services and to steer the time and attention of health workers towards certain activities, such as an increase in the number and length of consultations for people above a certain age. Patients value sufficient time during consultations, which becomes even more important for people when they suffer from several chronic diseases (OECD, 2025[45]). Vice versa, shorter visits in primary care have been associated with some increases in inappropriate prescribing (Neprash et al., 2023[46]) For example, a change in the price structure due to a rearrangement of Medicare structures in 1997 led to an increase in services in the United States, with a 2%-price increase translating into a 3% increase in service provision on average (Clemens and Gottlieb, 2014[47]). Similarly, changes in the Affordable Care Act led to price increases in some states in the United States, which in turn resulted in increased services (Devlin and McCormack, 2023[48]). Increases in prices were also found to improve access for underserved patient groups. Financial incentives in France led to an increase in workload among specialist physicians and improved access for low-income patients (Kingsada, 2024[49]).
Increases in prices can come with negative consequences unless well-designed. In Norway, physicians are allowed to charge higher prices once they have obtained their specialisation in general practice, which was found to lead to an increase in visits but at the expense of a reduction in consultation time (Brekke et al., 2017[50]). Countries can counteract reductions in consultation time by introducing a minimum length of consultation time to bill such an item, but an increase in one set of services will come at the expense of the service provision in other areas. Evidence on the effect of payment increases on integration is mixed. Lower prices have been found to incentivise integration between providers because it can increase the need for providers to explore efficiency gains through integration, while price increases have also led to more integration because it gave providers the means to build better co‑ordination and interaction with providers.
An increase in the share of older people is projected to lead to an increase in healthcare use, such as an increase in hospital stays, which already meets tight financial resources and can pose risks to older people. In many countries, the average costs of a hospital stay are equal to or considerably exceed average annual health expenditures per person. For older patients, hospital stays can often be stressful and expose them to risks. They can lead to an increase in limitations of (instrumental) activities of daily living (hospital-associated disability) (Loyd et al., 2020[51]), cause delirium after operations, which can exacerbate cognitive decline (Kunicki et al., 2023[52]; Saczynski et al., 2012[53]) and expose them to hospital-acquired infections (OECD, 2023[54]; Bates et al., 2023[55]). As a result, the benefits of hospitalisation do not always outweigh the risks.
A range of OECD countries aim at reducing and shortening hospital stays by improving the amount and quality of care provided outside of hospital settings. These initiatives aim at outright avoiding admissions, substituting inpatient stays with intensified home care, reducing readmissions after hospital discharge, and shortening length of stay in hospitals, either through an increase in services provided at a person’s residence, or the introduction of new, physical provider structures that regroup medical specialties and can offer better patient-centred primary care, or offer an intermediate layer in between a physician’s office and a hospital.
4.4.1. Avoiding hospitalisations through outreach teams
Several OECD countries have set up primary care teams that visit patients in their homes to provide care support to avoid health deteriorations and hospital (emergency) admissions. For example, in Australia, the Community Older Persons Intervention and Liaison Outreach Team (COPILOT) in New South Wales offers care to people in their own homes and long-term care facilities for ten conditions and services, such as pneumonia, cognitive decline, fall prevention, malnutrition and polypharmacy. The outreach team is composed of geriatricians, nurses, social workers, physiotherapists, pharmacists, dietitians and occupational therapists (NSW Government Agengy for Clinical Innovation, 2024[56]). The Residential In-Reach programmes in Victoria and the Residential Aged Care Facility Support Service in Queensland particularly target people in long-term care facilities, where hospitals dispatch medical doctors and nurses to facilities in urgent, non-life‑threatening situations to reduce the need for emergency admissions (Victoria Department of Health, 2024[57]; Queensland Government, 2022[58]). Similarly, several provinces in Canada have such outreach teams, such as the Primary Care Outreach to Seniors programme in Ontario or the Older Adult Outreach Program in Vancouver (Vancouver Coastal Health, 2024[59]; Provincial Geriatrics Leadership Ontario, 2025[60]). A team of a registered nurse and a community health worker, which collaborates with other health and community care providers, help with medication review, help manage chronic illnesses, and may also offer clinical assessments and follow-ups and advanced nursing care in a person’s home. In Ireland, community intervention teams offer patients in need of acute care support in their homes to avoid hospitalisations, facilitate early discharge and support people with chronic diseases in their homes, and can offer a set of services such as the administration of intravenous antibiotics, enhanced nurse monitoring, wound care and dressings. Several parts of the United Kingdom have introduced these teams for general and disease‑specific purposes, such as the Older Persons Mental Health Liaison and Care Home Outreach Team in Wales.
Denmark established a new model in Odense (Southern Denmark) where emergency consultants are dispatched to long-term care facilities to provide emergency care in non-life‑threatening conditions and perform diagnoses and treatment, such as intravenous fluids and antibiotics, on-site and help set up a treatment plan. In Finland, mobile hospitals (Liikkuva sairaal, LiiSaa) offer diagnostics and treatment in non-life‑threatening emergency situations to people who receive long-term care at home or in a long-term care facility to avoid emergency admissions. A nurse visits patients in their living arrangements to assess their health and can perform diagnostics and offer simple interventions, such as treating wounds and urinary problems and giving intravenous hydration and antibiotic drips.
Evidence on the effect of outreach programmes on health outcomes and costs is very limited, but the little evidence available points at promising results in curbing emergency admissions. Findings from Australia found a significant reduction in emergency department visits and hospital admissions from long-term care facilities (Hutchinson et al., 2014[61]; Fan et al., 2015[62]; Kwa et al., 2021[63]). Similarly, an investigation from Finland recorded a reduction in less acute emergency admissions from long-term care facilities by around 20‑30% depending on the severity with savings of 14% per resident in a long-term care facility (Mäki et al., 2023[64]; Perttu et al., 2025[65]). First impressions by patients and caregivers also suggest positive experiences. In Denmark, patients valued remaining in their familiar surroundings, reducing confusion and stress, and caregivers reported that it was less disruptive and more effective than a hospitalisation, which would have been more difficult to integrate in their daily lives than a visit at home, for example through accompanying their relative to the hospital, which would require some to take time off work and to arrange childcare (Udesen et al., 2021[66]).
4.4.2. Replacing and shortening hospital stays through more intensified care at home
A set of countries have been introducing programmes that aim at outright replacing a hospital stay, or at allowing for an earlier discharge from hospitals to home, through intensified monitoring in a patient’s home. These “hospital-at-home” programmes have been introduced in the 1970s and recently gained momentum to help address long waiting lists and capacity constraints, to navigate increasing demand amid financial constraints, and to offer safe care at home during the COVID‑19 pandemic (Pandit et al., 2024[67]). Today, at least 22 OECD countries offer hospital-at-home programmes, among them Australia, Canada, Chile, France, Israel, Japan, Mexico, the Netherlands, Norway, Switzerland (e.g. Geneva, and additional pilots in Basel-Land and Zurich), Spain, the United Kingdom and the United States (Table 4.1). In addition, selected countries, among them Denmark, Estonia, Germany (Berlin), Latvia and Ireland, are currently piloting them and Luxembourg has announced the development of Hospitals at Home in its 2023 coalition agreement.
Note: COPD=Chronic obstructive pulmonary disease, DVT=Deep Vein Thrombosis, GP=General Practitioner, UTI=Urinary Tract Infection.
Source: Austria: (Österreichische Gesundheitskasse, n.d.[68]); Belgium: (Farfan-Portet et al., 2015[69]; INAMI, n.d.[70]) (RIZIV-INAMI, 2023[71]); Canada (British Columbia): (Vancouver Coastal Health, 2025[72]); Chile: (Campos Alarcón and Leiva Parisi, 2021[73]); Colombia: (Mi Salud me Mueve, 2024[74]; Secretaría Distrital de Salud, 2023[75]); Denmark: (Nordsjaellands Hospital, 2023[76]; Nordsjællands Hospital, n.d.[77]); Estonia: (Ülikool, 2023[78]); Finland: (Pohjanmaan hyvinvointialue, n.d.[79]);France: (République Française, 2025[80]); Germany: (Charité, 2024[81]); Greece: (Skylakakis, Plevris and Gaga, 2023[82])ΦΕΚ 3 396/19‑05‑2023 τ.Β’ Νοσοκομειακή Κατ’ Οίκον Νοσηλεία και Φροντίδα Υγείας.; Ireland: (HSE, 2024[83]; Vhi, 2025[84]); Israel: (Sabar Health Hospital at Home, 2025[85]); Latvia: (Ministry of Health, 2025[86]; Ozolina, 2025[87]); New Zealand: (Wrigley, 2024[88]; New Zealand Government, 2024[89]); Norway: (Helseinnovasjonssenteret, n.d.[90]; Inger et al., n.d.[91]); Spain: (IFSES, 2024[92]; Gómez Rodriguez de Mendarozqueta et al., 2020[93]); Sweden: (Region Stockholm, 2025[94]); Switzerland: (imad, 2024[95]; imad, 2023[96]; Hospital@Home, n.d.[97]); England: (Hospital at Home, 2022[98]); United States: (MedPac, 2024[99])
In hospital-at-home programmes, patients generally have access to a 24‑7‑hotline, receive visits at home by doctors and nurses in their home and can also receive additional digital assistance depending on the programme. The exact type, frequency of services and content differ across countries and programmes (Table 4.1). The number of providers of Hospital-at-Home services and the share of patients in these structures is small but growing across various OECD countries. For example, France counted 293 providers of hospital-at-home services in 2023 that treated a total of 278 600 inpatient stays and accounted for 6.8 million patient days (DREES, 2025[100]). Similarly, the United States recorded a total of 366 Help-at-Home providers under the Acute Hospital Care at Home Initiative (AHCAH) in 2024 (Adams et al., 2024[101]).
Hospitals at home are mostly hospital-led and paid through the country’s respective hospital payment system. The hospital has a co‑ordinating role and provides at least part of the workforce, such as nurses who visit the patient in their home to provide care. Hospital-at-home programmes are generally financed via the regular hospital payment system, based on diagnosis-related groups, global budgets, or a combination of diagnosis-related groups and per-diem payments. In the United States, under AHCAH, hospitals can bill the diagnosis-related group of the inpatient stay, but provide care in a less costly setting, which offers a strong financial incentive to hospitals. For payers, this approach does not offer financial gains from the hospital stay itself but can offer indirect efficiency gains from fewer hospital re‑admissions. In Australia and France, hospital-at-home stays are paid through diagnosis-related groups. In France, patients are allocated into one of the 31 diagnosis-related groups for hospital-at-home stays based on their main and co-diagnoses, their dependency determined based on the so-called Karnofsky index, and the length of stay (Système National des Données de Santé, 2024[102]; ATIH, 2024[103]). Medication is charged separately. In England, the payment for hospital-at-home programmes (virtual wards) is determined by regional authorities (Integrated Care Systems). NHS England has made GBP 450 million available in 2022-2024 for the expansion of hospitals at home, which is allocated to these authorities to expand services in their regions. Most of this funding is expected to contribute to workforce costs (NHS England and NHS Improvement, 2022[104]). Other countries that use global budget schemes, such as Scotland and parts of Spain (e.g. Valencia, Madrid), finance hospital-at-home programmes through the general hospital budget, or use additional activity-related payments (e.g. Catalonia, Basque Country) (SEHAD, 2020[105]). In Israel, hospitals at home are also part of the global budget payment, but hospitals face a 1%-penalty if they do not expand on this service. In Belgium, hospitals at home are paid via a combination of lump-sum, flat-rate, and fee‑for-service payments for hospitals, specialists, GPs and home nurses.
Overall, findings indicate that hospital-at-home programmes yielded the same, or better outcomes, and are cost-effective (Shepperd et al., 2021[106]; Arsenault-Lapierre et al., 2021[107]). Mean hospital costs of hospitals at home were generally around 20% to 30% below their comparable inpatient stays (Cryer et al., 2012[108]; Singh et al., 2021[109]; Yehoshua et al., 2024[110]). Lengths of stay in hospitals are often shorter and patients have fewer referrals to emergency departments. Similar results were found in the United States for providing post-acute care for people with dementia at home, which resulted in similar outcomes at lower costs than skilled nursing facilities (Burke et al., 2021[111]; Ruiz et al., 2017[112]).
Patients are reporting high levels of patient satisfaction with hospital-at-home stays, which generally exceed satisfaction with inpatient stays (Leff et al., 2006[113]; Pandit et al., 2024[67]; Shepperd et al., 2021[106]; Wang, Stewart and Lee, 2023[114]). They feel more relaxed, less anxious and less depressed in their home settings, which might have helped their recovery. Caregivers have also reported positive experiences and reported feeling more comfortable and less stressed, but also show room for improvement in preparing them for their roles and in integrating them into the care pathway (Rossinot, Marquestaut and de Stampa, 2019[115]). Caregivers in the AHCAH programme noted the initial orientation they received as key to preparing for the start of Hospital-at-Home (CMS, 2024[116]).
To date, the number of hospitals at home is still limited. While they are increasing steeply in rate, some barriers hamper their growth. The expansion of hospital-at-home structures is subject to similar workforce shortage constraints as other healthcare sectors. While hospitals at home are less workforce‑intensive then regular inpatient admissions, they require an active restructuring of staff that is otherwise allocated to inpatient care. The efficiency and cost-effectiveness of the structure depend on the price‑setting. If hospitals receive the same tariff for a hospital-at-home stay as for an inpatient stay, the tariff will largely exceed costs and make hospitals at home lucrative to them but offer no direct gains for payers. Such a structure might be used to set an incentive to providers in the first years of the programme, but lower cost structures of hospitals at home should be accounted for in price‑setting in the longer run.
Hospitals-at-home are also at risk of exceeding the time period for which they are intended. Experience from Canada shows that hospitals-at-home programmes can last longer than the intended acute care phase, becoming a cost and resource‑intense discharge programme that might not be medically necessary. In this case, the economic gains from an earlier discharge are overtaken by the costs of the hospital-at-home programme which might not have been medically necessary and just duplicate existing programmes at a higher price (Crisci, 2023[117]). This makes a clear definition of the role and scope of hospital-at-home programmes necessary to ensure that it does not exceed the medically necessary period and does not duplicate existing structures.
Finally, patients and caregivers are often unaware of the option of hospitals at home (Rossinot, Marquestaut and de Stampa, 2019[115]). In addition, some programmes might need to expand on the nursing care provided to ensure that informal caregivers do not have to take additional time off or hire additional support out of pocket (CMS, 2024[116]).
4.4.3. New provider types can improve access and efficiency of care delivery
Several OECD countries have introduced new provider types to offer an intermediate layer in their healthcare systems, and rearranged the way they provide care to avoid or shorten hospital stays for older people. These incentives aim at providing care that is better tailored to the needs of older people, and at shifting the delivery of care from hospitals to other providers to reduce costs and bed blocking, where patients stay longer in a hospital bed than medically necessary, thus “blocking” a hospital bed.
Two dominant forms prevail across OECD countries. Firstly, countries are building health centres for older people in primary care, which group various specialties and can include experts from other policy sectors, such as social care workers, and can collaborate with other health, social and long-term care structures (OECD, 2020[6]). Secondly, countries are setting up intermediate care structures that are located between the in- and the outpatient sector and generally offer beds for overnight stays for a limited number of days, and can be physically integrated in a hospital, or a separate, free‑standing facility. They aim to either prevent a hospital admission altogether by offering an alternative place of care provision that does not require complex structures, or to allow for a quicker hospital discharge to reduce bed blocking for people that require some monitoring or post-acute care and are not ready to be discharged to a home setting, but also do not require the level of hospital care, anymore.
Teams are a promising structure to improve access to primary care and to facilitate the teaming up of different professions through multidisciplinary teams that operate within one network (primary care teams), or under one roof (primary care centres). Primary care centres are generally not exclusive to older people, but as the complex health status of older people requires patient-centred care from a set of different specialties, they are a core target group of these centres. For example, Greece launched primary care centres (Τοπικές Μονάδες Υγείας, ToMYs) in 2017, which are part of a general restructuring of the health system. In these around 120 structures, a team of general practitioners, internists, paediatricians, nurses and social workers offers health prevention and promotion, diagnosis, treatment, monitoring and care. Austria, Germany (Baden-Württemberg) and several cantons in Switzerland are also in the process of reorganising primary care structures in light of an ageing population. These primary care centres (Primärversorgungszentren) regroup a set of primary care specialties, such as general practitioners, nurses, dieticians and extend services beyond existing group practices and care centres (Baden-Württemberg, 2022[118]). Poland is currently introducing one health centre per 100 000 inhabitants for people aged 75 and above (Centra Zdrowia 75+) over the next five years, totalling about 300 centres for the whole country. Similarly, the Slovak Republic is running additional pilots of that link between health and long-term care.
Primary health centres and teams can increase access to care. Family Health Teams in Canada (Ontario) helped expand service volumes to people enrolled in their networks, had lower referral rates and treated slightly sicker patients than regular primary care teams (Somé et al., 2020[119]; Kantarevic, Kralj and Weinkauf, 2011[120]; Strumpf et al., 2017[121]). Findings from France echo Canada’s experiences, which reported increases in the number of patients seen, and the targeted allocation of Primary Care teams in rural areas also helped improving the recruitment and retention of doctors, thus improving access to primary care for people in poorly served areas (Chevillard and Mousquès, 2021[122]; Cassou, Mousquès and Franc, 2020[123]). The integration to foster the integration of general practitioners and advanced practice nurses and to delegate tasks to nurses was found to further increase access through an increase in the number of patients registered and seen (Loussouarn et al., 2020[124]).
At the same time, primary care teams have experienced difficulties in engaging older patients in decision making, reported shortages in healthcare resources particularly in rural areas, and insufficient interaction with other providers, such as specialised dementia care, partly resulting from a lack of knowledge (Elliott et al., 2018[125]). The introduction of primary care centres can be cumbersome. The roll-out of primary care centres in Greece was slow and heterogeneous, faced criticism by health professionals, low enrollment and its effects on improving access to primary care has been limited, so far (Emmanouilidou, 2021[126]; Myloneros and Sakellariou, 2021[127]). In addition, while some primary care teams increased their list sizes, the service volume did not always increase. Instead, primary care teams did not change their service volume or reduced it compared to other, “regular” general practitioners (Cassou, Mousquès and Franc, 2023[128]). It is not clear whether this results from quality improvements, which make fewer visits necessary, is due to task shifting, or could point at under provision of care.
In Canada, various provinces are operating transitional care units to offer a transition from a hospital to home for people who do not need full hospital care, but require monitoring and receive care from nurses, personal support workers, and rehabilitation providers if needed (Barber et al., 2024[129]). Ireland has been setting up geriatric day hospitals, allowing for a faster discharge (Romero-Ortuño, 2025[130]). People above the age of 65 receive care from a multidisciplinary team for a number of conditions, such as chronic illnesses, cognitive impairment, poor nutrition and incontinence, and return to their own homes overnight. They are integrated in hospital structures and engage with other departments, for example for diagnostics. Similarly, France has launched several system interventions to better accompany people who have recovered enough to be discharged from the hospital but still require some monitoring and do not receive sufficient care at home. The hérbergement temporaire en sortie d’hospitalisation (HTSH) after a hospital stay takes place in long-term care facilities and is available for up to 30 days for people aged 60 and above. This compliments two already existing programmes, them being the programme d’accompagnement au retour á domicile après hospitalisation (PRADO) and the Aide au retour á domicile après hospitalisation (ARDH). In addition to that, France offers hôpitaux de proximité, which collaborate with primary care providers and long-term care facilities and offer preventive services, diagnostics, and short-term hospitalisations close to people’s homes. Italy offers community hospitals (ospedali di communità), which consist of around 15 to 20 beds and offer care to people who were discharged from acute care hospitals, acute care or rehabilitation facilities, or are admitted from home and have chronic conditions or frailty. Their condition is too severe to allow them to be at home, but they also do not require high complexity care and spend up to six weeks in a community hospital but also do not require intense monitoring. Hungary is in the process of introducing “specialist nursing” departments in hospitals for people that do not require full hospital care but still need some monitoring. These units are placed under the competencies of the social care sector. In 2023, this plan covered six centres with a total of 318 beds (Directorate-General for Social Affairs and Child Protection, 2023[131]). In the United States, skilled nursing facilities also offer an in-between layer between hospitals and home‑based care or long-term care facilities, offer around-the clock care, provide help in activities of daily living and are staffed by doctors, physical therapists, and other medical professionals.
Intermediate care facilities have largely been identified as successful in improving health outcomes, for example reductions in hospital readmissions, and have been found to be cost-effective, and might be worth the investment (Weeks et al., 2018[132]; Verhaegh et al., 2014[133]). In the United States, discharges to home care had lower costs, but higher 30‑day readmissions than discharges to skilled nursing facilities, suggesting that lower expenditures could come at the expense of quality of care (Werner et al., 2019[134]).
So far, intermediate care facilities are limited in scale and scope and are often in a pilot stage. Shortages present a barrier in increasing the availability of intermediate care facilities (Leland et al., 2024[135]). Intermediate care facilities are also prone to care fragmentation, which can negatively impact quality of care. Outcomes of intermediate care facilities (skilled nursing facilities) in the United States that have good levels of integration with hospitals enjoyed significantly better health outcomes than those with poor levels of integration (Rahman et al., 2018[136]), but low levels of data sharing (Adler-Milstein et al., 2021[137]) hinder co‑ordinated and patient-centred care.
While transition care facilities can be a viable policy option to shorten inpatient stays, patients can also spend excessive lengths in such units because of a lack of supply and long waiting times for long-term care at home or in facilities. Canada has been experiencing both waiting times for transitional care facilities, and delayed discharges to long-term care settings. In addition, some countries display further room to improve efficiency along the pathway from hospitals to long-term care. Large spending increases on skilled nursing facilities and other post-acute care settings in the United States have raised questions about additional efficiency gains and financial incentives might lead to longer hospital stays then medically necessary (Chandra, Dalton and Holmes, 2013[138]; McGarry et al., 2021[139]). In addition, just setting up any new physical structure for older people does not automatically lead to cost-effective care. Long-term care hospitals in the United States, which provide care similar to Skilled Nursing Facilities, but receive much more generous payments, have generated wasteful spending that are estimated to equate to USD 4.6 billion per year (Einav, Finkelstein and Mahoney, 2023[140]).
Intermediate care facilities can represent a successful strategy in shortening hospital lengths of stay by offering a step-down structure for people that still require some form of monitoring and supervision. Intermediate care structures can improve the efficiency of healthcare systems by directing patients, who do not require high-intensity hospital structures anymore to a less resource‑intense setting. This frees up human and financial resources for patients that require such intensity. At the same time, patients can get stuck in intermediate structures, for example though a shortage in long-term care facilities that patients could be discharged to from an intermediate care structure. To further improve the efficiency of healthcare systems, countries have to make sure to offer sufficient structures post-intermediate care. Clear pathways, data sharing arrangements, and co‑ordination and integration with other providers can help address fragmentation or adding another layer these challenges, for example through a formalised agreement with other providers.
Care provided to older people is often fragmented. They receive care from a set of different providers from different sectors, which is challenging to co‑ordinate and align. Older people often face several limitations and multiple chronic diseases concurrently, requiring a set of interventions to help them maintain and improve their health status. Interventions that focus on individual mechanisms alone tend to work below potential and care provided to older people often displays high variability (Jarman et al., 2022[141]). They often do not sufficiently address the risk, and if they do, might not materialise in better health outcomes. For example, programmes that support deprescribing are very limited and their success in reducing polypharmacy is mixed. Even if they are successful in reducing polypharmacy, lower rates do not always lead to improvements in health outcomes, such as reductions in hospitalisation rates (Cole et al., 2023[142]). Similarly, evidence on deprescribing fall-risk inducing drugs indicates that deprescribing alone might not be sufficient to reduce falls if not combined with other fall-reducing policies (Lee et al., 2021[143]). Countries are working with care pathways to better structure the care provision along a patient’s care pathway and are setting up integrated care programmes to further support and formalise the integration of care from a set of different providers.
4.5.1. Care pathways aim at streamlining care along the patient pathway
A total of nine countries (Colombia, France, Iceland, Ireland, Luxembourg, the Netherlands, Norway, the Slovak Republic and Slovenia) reported that they have introduced care pathways for older people to harmonise and streamline the provision of care. They are often broadly structured along the steps outlined by the World Health Organization (2024[144]) in the handbook for integrated primary care for older people, which consist of a basic assessment, in-depth assessment, developing a personalised care plan, and implementation and monitoring. Each of these steps may contain a range of actions depending on the patient and condition and should integrate various healthcare providers as well as the community. For example, Norway offers several disease‑specific guidelines for older people. In 2009, it introduced the Patient Trajectory for Home‑dwelling elders (PaTH) to improve the discharge from inpatient care and primary care follow-up, and while the programme has potential to improve care co‑ordination and follow-up, low adherence has been limiting its impact. Specifically, training home care staff to use the care pathway and integrate it into daily practice required substantial work, but when municipalities achieved this, it could function as a management tool to drive change and enhance knowledge and skills (Røsstad et al., 2015[145]). The United States introduced the Financial Alignment Initiative (FAI) in 2001 to better align services for people with dual eligibility (Medicare and Medicaid).
Source: Australia: (NSW Health, 2023[146]; Palk et al., 2008[147]; Fitzgerald et al., 2019[148]); France: (Ministère de la Santé, 2025[149]; Gand et al., 2017[150]); Ireland: (Health Management Institute of Ireland, 2022[151]; Kennelly, Fitzgerald and O’Shea, 2017[152]; OECD, 2025[153]; Ward et al., 2022[154]); Italy: (Gervasi et al., 2020[155]); Netherlands: (van der Velde et al., 2025[156]; de Koeijer et al., 2025[157]); Norway: (Røsstad et al., 2017[158]); United Kingdom: (NHS England, 2024[159]; NHS England, n.d.[160]; Duncan and Sayers, 2023[161]; Hopper, 2021[162]; NHS Confederation, 2022[163]; McGrath, Almeida and Law, 2019[164]); United States: (State of Indiana, 2025[165]); GERONTE: (GERONTE, 2021[166]; Seghers et al., 2024[167]).
Care pathways can help health workers streamline the provision of care and are often associated with improvements in health outcomes (Seys et al., 2017[168]), but can be challenging to implement. The diffusion of clinical guidelines and care pathways takes time, and time constraints, staff shortages and turnover are only some of the limiting factors that hinder the adherence to care pathways (Gladman et al., 2016[169]; Evans-Lacko et al., 2010[170]). Context-specific challenges to implementation, such as insufficient knowledge about palliative drugs or taboos around dying for palliative care pathways, may further complicate adherence, while other barriers like a lack of multidisciplinary teams or resistance to change are more general (Watson, Hockley and Dewar, 2006[171]).
Although the need for care pathways for older people has been identified long ago (Katsaliaki et al., 2005[172]), systematic research is still scarce. Evaluations of many pathways are complicated by poor adherence and if available, point at mixed results, indicating a need to more thoroughly consider prerequisites for effective implementation (Røsstad et al., 2017[173]). However, there are some promising studies on care pathways for specific outcomes after acute issues, such as reducing frailty in trauma patients among older people (Bryant et al., 2019[174]) or in acute care, where the implementation of geriatric care pathways reduced costs and shortened hospital stays while health outcomes remain similar (Ijadi Maghsoodi et al., 2022[175]). Similarly, Suhm et al. (2014[176]) found that co-managed care pathways for older hip fracture patients reduced the length of hospital stays and complications while in the hospital compared to usual care.
4.5.2. Integrated care programmes increasingly link health with social and long-term care
In the OECD Policy Questionnaire on Healthy Ageing and Community Care, a total of 20 OECD countries responded that they have already introduced integrated care programmes for an older population, with another 3 planning to do so. Countries can build on the experience with more “traditional” programmes that aimed at integrating providers within one sector and are widespread cross the OECD, for example to improve care co‑ordination for people with chronic diseases (OECD, 2023[10]). Integrated care programmes that particularly target older people are either exclusive to people beyond a certain age threshold, such as 60 or 65 years, or are open to everyone, but focus on certain conditions that tend to be more prevalent among older people. While integrated care pathways are usually designed systematically based on existing experience and relevant research (Dubuc et al., 2013[177]), follow-up research to determine their real-world effectiveness is often lacking.
Source: 2023 OECD Policy Questionnaire on Healthy Ageing and Community Care.
More recently, countries have been active in reaching beyond the healthcare system alone. This reflects a move towards a more comprehensive understanding of care beyond the healthcare system and interacts with social and long-term care (See Table 4.3). Integrated care programmes generally combine at least two different sectors. The long-term care sector is the most frequently involved sector, with 21 countries integrating long-term care in their integrated care programmes, followed by social care (19 countries), outpatient care (16 countries) and inpatient care (15 countries). Seven countries also co‑operate with other providers and sectors, such as short-term and rehabilitation and palliative care in Portugal, and private sector companies, volunteers, and non-profit organisations in Japan (OECD, 2023[178]).
Integrated care programmes for older people combine a variety of different health professions, reflecting a move towards more patient-centred care through multi-disciplinary teams. Long-term care facilities were involved in all 21 countries that responded to having implemented an integrated care programme. Nurses (18 countries), general practitioners, home care providers and social care workers (17 countries each) were also prominently involved, followed by outpatient specialists (16 countries). Inpatient providers were slightly less involved (14 countries), and 12 countries also interacted with other professions, such as occupational therapists in Iceland, physiotherapists in the Netherlands, volunteers and informal carers in New Zealand, and professionals from the voluntary, community, and social enterprise sector in the United Kingdom.
Integrated care programmes differ in scale and scope. Belgium and Luxembourg are both in the process of introducing integrated care programmes. Belgium launched a pilot of 12 programmes for chronic diseases in 2018, and of another 19 programmes for alternative forms of care for older people in 2019 and is currently integrating its findings into a new plan on integrated care (RIZIV-INAMI, 2023[179]), while Luxembourg is teaming up providers for a selection of pathologies (réseaux de compétences), them being neuro-degenerative diseases, immuno-rheumatology in adults and children, diabetes and morbid obesity for children and chronic pain (Ministry of Health and Social Security of Luxembourg, 2024[180]). These link patients and caregivers with hospitals, care co‑ordinators, home care providers, outpatient physicians, and other professionals to one joint network. In Canada, several provinces have gained experience with integrated care for older people. For example, Quebec launched the Program of Research to Integrate the Services for the Maintenance of Autonomy, also known as Réseau de Services Intégrés aux Personnes Âgées (PRISMA, or RSIPA) in 1999, which was later integrated in standard care. Costa Rica has set up the Progressive Care Network for the Comprehensive Care of Older Adults (Red de Atención Progresiva para Cuido Integral de las Personas Adultas Mayores en Costa Rica). France has experimented with different iterations of Integrated Care Programmes for older people. In 2014, it launched the programme parcours santé des aînés (Paerpa) for people aged 75 and above and their caregivers in nine French regions. The programme aims at supporting older people to stay at home for as long as possible, improving care co‑ordination and quality of life. The new pilot programme, the expérimentation d’un paiement forfaitaire en équipe de professionnels de santé en ville 2 (PEPS2) builds on this experience. A group of at least five medical professionals, covering at least three general practitioners, and at least one nurse, receive a global budget to provide care for a certain population group, such as people aged 65 and above, or people aged 50 to 64 with cognitive impairment. Ireland has introduced Enhanced Community Care (ECC). In New Zealand, several regional programmes focus on providing integrated care to frail people, or those at risk of becoming frail, such as the community health of older people initiative (CHOPi) in Wellington, and the Kare Project in Auckland. Portugal has launched a pilot project of local health units (Unidade Local de Saúde) that team up Primary Care, outpatient specialist services and inpatient care and shall improve vertical integration (Goiana-da-Silva et al., 2024[181]). This structure resembles Integrated Care Systems in the England, which were introduced in 2022. The country’s 42 ICSs are responsible for commissioning health, social and long-term care, serving 0.5 to 3 million people each. In the United States, several states have set up new structures under the Program of All-Inclusive Care for the Elderly (PACE).
Several additional OECD countries are in the process of setting up Integrated Care Programmes in their countries. For example, Czechia has launched a Regional Health and Social Plan (Krajské zdravotně sociální plány, KARPL). The Ministry of Health co‑operates with the Ministry of Labour and Social Affairs on mapping already existing health and social services to assess unmet need, and to identify areas of improvement for co‑operation and co‑ordination, and on developing and piloting a strategy on how to address both (Czech Ministry of Health, 2024[182]).
4.5.3. Integrated care programmes reform the way providers are paid to foster integration
Integrated care programmes are either paid through a combination of different payment schemes, or through a capitation-based approach. A group of countries uses existing payment schemes, such as payments based on diagnosis-related groups for inpatient providers, and fee‑for-service for outpatient providers, and monthly contributions for long-term care facilities. Some countries have decided to reform the way providers are paid and use payment schemes to support provider integration. In these programmes, a group of providers is either entirely paid based on a global budget, or through a combination of a global budget and their traditional payment scheme. In France, provider groups of the pilot programme PEPS 2 receive a capitation-based global budget to provide care to a group of patients, replacing the existing fee‑for-service scheme. Capitation payments per patient are adjusted by age, sex, the number of chronic conditions, the presence of one or more out of five selected chronic conditions, and the socio‑economic background of the patient. In addition, a regional factor is applied based on average expenditures, density of General practitioners, and socio‑economic status of the region based on poverty rates of the areas the patients and provider are located in. Additional payments can be issued for nursing-related costs (Ministère du Travail, de la Santé, des Solidarités et des Familles, 2024[183]; Ministère du Travail, de la Santé, des Solidarités et des Familles, 2024[184]). Similarly, Luxembourg and Portugal are currently in the process of moving Integrated Care Programmes towards global budget schemes. In the United States, in PACE, providers are paid monthly on a capitation-basis, replacing the traditional fee‑for-service method. Capitation payments consist of four components, them being health provider-related costs (Medicare Part A and B), which are adjusted by morbidity and frailty, drug-related costs (Medicare Part D), which are adjusted based on a patient risk score, Medicaid payments that are determined based on a state‑level, which in most states consists of a flat-rate for Medicaid eligibility, and private payments, that generally represent about 1% of total costs (CMS, 2011[185]).
Several countries are adjusting payments or offering add-on incentives for quality of care to financially incentivise quality improvements. At least 10 OECD countries link integrated care payments to quality indicators. In some instances, these are part of a regular pay-for-performance programme and focus on a specific sector. Latvia and England target general practitioners, Poland rewards for cardiovascular prevention and Iceland targets home‑care providers. Four countries, them being France, Japan, Portugal and the United States, have set more comprehensive pay-for-performance programmes that address integrated care more specifically. These programmes are very heterogeneous in their design. France ties part of the payment to quality indicators in PEPS2. Provider networks are paid on a capitation basis, where providers can receive an additional up to 10% for continuity of care, prevention and health education as well as patient experience (Ministère des Solidarités et de la Santé, 2019[186]).
4.5.4. Integrated care programmes are intuitive, but gains are difficult to materialise
While the introduction of integrated care programmes seems intuitive to fight fragmentation through integrated, patient-centred care, tangible improvements in quality of care and reductions in expenditures are difficult to achieve and are insufficient to offset major deficiencies of health systems, such as health workforce shortages and insufficient capacities of providers. Overall, evaluations of Integrated Care Programmes show mixed, heterogeneous results and gains take time to materialise. For example, the French programme PAERPA was successful in reducing avoidable hospital admissions, and reducing polymedication, inappropriate prescriptions and visits to emergency rooms, but not on hospitalisations and suffered from low engagement of health professionals (Or, Bricard and Penneau, 2019[187]). Three integrated care programmes for older frail people in the Netherlands largely failed to offer significant improvements in quality of care and largely failed on measures of cost-effectiveness (Hoogendijk, 2016[188]). Some programmes in England were successful in mitigating avoidable admissions, but results are heterogeneous across different integrated care programmes (Morciano et al., 2021[189]).
Integrated care programmes seem to work better when professionals already have some level of team integration and trust, but these take time to build, especially when programmes aim at integrating providers from different sectors with different modes of operation. Knowledge of integrated care, communication, teamwork and shared decision making are key skills to delivery integrated care (OECD, 2025[190]; OECD, 2025[191]). In Canada (Ontario), trust was identified as a key enabler to integrating care, but this process takes time to build and has a gradual phase‑in (Embuldeniya et al., 2018[192]). Similarly, in the Netherlands, building integrated care took several iterations and financial and expert support (Nies et al., 2021[193]).
Changes in provider payments can support continuity of care, foster the identification as a team, and offer financial security to providers. For example, a move from existing, separate payment schemes, such as fee‑for-service for outpatient providers, diagnosis-related groups for hospitals and per-diem payments to long-term care providers towards a quality-adjusted capitation payment to a group of professionals holds a group of different providers accountable for delivering care. At the same time, a move towards payment schemes that support continuity of care, offer financial security to providers and facilitate longer-term planning can come at a risk of longer waiting times and efficiency reductions. Providers that operate in Integrated care programmes often report that measures to foster trust, integration and team building, such as multidisciplinary team meetings, are insufficiently covered in the financing of integrated care programmes (Grol et al., 2021[194]). Policymakers can add these dimensions to the way providers are paid, but it increases the costs of integrated care programmes and counteracts efforts to reduce spending.
Flexibility for local authorities to adapt programmes to people’s needs is difficult to balance with limitations in skills and capacity constraints. Providers that participated in integrated care programmes in Canada (Ontario) highlighted the wish for greater accountability and flexibility (Embuldeniya, Gutberg and Wodchis, 2021[195]). At the same time, experience from England and the Netherlands has shown that regional entities and provider groups might require some additional expert support in making use of their increased autonomy and also need some financial support in setting up new governance structures (Morciano et al., 2021[189]).
A community-based Integrated Care Programme improves outcomes and reduces expenditures
Japan offers Community-Based Integrated Care systems that group providers from a variety of sector from the health, social and long-term care centre and are centred around the patient. It offers healthcare, nursing care, prevention, housing and livelihood support to ensure that people can age actively and independently in place. Services are co‑ordinated by a care manager and are offered within a catchment area of 30 minutes and older people are referred to it based on their need.
Source: MHLW (2025[196]), 地域包括ケアシステム [Community Integrated Care System], https://www.mhlw.go.jp/stf/seisakunitsuite/bunya/hukushi_kaigo/kaigo_koureisha/chiiki-houkatsu/.
This structure originated in Mitsugi in 1974, resulting in half a century of experience in designing and implementing integrated care for older people. Japan is currently revising its Community-Based Integrated Care System and moving towards a new system by 2025. Municipalities and prefectural governments are tasked with creating such community-based integrated care systems as insurers of long-term care and are responsible for tailoring it to the needs of their municipality. Since 2025, municipalities have to formulate a long-term care plan every three years and implement community-based comprehensive care system in their respective entity. As part of it, municipalities have established community comprehensive support centres, in which public health nurses, social workers and other specialists offer mental and physical health support. In 2024, there were 7 362 such centres available across the country.
The comprehensive system has been successful in preventing the rate of hospitalisations and institutionalisations (Tomita, Yoshimura and Ikegami, 2010[197]). Integration and a shared vision were reported as key enablers in building successful integrated care systems (JICA, 2022[198]), but staff shortages and difficulties of informal caregivers, such as relatives, to reconcile caregiving roles and labour supply, remain constraining factors of community-based integrated care (Costantini, 2021[199]).
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