This chapter presents a possible cycle for integrated home care in Italy. It sets out an integrated care pathway based on unified access, assessment and personalised care planning, stressing the importance of co‑ordination across health, social and family support and of keeping the individual at the centre. It then examines the mix of interventions and providers needed to deliver comprehensive responses, and the mobilisation of public and private resources to sustain home care. Finally, the chapter identifies key enabling factors for integration, including a supportive legal and institutional framework, stronger social economy ecosystems, robust monitoring and information systems, the use of cost-effective health technologies, and investment in strengthening workforce skills, competencies and knowledge for effective integrated care.
Towards a Structured and Systemic Integration of Home Care for the Non-Self‑Sufficient in Italy
Abstract
A home care system capable of offering a realistic and effective response to the health needs of non-self-sufficient elderly people and their families must simultaneously address the three dimensions of care, assistance and protection without shying away from the complexity that this entails.
For healthcare, there is the fundamental issue of “long-term” home care, a setting that is addressed in residential and semi-residential care through the so-called “long-term care” referred to in Article 30 of the 2017 Prime Ministerial Decree “Nuovi LEA” (New Essential Levels of Care). Healthcare organisations are increasingly accustomed to operating through the provision of individual services, intended for use by individual persons, administered within a specific period determined by precise elements of temporal appropriateness and duration. Outside this model (individual services, for individual use, with predetermined administration), current healthcare organisations are finding it increasingly difficult to understand, organise and manage the set of interactions necessary to deliver interlinked services guided by multidimensional care processes. While this difficulty is clearly evident in fully managed healthcare settings (hospitals, outpatient clinics, residential facilities), it is even more pronounced in home care settings, where the complexity of multidimensional care processes is compounded by the individual capabilities of the person being cared for, their family situation and their living and housing conditions. These complexities cannot be confined to care slots with a predefined term of effectiveness and appropriateness in the “long term” and are characterised by “clinical instability and symptoms that are difficult to control, requiring continuity of care and planned interventions”, as stated in paragraph 3, letter d) of the 2017 Prime Ministerial Decree “Nuovi LEA” (New Essential Levels of Care).
In the social sphere, the fundamental question arises of the actual “consistency and extent of protection” provided by municipal organisations to disadvantaged individuals and families receiving home care. The content of the fundamental public function of “Social Assistance” consists in “the planning and management of the local social services system and the provision of related services to citizens, in accordance with the provisions of Article 118, paragraph 4, of the Constitution”. The focal point of service provision is conditioned both by means testing (ISEE) and by the assessment of the needs for protection, assistance, support and social assistance arising from the conditions of the person, their family and their formal and informal networks of reference. The “protective” nature of the public function of social assistance is expressed precisely in this access filter, which focusses public action on individuals and families in greatest difficulty in order to help them regain a degree of autonomy in relation to economic, social, employment, housing, training and educational inequalities, combined with individual functional and bio-psycho-social characteristics. However, the current response capacity of municipal social services is limited, as is the capacity for action of the Home Care Service. In this regard, it is worth noting that Legislative Decree 29/2024 addressed the issue of semi-residential care, which, from a social welfare perspective, aims to combat social isolation and the deterioration of the personal conditions of older people.
The lack of systemic and structural co‑ordination between ADI and SAD has always been considered the factor responsible for the historical fragility of home care services dedicated to complex and multidimensional needs, but perhaps other factors of equal importance within health and social organisations need to be added.
the tendency of healthcare organisations to provide home care rather than home assistance services, which are moreover standardised and prepackaged in terms of both content and duration, even for non-self-sufficient elderly people.
the limited scope and extent of protective assistance provided by municipalities to socially vulnerable or marginalised individuals and households, which is currently too limited to support the progressive increase in inequalities and the advance of poverty.
However, the central issue for a long-term home care proposal is that of personal care. Situated between healthcare and social protection (assistance), this dimension is in fact almost entirely delegated to the internal resilience of families and private economic resources, except for the Accompanying Allowance and other forms of cash transfers. However, these allowances and cash transfers are not co‑ordinated, integrated or finalised in the typical daily care routine of a non-self-sufficient individual living at home. This is by no means a trivial task, as it is essential to organise it both in terms of the specific needs of the individual and the family with regard to the performance of ordinary daily tasks, and in terms of access to the complex organisational network outside the home that is essential for the treatment of diseases, the promotion of health, the preservation of residual individual autonomy, and the relief and support of individuals and families.
One viable option is to recompose, or reunify, social (protection), healthcare (treatment) and welfare functions, leaving their current ownership unchanged. This approach involves the joint performance of both planning activities (integrated planning) and delivery activities (unified territorial organisation) through unified governance bodies that include the various stakeholders at the state, regional and local levels (multi-level governance) (Caiolfa, 2022[1]). The cycle proposed for the overall home care system reflects this approach and is based on three macro-functions that must be interrelated (Figure 5.1):
the integrated care pathway
the mix of measures and providers
the range of activated and achievable resources.
Population stratification – following the models and standards for community care defined by Ministerial Decree 77/2022 – is crucial for organising individual care systems based on their level of health and social care needs. Stratification systems have a significant strength in that they can be defined at multiple levels of healthcare planning – national, regional, and corporate – to best adapt to the diverse characteristics of a region's care demand. These stratification tools can be complemented by systems for classifying the degree of non-self-sufficiency,1 useful for differentiating and scaling interventions to support a cycle of integrated home care.
5.1.1. The integrated care pathway
It is considered essential to build a unified territorial system of services, access, and multidimensional assessments, permanently shared by healthcare and social services. This approach requires not only systematic and structural interaction between the two organisations, but also a greater awareness of the integration needed within the healthcare system, to overcome traditional and newly established corporate silos, and in the social sector, to co‑ordinate the various municipal administrations that constitute a territorial area. With reference to the reforms introduced by component 2 of mission 5 (social dimension of healthcare policies for the elderly) and component 1 of mission 6 of the National Plan for the Prevention and Rehabilitation (PNNR) (interventions for the development of proximity networks, facilities, and telemedicine for local healthcare), the integrated care model process can be divided into the following phases:
Request/report and access to the Single Access Point (PUA) front office
Pre‑assessment and identification of simple and complex social and healthcare needs (PUA front office)
Multidimensional assessment for complex needs that are both social and healthcare and fall within classes 4, 5, and 6 of the risk stratification system (Multidimensional Assessment Unit at PUA back office)
Formulation of the PAI (health, social, and welfare) and, where indicated, the health budget (UVM at PUA back office), with identification of the institutional case manager
Provision or implementation of integrated care
Monitoring of integrated care.
To achieve comprehensive management of complex healthcare needs, the PUA is not just a physical location but represents a set of shared health and social resources and tools. In the Community House, it is a single and integrated access service – also through the Local Operations Center – that provides reception, orientation, information, support, simple problem solving, and assessment of complex cases. In addition to the establishment of a multi-professional assessment team, the innovations brought about by ongoing reforms make it essential to establish a highly codified organisational relationship with the community homes’ internal team, the organisational structure that can conduct in-home assessments and organise the related integrated responses. To this end, within the PUA, it is necessary to establish a qualified micro-team, made up of a nurse, social worker, and doctor, who will serve as a stable point of contact for assessing needs both in the Community House and at home. In the home setting, the integrated social and healthcare model consolidates the interventions, services, and any monetary transfers related to health, welfare, and social protection services and measures under state, regional, or local jurisdiction into a single Individual Care Plan (PAI). The reorganisation implemented by the PAI aims to make the set of interventions, measures, and services appropriate and effective with respect to the health and social care needs of the individual and their family unit, as identified and assessed by the Unified Multidimensional Evaluation system. To this end, the PAI pursues the reorganisation, co‑ordination, and contextual delivery of all planned interventions, according to the methods and timeframes defined and shared with the individual, caregivers, and family members, where indicated. All these activities must be consolidated in the same home setting and co‑ordinated into a single ongoing program. Until now, home care has been primarily considered a form of care useful for reducing hospital burden, in the case of planned discharges or in-home hospital therapies, supplemented by short-term nursing and rehabilitation activities. The ongoing demographic transition requires us to reconsider the home setting as a much broader and more generalised approach, capable of addressing the complex care burden that will increasingly burden individuals and families. It is therefore essential to adopt a different approach to constructing the home setting, considering it the natural and customary place of care and assistance. This shift requires designing home care according to the actual and specific characteristics of the individual involved, the living environment in which they live, and their family unit with their social support network.
5.1.2. The mix of measures and providers
If, as part of a care pathway, a Care Plan has been developed that effectively addresses the complex health needs of a non-self-sufficient elderly person, how can a programme of interventions be organised to accommodate this complex level of care, assistance, and protection? Answering this first organisational question means simultaneously addressing the organisation of interventions into service packages, the mix of services potentially included in these packages – which address chronic diseases and conditions, care and ADLs, protection and social vulnerability – their gradation based on the assessed intensity, and their essential customisation. The second question to be addressed concerns the possible avenues for organising the provision of all complex home‑based responses in a given area; that is, all the interventions contained in all the home‑based PAIs developed in a given area, during a given financial year. This poses the key to the essential evolution of current delivery systems, which are excessively focussed on the production of divisional services and activities. The mix of interventions required to develop multidimensional responses, leading to the creation of truly multidimensional PAIs, requires a consequent evolution in the relationships between public organisations, private organisations, and local and community network organisations, as well as the related accreditation methods. Reorganising current healthcare, assistance, and social services into a unified service capable of fully implementing the PAI and serving as a true global reference point for individuals receiving home care and their families requires the development of innovative forms of home‑based social and health care. These forms of care combine ADI interventions with SAD interventions, integrate them with care activities initiated by individuals and their families, unify the methods of activating and using specialised services – including through digital healthcare – and provide a single platform for accessing assistive devices, as well as national, regional, and local support and assistance activities. These innovative organisational forms should be able to co‑ordinate, according to a complementary approach, direct public activities, services of accredited private organisations, and co-planning with third sector entities.
5.1.3. The range of activated and achievable resources
The shift in perspective resulting from the new and necessary relationship between the complex demand for health and the corresponding complex response, which must also be implemented in the home setting, is leading the system to approach the issue of funding and resource allocation differently. If the home setting for non-self-sufficient older adults is in any case linked to chronic conditions, complex interventions, and a long-term perspective, it is therefore inevitable to consider an integrated construction of related funding. There are two directions for change: achieving constant co‑ordination between public health (corporate) and social (municipal) resources, including through joint planning between the health district and the social territorial area; building joint health and social allocations based on long-term care and PAI, which are therefore not closed and open to each individual intervention – or weekly intervention cycles – but remain open, accommodating nursing, rehabilitation, specialist, care, guardianship, support, and promotion interventions from time to time. Similarly, after seeking ongoing co‑ordination between healthcare and social resources and allocations, the crucial step comes into play involving private resources – those of the individual and their family, and those of their friendship network and living environment. It seems difficult to seek a truly multidimensional approach to home care without addressing this, perhaps the most challenging step. The point is that, net of protective activities aimed at families experiencing social vulnerability, ADL assistance is almost entirely covered by the support and caregiving capabilities of families – through the direct activities of caregivers or family assistants, supported in part by INPS (National Institute of Social Security) or regional or local financial transfers. Obviously, without assistance with activities of daily living, no home care programme for dependent elderly people can sustain itself. This opens up two main perspectives regarding the ability of public organisations to understand the real dynamics of current home care. The first perspective concerns the possibility of envisioning a much more advanced public procurement system than the current one – sectoral and divisional – capable of also impacting the healthcare dimension by engaging families’ direct and indirect resources in an innovative and advanced form of accreditation, which also includes specialised and care services and can be funded through the co-payment of family resources. The second perspective concerns the development of the so-called Care and Assistance Budget, which calls for the co‑ordinated, and contextual use of all public and private resources for individuals and their families, as well as a propensity for the active involvement of local and community networks, including through the institutions of Shared Administration (co-programming and co-design).
Although there is extensive literature on the subject, and integrated care can reduce the length of hospital stays, emergency room visits, and admissions to nursing homes, evidence of its impact remains limited. This is partly due to the difficulty of interpreting and generalising evidence from local (micro-level) interventions, given the wide variability in the meaning and application of the term “integrated care” across OECD countries. However, there is a growing body of knowledge on the factors enabling integrated care.
5.2.1. Creating a supportive legal and institutional framework
The development of an effective integrated care system requires a collaborative and cohesive approach between different levels of government and stakeholders. To achieve this, it is essential to define a clear and shared legal and institutional framework based on common values and mutual respect for roles and responsibilities.
A key element of this framework is the establishment of qualified local teams, bringing together different professionals to drive meaningful change and innovation. It is also necessary to invest in building strong and reliable relationships between professionals, management, policymakers, patient representatives and the community.
Open communication and transparent, consensus-based decision making enable common ground to be identified, leading to effective and informed choices. By adopting these principles and working together towards a shared vision, stakeholders can promote a cycle of integrated home care that optimises outcomes for patients, delivers high-quality care and support, and ensures the well-being of the entire community.
5.2.2. Promoting community action
Recognising the role of civil society and all stakeholders – public and private – in addressing the economic and social challenges facing communities can facilitate the creation of social economy ecosystems, conceived as a set of actions aimed at promoting, growing and developing social innovation, including through improved relations between the various actors involved. Approaches to maximise the involvement of local communities – including those most at risk of poor health – may improve health and well-being and reduce health inequalities.
5.2.3. Ensuring timely and robust evaluation of the implementation of integrated care
The availability of monitoring and evaluation tools and processes foster a culture of openness, transparency, continuous professional development and improvement in service delivery. To strengthen the evidence base and legitimacy of integrated care, timely and robust evaluations – including on the quality and level of care co‑ordination and possibly built into routine data collection – are needed.
A well-functioning information and communication technology system is a prerequisite for better collaboration, effective communication and streamlined care processes. However, in many areas, privacy legislation will need to be revised to allow for interoperability and data exchange between operators.
The development of shared information infrastructure is the most promising long-term prospect. This approach ensures that systems meet the specific needs of the workforce and patients, do not increase the administrative burden, and facilitate professional work rather than hindering it.
5.2.4. Encouraging the use of cost-effective health technologies
Common assistive technologies that improve vision, hearing, mobility, safety and communication are essential for promoting functional activities and movement.
Wearable devices and telemedicine enable the monitoring of a wide range of chronic conditions, allowing for the detection of serious problems, better patient adherence to treatment guidelines and a reduction in the risk of intensive care and long-term care.
Healthy ageing can be facilitated by technologies that enable people to live safely and independently in the community, thereby delaying the need for and demand for informal and formal long-term care services.
5.2.5. Strengthening workforce skills, competencies and knowledge for effective, person-centred integrated care
Three key components can promote effective integrated working: effective, integrated professional, organisational and clinical governance; the right workforce skills, competencies and knowledge, such as health system knowledge, transversal skills (e.g. problem solving, adaptability, mentoring), and IT-related skills; and effective working practices within the team, including a strong understanding of roles, responsibilities, key processes and objectives of the team. Those three dimensions are mutually supporting and need to be in place for the workforce to make meaningful steps towards sustainable and impactful integrated care delivery.
The development of new professional skills and roles, such as advanced nursing roles and case managers, can promote a more competent and collaborative workforce that is better equipped to manage the complex needs of individuals who are not self-sufficient and create better integration between the healthcare and social sectors.
Integrated learning – around communication, teamwork, collaborative practice – should become a core part of lifelong learning of all health and social care professionals. After an initial introduction to integrated care in undergraduate education, health and social care professionals’ skills and knowledge should be further developed in postgraduate education and throughout continuing professional development.
References
[1] Caiolfa, M. (2022), Il Sistema Nazionale Anziani: unagovernance multilivello per la nonautosufficienza.
[2] Llena-Nozal, A., A. and K. Killmeier (2025), Needs assessment and eligibility criteria in long-term care: How access is managed across OECD countries, https://doi.org/10.1787/461811c4-en.
← 1. As an example, in France people are assigned to six categories by assessing their degree of loss of autonomy. Only four out of six categories grant entitlement to benefits. Individuals in categories 5 and 6 are considered autonomous enough to live without formal support; however, they have options to receive support at home with certain household tasks such as cleaning, preparing meals, doing laundry or shopping if they have limited financial capacity to pay for these services themselves (Llena-Nozal, and Killmeier, 2025[2]).