Towards a Structured and Systemic Integration of Home Care for the Non-Self‑Sufficient in Italy

3. International experiences of social and healthcare integration

Abstract

This chapter reviews international experiences of social and healthcare integration. It first outlines the regulatory and policy frameworks for services for non-self-sufficient individuals across OECD countries. It then examines governance models that promote closer alignment between health and social care. A set of case studies – Japan, England (United Kingdom), Denmark, Australia and the Basque Country (Spain) – provides concrete examples of different integration approaches, covering governance arrangements, interventions and providers, information systems and interoperability, available resources, and transferability. The chapter concludes by identifying key characteristics of successful integration and drawing lessons of potential relevance for Italy.

The integration of social and healthcare services for people who are not self-sufficient is a complex issue that is currently central to many OECD countries and European Union policies. Numerous regulations and reforms have been introduced at international level in recent decades to extend coverage, improve quality, ensure sustainability and promote the integration of services for people who are not self-sufficient. Although these interventions share similar objectives, their characteristics depend on various factors, such as available resources, the target population, the models adopted, the objectives defined and local conditions. To fully understand the challenges and opportunities of social and healthcare integration in Italy, it may be useful to look at international experiences and understand their context, measures, challenges and successes.

3.1. Services for non-self-sufficient individuals: International regulatory and policy framework

At the international level, access to Long-Term Care (LTC) is recognised as an essential component of social protection and universal health systems (ILO, 2022[1]; WHO, 2015[2]). Consistent with this, in the context of the 2030 Agenda for Sustainable Development, Target 3.8 aims to ensure universal health coverage, including essential care services, while Target 5.4 promotes the recognition of unpaid care work and the development of accessible public care services (United Nations, 2015[3]). At the same time, there is still no internationally agreed definition of non-self-sufficient persons.

Within the UN framework, the Convention on the Rights of Persons with Disabilities obliges States to provide home and community support measures for elderly people who are not self-sufficient (United Nations, 2006[4]). The UN Decade of Healthy Ageing 2021‑2030, promoted by the UN and the World Health Organization (WHO), calls for integrated LTC systems based on multidimensional needs assessment, personalised interventions and the involvement of family and community networks (WHO, 2020[5]). In this context, the Integrated Care for Older People (ICOPE) model, developed by the WHO, provides an evidence‑based operational approach to delivering integrated care at the primary and community levels, including co‑ordinated action plans between health and social services and support for caregivers (WHO, 2017[6]; 2019[7]).

On the social protection front, the International Labour Organization included LTC among the basic social rights in its Recommendation No. 202 (ILO, 2012[8]). The Care at work report notes significant gaps in terms of accessibility, quality of services and working conditions of care staff, calling for adequate public investment and the setting of minimum standards of coverage and quality (ILO, 2022[1]).

In the context of the European Union (EU), the Social Rights Pillar states in its Principle 18 the right to quality LTC services and sustainable financial conditions for users, in particular home care and community-based services (European Commission, 2017[9]). As care is the responsibility of the Member States, the EU supports them through legislation such as the Work-Life Balance Directive, and with guidance, funding, monitoring and analysis. The European Care Strategy sets out a vision for transforming care in order to ensure quality, affordable and accessible services and to improve the situation for both recipients and carers professionally or informally (European Commission, 2022[10]). At the same time, the EU Council Recommendation on LTC services recommends that Member States set high quality standards for all LTC facilities and ensure fair working conditions for healthcare workers, including wages, by promoting social dialogue and collective bargaining (Council of the European Union, 2022[11]). To address skills needs and labour shortages, Member States should also improve initial and continuing education and training, build career paths through reskilling and upskilling, establish pathways to regular employment status for undeclared LTC workers, explore legal migration pathways for LTC workers, and make the profession attractive to both men and women. Instruments such as the European Semester and the Recovery and Resilience Plans (NextGenerationEU) complement these principles, acting as levers for investment and reform in the sector (European Commission, n.d.[12]).

3.2. Towards greater integration of social and healthcare services: Governance models in OECD countries

Many OECD countries face common challenges: fragmentation of services, limited home coverage, shortage of trained staff and financial sustainability issues. People with limited self-sufficiency receive a mix of mainly healthcare and mainly social services, and their provision is often poorly integrated. The governance of these services is therefore often divided between the Ministry of Health and the Ministry of Social Affairs, and responsibility is often shared between central government and local authorities. Local authorities also often play the leading role in service delivery (OECD, 2022[13]). The important role of the informal sector (i.e. family carers and personal caregivers) and the poor integration of information systems are additional challenges shared by many OECD countries.

A growing number of OECD countries are implementing measures to improve the integration of social and healthcare services. Finland, the United Kingdom, Slovenia and Spain, for example, are currently undergoing a long process of reforming their health and social services. Greater integration of social and health services requires improvements in integration at the political, institutional, organisational, functional and operational/care levels. Some of the most common measures in OECD countries include: 

• A single ministry or department for healthcare and social policies. In 2023, 11 OECD countries had a ministry or department responsible for health and social policies. In other countries, however, responsibilities are separated, with the aim of ensuring that each sector receives specific attention. In these cases, strong inter-ministerial co‑ordination mechanisms are essential to ensure policy coherence and effectiveness.

• A single public body and pooled funding for services for people who are not self-sufficient: In some countries, responsibility for social and health services for older people, people with disabilities or people who are not self-sufficient is centralised in a single body. For example, since 2020, France has given an increasing role to the National Solidarity Fund for Autonomy (CNSA). Traditionally responsible for financing services for people with disabilities, the agency will be responsible for services for the elderly and people with disabilities by 2030. In this model, the various funding streams are transformed into a pooled funding system – a key tool for promoting the integration of LTC.

• Intergovernmental bodies for co‑ordination between national and local actors in LTC services. In Spain, for example, the Territorial Council of the Public System for Autonomy and Dependency Assistance brings together the state and the regions; in France, the “Conference of Funders” discusses measures and resources for non-self-sufficient people over 60; in Finland, there are plans to establish 21 “well-being districts”, funded by the central government, which will be responsible for social and health services previously managed by municipalities.

• Co‑ordination and communication systems between actors involved in service planning and management. Other OECD countries have set up co‑ordination systems (e.g. intergovernmental committees, regular meetings) to improve integration and co‑operation between service providers. In several Nordic countries, central government and local authorities meet regularly to discuss measures concerning services and any difficulties to be addressed.

• Integration between the formal sector and family caregivers, personal caregivers, and foreign workers. Currently, most OECD countries have support mechanisms for family caregivers and informal carers. About two‑thirds of OECD countries provide leave for caregiving, although it is not always paid, while training opportunities are often limited and offered online by the third sector. Some countries, including Canada, Germany, Israel and Spain, have mechanisms in place to facilitate the regularisation of informal migrant caregivers (European Commission, 2022[14]).

• Improving the integration of health and social information systems. In Finland, for example, the national statistics institute is creating a single data register for services provided, using the Kanta model, https://www.kanta.fi/en/professionals, facilitated by the existence of a single Ministry for Health and Social Affairs.

• Strengthening the healthcare and support workforce: For example, in the United Kingdom, the “People at the Heart of Care” plan provides for 50 000 additional nurses in the National Health Service (NHS) and at least GBP 500 million for adult care reform. Health Education England is leading the 15‑year planning process, with a focus on initial and continuing training for cross-sector roles and the introduction of an “Integrated Skills Passport” to facilitate the transfer of skills and knowledge between health and care (Department of Health and Social Care, 2022[15]).

• Quality frameworks. Several countries are updating their quality frameworks with the aim of promoting uniform standards and continuous improvement in social and long-term care services. France, for example, introduced a single national framework for over 40 000 facilities in 2022. The expansion of the role of public, non-profit and for-profit providers makes quality standards and monitoring mechanisms increasingly relevant, despite the limited availability of up-to-date data (OECD, 2022[13]).

Governance systems also require the involvement and co‑ordination of a range of actors and different entities at the local level, including the various bodies that constitute and promote social innovation (see Box 3.1).

Box 3.1. Social innovation supporting social and healthcare integration

Social innovation can make a valuable contribution to improving the integration of health and social services, especially in the care of non-self-sufficient elderly people. These are new initiatives, often tested at local level, which arise from collaboration between different actors – public institutions, third sector organisations, volunteers and citizens – to respond to complex needs that are not fully covered by traditional systems. Various examples show the potential of social innovation to build more people‑centred, flexible and sustainable care systems based on collaboration between different actors.

The OECD report Starting, Scaling and Sustaining Social Innovation shows how these initiatives develop through three phases: starting, when a problem is addressed in a new way by those close to the local area, often with limited resources but great flexibility; scaling, in which effective solutions are adopted by other areas, supported by alliances with public administrations or integrated into national policies; and sustaining, which requires stability over time, including long-term funding, the ability to adapt to change and tools to assess impact.

Various projects show how social innovation can strengthen integrated care for older people. In Poland, for example, a project supported by the European Social Fund has developed an integrated model of long-term care for people with chronic diseases in rural areas affected by depopulation and weak family networks. In Sweden (Västernorrland), the IMPROVE (Involving the community to co-produce public services) project used a living lab approach to co-design sustainable home care solutions in remote areas, including technologies such as incontinence sensors and night-time monitoring cameras. The transnational project SI4CARE (Social Innovation for integrated healthcare of ageing population in ADRION Regions) in the countries of the Adriatic-Ionian region aims to strengthen co‑operation between different levels of the healthcare sector to promote social innovation in care services for older people. The initiative involves public and private actors to improve the capacity to develop policies, co‑ordinate strategies and offer integrated and innovative services.

Source: OECD (2025[16]), Starting, Scaling and Sustaining Social Innovation: Evidence and Impact of the European Social Fund, https://doi.org/10.1787/ec1dfb67-en, and OECD (2024[17]), “Assessing the framework conditions for social innovation in rural areas, https://doi.org/10.1787/74367d76-en.

3.3. A look at social and healthcare integration in some OECD countries

The transformation of care systems for non-self-sufficient older people is a challenge for many OECD countries, which must reconcile demographic ageing, the sustainability of services and the growing demand for home care. In this context, five case studies – Japan, England, Denmark, Australia and the Basque Country (Spain) – explore different solutions for promoting effective integration between health, social, housing and community support services, and provide insights that could be transferred to Italy.

3.3.1. Japan: The community-based integrated care system

With the proportion of people aged 65 and over set to rise to 34.8% by 2040, Japan is at the forefront of adapting care systems to demographic ageing. In 1973, Japan introduced free healthcare for older people. However, the increase in hospital admissions of older people with social needs prompted the government to launch a ten‑year strategy for promoting the health and well-being of older people in the early 1990s, known as the Gold Plan. This was followed by the New Gold Plan and, in 2000, the Long-Term Care Insurance (LTCI) Act, designed to ensure more sustainable financing of LTC (Szczepura et al., 2023[18]). The LTCI supported the extensive development of home and community care, with a 203% increase in utilisation in the first decade (Tamiya et al., 2011[19]).

In 2012, the Community-based Integrated Care System was introduced as an extension of the LTCI to integrate healthcare, long-term care, preventive care, daily living support and housing solutions (OECD, 2018[20]). The model, inspired by the Health and Welfare Centres already tested in isolated areas, aims to promote ageing “at home” by reducing dependence on hospital or institutional care (Szczepura et al., 2023[18]; Hatano et al., 2017[21]).

The governance model

The Japanese model of integrated care is based on multi-level governance with a strong focus on the local area. At the local level, there are Comprehensive Community Support Centres (CCSCs) in every municipality, which are designed to be a single point of access to services for older people and their families. In larger centres, the service may be divided into several locations.

CCSCs act as local hubs for the assessment, planning and co‑ordination of health, social and housing services available in the community; they also lighten the co‑ordination burden that would otherwise fall on individual professionals and facilities. Each centre is run by a multidisciplinary team of public health nurses, social workers and long-term care specialists.

The clinical co‑ordination function is entrusted to the Care Manager, a central figure in the system. The Care Manager – who must have a national qualification in healthcare, medicine or social work and at least five years’ experience – assesses the level of certified need, draws up an Integrated Care Project and accompanies the user in accessing services (Szczepura et al., 2023[18]).

Each Centre is supported by appropriate housing solutions and community-based ageing support services, with a focus on health promotion, prevention, rehabilitation and recovery support. The Centres also offer guidance on housing and long-term care, excluding nursing homes.

Interventions and providers

The Japanese model has been described as an example of “integrated care neighbourhoods”, in which services are organised to provide an integrated and accessible response to the complex needs of the elderly population at the local level (Szczepura et al., 2023[18]). The model is based on person-centred care rooted in the community. The Individualised Care Plan may include preventive measures, primary care, home care, rehabilitation, support for daily activities, adapted housing solutions and the promotion of social interaction.

Interventions are provided by accredited public and private entities. Access to services is regulated by the LTCI system, which determines the level of care needed through a standardised 74‑item questionnaire, a home visit and a medical report (Tamiya et al., 2011[19]). Elderly people who are not eligible for LTCI benefits can access preventive services.

A distinctive feature of the Japanese system is its multi-level structure, based on four interdependent pillars (Datta et al., 2025[22]):

• Self-help (Ji-jo): Promotes individual and family autonomy through educational initiatives, health check-ups, lifelong learning and voluntary activities for healthy older people.

• Mutual assistance (Go-jo): Values informal support and volunteering, including with institutional participation; municipalities finance volunteer training and Social Welfare Councils (local co‑ordination bodies responsible for promoting social well-being in communities) co‑ordinate activities, facilitating integration with formal services.

• Social solidarity (Kyo-jo): This is the backbone of the insurance system: all citizens over the age of 40 pay premiums for LTCI and certified older people are entitled to services. Co‑operatives and solidarity organisations also operate at the local level.

• Public support (Ko-jo): This includes mandatory public services financed by tax revenue, service regulation, and economic and housing support programmes for low-income older people.

This arrangement allows for a flexible and adaptable response to the complex needs of the elderly population, combining national consistency and local implementation. The system encourages ageing in the community, reduces pressure on hospitals and residential facilities, improves quality of life, and makes care more financially sustainable, thanks to potentially lower costs compared to exclusively formal models. (Datta et al., 2025[22]).

Information systems and interoperability

Japan is investing structurally in technological innovation to support the transformation of its care system. A new academic discipline, Care Science, complementary to medicine and nursing, has been introduced to promote the development of assistive technologies, including robotics, sensors and artificial intelligence.

In 2021, the Japanese Ministry of Health established the LIFE (Long-Term Care Information System for Evidence) information system, which aims to support scientific evidence and the measurement of care outcomes, as well as to promote the digital transformation of the sector by encouraging the adoption of new organisational models and service delivery methods (Szczepura et al., 2023[18]).

Resources

The Japanese LTCI system has established specific insurance for non-self-sufficiency. Funding is based on a combination of insurance contributions and general taxation, with approximately half of the funds coming from individual insurance premiums and the other half covered by municipal and national taxes (Datta et al., 2025[22]). Residents over the age of 40 pay compulsory insurance premiums; from the age of 65, they are entitled to LTCI benefits based on their certified level of need.

The user’s contribution to the cost is on average 10% of the value of the service (Datta et al., 2025[22]), but there are support measures for people on lower incomes. A separate insurance fund is available for people with disabilities between the ages of 40 and 65. In addition, municipal governments finance complementary measures to promote health, prevent frailty, provide social housing and develop community networks, often in partnership with organised voluntary organisations (Szczepura et al., 2023[18]).

The Care Managers play a central role in resource management: they define the care plan within the limits set by the insurance system, monitoring the efficient use of available services.

Transferability

The Japanese model shows that maintaining quality of life in old age requires integrated measures combining healthcare and long-term care, support for daily living and economic protection. The transferability of this model requires functional multi-level governance, an integrated information system, a stable financing framework and adequate availability and co‑ordination of qualified personnel. The Japanese experience shows that integration is not only a question of organisational structure, but also of professional culture and civic participation. The creation of local networks, the involvement of community actors and a person-centred approach are essential elements for effective integration (Sano et al., 2023[23]).

The widespread presence of community support centres is a key element in identifying local needs and resources and connecting older residents with appropriate medical and social services. Replicability depends on the ability to integrate formal services and community resources within a territorial framework. The system is also based on a balance between public intervention, self-help and mutual support, easing pressure on public services and strengthening community resilience (Datta et al., 2025[22]).

3.3.2. England: Integrated Care Systems – ICS

In England, the issue of integrating health and social care for older people has undergone a long evolution. After the creation of the National Health Service (NHS) in 1948, which guaranteed free healthcare for all, social care for older people who were not self-sufficient remained separate and subject to economic eligibility criteria. It was not until the 2000s that a reform process was launched to overcome this fragmentation, supported, for example, by the 2006 White Paper “Our Health, Our Care, Our Say”, which sought greater integration of services for older people.

In recent decades, health policies in the United Kingdom have repeatedly reaffirmed their commitment to shifting the provision of care from hospitals to settings closer to the community and people’s homes. Among the most significant measures are the 2014 NHS Five Year Forward View and the 2019 NHS Long Term Plan, together with the 2014 Care Act and related regulations and guidelines.

With the entry into force of the Health and Care Act in 2022, 42 Integrated Care Systems (ICS) were formally established in England with the aim of overcoming historical, cultural, legal and financial barriers to integration and improving the living conditions of people living in their respective areas. One of the main aims of these local partnerships is to facilitate the transition from hospital care to forms of care and support closer to people’s homes and communities. (Szczepura et al., 2023[18]; Age UK, 2024[24]).

The governance model

In each of the 42 geographic areas of the ICS, NHS bodies and local authorities are organised into two bodies (NHS England, n.d.[25]; National Audit Office, 2022[26]):

• the Integrated Care Board (ICB), an NHS body whose members are appointed by hospital trusts, primary care providers and local authorities. The ICB receives funding from NHS England to plan and purchase health services in the area covered by the integrated system. Each ICB manages the health budget and works with local providers (hospitals, general practitioners, etc.).

• the Integrated Care Partnership (ICP), a joint committee set up by the ICB together with local authorities, with the possibility of including other stakeholders, such as third sector organisations. The ICP is responsible for developing an Integrated Care Strategy that sets out how to meet the health and care needs of the local population. The ICB, local authorities and NHS England are required to take this strategy into account when planning and delivering services.

Interventions and providers

Local authorities are responsible for social care, public health and other services crucial to well-being (housing, education, transport, leisure). When planning their activities, they must take into account the strategy developed by the ICP.

The ICS model promotes a multidisciplinary approach to caring for frail older people. Teams include nurses, social workers, volunteers and other professionals, and operate both in the home and in residential facilities. Services also include the Social Prescribing Link Worker, a role introduced to facilitate access to non-clinical services provided by volunteers and the community, often to address social issues. Although not exclusively aimed at the elderly population, this professional figure represents a cost-effective solution to the fact that around a quarter of visits to general practitioners are motivated by social issues – access to services, housing or employment problems, guidance on welfare services – which require skills and advice other than strictly clinical ones (Szczepura et al., 2023[18]). Analysis of some local experiences has also shown that integration between nurses and social workers has led to a reduction in hospitalisations.

Information systems and interoperability

England has invested heavily in the digitisation of health and social care services. The Plan for digital health and social care published by NHS England in 2022 provides for the complete digitisation of health and care records in the 42 ICSs and the extension of broadband to all care homes to facilitate remote care. The Care Quality Commission has launched a new strategy to improve service monitoring through digital data collection. At the same time, the National Institute for Health and Care Excellence (NICE) is developing a database for digital technologies and artificial intelligence in the social sector (Szczepura et al., 2023[18]).

Analyses of data use within ICSs reveal considerable heterogeneity in terms of the maturity of digital infrastructures, organisational capacity and data usage patterns. Only a few systems have advanced technologies and are able to use data effectively for individual care and population health management. Technological development is often not accompanied by an adequate evolution of organisational culture and staff skills, making targeted training and refresher courses necessary. Recruiting and retaining professionals with digital skills remains a significant challenge. Many ICSs also report difficulties in balancing daily operational needs with a more strategic use of data, calling for greater clarity on long-term national priorities in this area. Although there is consensus on the importance of involving patients and citizens in decisions regarding the use of data, different views remain on who should take responsibility for this. Finally, those consulted in the context of the analysis recognise ample opportunities for improvement, emphasising the importance of collaborative action between ICSs and more structured dialogue with national decision makers to strengthen the systemic use of health data (Understanding Patient Data, 2024[27]).

Resources

ICSs are mainly funded through funds allocated by NHS England, which receives resources from the Department of Health and Social Care (DHSC). The DHSC also provides a direct contribution to local authorities for public health services. NHS England distributes funds to ICBs according to a formula that takes into account factors such as population size and health needs. ICBs manage the budget by purchasing services or delegating funds (National Audit Office, 2022[26]). In addition to regular funding, ICSs may receive additional funding for integration projects from NHS England, DHSC or local authorities. To support the delivery of integrated care, many ICSs use pooled budgets with local authorities.

Transferability

The English experience shows a system undergoing progressive transformation towards the structural and operational integration of services for older people. NHS England (n.d.[25]) mentions as the main features of the model the promotion of integrated services across sectors, partnerships between the NHS and local authorities, unified staff management, a focus on prevention, decentralisation at local level, the activation of multidisciplinary local teams, collaboration between providers and support for the social and economic development of communities. The evidence gathered suggests benefits in terms of perceived quality and reduction in avoidable hospitalisations. However, inconsistencies between ICSs, shortcomings in staff training, limited formalisation of protection, and the need for investment in data interoperability represent significant challenges. The transferability of the model requires strong central co‑ordination, dedicated resources, and the promotion of a collaborative culture across the country (Szczepura et al., 2023[18]). Multi-level governance is one of the most complex but also strategic aspects of ensuring consistency between national choices and adaptation to local needs, which is crucial for the sustainability of the ICS model.

3.3.3. Denmark: Pilot projects for interdisciplinary collaboration at local level

The Danish healthcare system, based on general taxation and universal access, guarantees high-quality care, with high patient satisfaction and few unmet needs. Governance is structured on three levels: the state, responsible for strategic direction; the regions, which manage specialist healthcare services; and the municipalities, responsible for social care, home care, care for the elderly, prevention and rehabilitation. Integration between these levels remains a key challenge. To strengthen it, 21 Health Clusters were established in 2021‑2022, each centred around a large hospital, to co‑ordinate regional and municipal responsibilities, promote coherent care pathways and overcome fragmentation. The Clusters bring together policymakers and health managers to define shared strategies at the regional level. (OECD, 2024[28]).

Alongside these national initiatives, several local projects have sought to improve integration, including one launched in six municipalities to strengthen interdisciplinary collaboration between health and social services. Following the Summit on Older People organised in 2020 by the Danish Ministry of Health, the municipalities of Faxe, Hedensted, Haderslev, Copenhagen, Ringsted and Rudersdal launched projects aimed at reorienting care services for older people based on the specific needs of their local areas. The initiatives were implemented as part of Fremfærd Sundhed og Ældre, an institutional collaboration that aims to strengthen the municipal labour market’s capacity to fulfil its welfare responsibilities, with a particular focus on long-term care.

A committee of experts, composed of trade union representatives, local authorities and municipal administrations, established a joint development space. This space allowed managers and operators from the six municipalities to co-design new approaches to elderly care, drawing on both local experience and the principles of the Dutch Buurtzorg model (see Box 3.2). The initiative was made possible thanks to dedicated funding provided by Fremfærd Sundhed og Ældre.

Box 3.2. The Buurtzorg model (Netherlands)

The Buurtzorg model, developed in the Netherlands since 2006, is based on self-managed nursing teams that provide holistic and personalised care at community level. Each team, consisting of up to 12 nurses and care workers, looks after 40 to 50 patients in their neighbourhood. The teams are responsible for organising their work, managing tasks and decision making, actively collaborating with GPs, therapists and other local professionals, and building their own network of users through word of mouth and referrals. Buurtzorg supports the teams’ operations through an IT platform to reduce administrative burdens, increase productivity and improve the quality of care. Through the platform, teams access information on performance, interventions and results, promoting mutual learning.

Over time, the model has evolved in different directions. Buurtzorg+ has strengthened prevention and collaboration between nurses and therapists. BuurtzorgT has extended the self-management approach to psychiatric care, promoting equality between staff and users, the use of digital tools for joint learning and greater autonomy for users in managing their own care pathways.

Source: OECD (2024[28]), Good practices in delivering integrated care: Examples from the Netherlands, Denmark, France and Ontario, Canada; www.buurtzorg.com/about-us/buurtzorgmodel; and www.buurtzorg.com/innovation/buurtzorg-te.

Each municipality participated in the development of the projects with a group of ten managers and operators, ensuring the involvement of key professionals and decision makers for the implementation of the projects. The experiences share an approach based on interdisciplinary collaboration: small permanent groups composed of therapists, nurses and social and health workers meet every morning to plan their work and co‑operate throughout the day, with the aim of ensuring better co‑ordinated care that is more focussed on the individual needs of citizens. The organisation of activities varies between municipalities. In Faxe, for example, a new role of professional co‑ordinator has been introduced, a social or health worker responsible for facilitating interdisciplinary meetings and promoting closer collaboration. The municipality of Hedensted, on the other hand, is creating joint physical facilities for home care and nursing. Groups of six to eight social and healthcare workers share a small number of home visit routes and plan their own shifts within the framework set by management. Some municipalities have involved staff in daily planning, organising care pathways and shifts; others have adopted tools inspired by the Buurtzorg model, such as dashboards for monitoring indicators such as care times, absences, continuity and rehabilitation outcomes.

The initiative was evaluated, highlighting how the organisation into small teams facilitated continuity in relations with citizens and was associated with lower absenteeism rates than other working groups. Operators recognised that the transition to new organisational forms takes time; planning and management functions remain necessary but take different forms, mainly geared towards supporting “bottom-up” decisions. The recommendations emphasise the importance of continuing to strengthen stable teams, composed of different professionals and equipped with an adequate level of operational autonomy.

The replicability of the model requires a public administration with strong organisational capacity at the local level.

3.3.4. Australia: The new Support at Home program

Australia is reforming its care system for older people to strengthen the integration of health and social services, with a particular focus on home care, in response to the recommendations of the Royal Commission into Aged Care Quality and Safety. The Support at Home program, due to start in November 2025, is the government’s main initiative in this area. The central objective of the reform is to ensure that older people who are not self-sufficient can remain in their own homes for as long as possible, receiving integrated support tailored to their health, functional and social needs. The reform aims to ensure fair prices, a greater focus on early intervention and higher levels of care for people with complex needs (Australian Government, 2025[29]).

In parallel, the Australian Government has developed the National Carer Strategy 2024‑2034 and the accompanying Action Plan 2024‑2027, which are highly relevant in this context. These initiatives promote better recognition of carers, emphasise the importance and of unpaid carers in the provision of care to older persons, and include measures to strengthen training and support for family caregivers, improve data on informal care to inform policy, and create opportunities for better work – caregiving balance (Australian Government, 2024[30]; 2024[31]).

The governance model

The reform is part of the new legal framework set out in the Aged Care Act 2024, https://www.legislation.gov.au/C2024A00104/latest/text, the federal government’s legislation on care for the elderly. The Act introduces a rights-based legal framework and strengthens the responsibilities of service providers in terms of transparency and quality. It will come into force on 1 November 2025, coinciding with the launch of the Support at Home, https://www.health.gov.au/our-work/support-at-home program.

Consolidation of existing programmes

The Support at Home programme will gradually absorb three existing home care schemes:

• Home Care Packages (HCP) Program: Provides packages of support at four different funding levels. It ensures personalised home care to enable older people to remain in their own homes for as long as possible, delaying the need for residential care. It offers a co‑ordinated mix of services, including support with domestic tasks, aids and equipment (such as walking frames), minor home modifications, personal care and clinical care, including nursing and rehabilitation services. The approach is based on consumer-directed care, ensuring that interventions are aligned with the person’s needs and goals. The programme will be replaced on 1 November 2025 (Government of Australia, 2025[32]).

• Short-Term Restorative Care (STRC) Programme: Offers temporary, intensive support for up to eight weeks, with the aim of preventing or delaying admission to residential facilities. The intervention focusses on functional recovery through a multidisciplinary approach, combining social and health support with a view to rehabilitation. The programme will be replaced on 1 November 2025 (Australian Government, 2025[33]).

• Commonwealth Home Support Programme (CHSP): For relatively independent older people who need limited help with daily activities, the CHSP provides essential services such as cleaning, meals, transport and social support. It will remain in place until at least July 2027, allowing for a smooth transition to the new scheme for providers and users (Australian Government, 2024[34]).

The gradual replacement of these three programmes aims to simplify access to services, reduce overlaps and promote greater integration between the health, functional and social aspects of home care. To this end, the Australian Government’s Department of Health, Disability and Ageing has allocated resources to support providers and stakeholders during the transition to the new Support at Home program.

Planned interventions and providers

The Support at Home programme aims to ensure better access for older people to services, aids, equipment and home modifications to help them stay healthy, active and socially connected to their communities. It offers three dedicated pathways: the Restorative Care Pathway, which provides multidisciplinary rehabilitation interventions to strengthen independence; the AT-HM scheme, which provides access to aids and home modifications based on assessed needs; and the End-of-Life Pathway, which provides more funding to access in-home aged care services in last three months of life (Australian Government, 2025[35]).

The services are divided into three areas: clinical supports (nursing care, allied health and therapeutic services, nutrition, care management and restorative care management), independence support (personal care, social support and community engagement, therapeutic services for independent living, respite, transport, assistive technology and home modifications), and everyday living assistance (domestic assistance, meals, home maintenance and repairs) (Australian Government, 2025[36]).

Each participant will receive a personalised package of services provided by a single provider, who will be responsible for the overall delivery of services.

When the Support at Home programme comes into effect, the Single Assessment System for aged care, https://www.health.gov.au/our-work/single-assessment-system, will already be operational. This is a unique assessment system for determining the needs of older people and their eligibility for the programme. Once the assessment is complete, the person will receive an individual support plan to share with their service provider. The plan will contain a summary of the elderly person’s care needs and personal goals; a classification of needs, associated with a recurring quarterly budget; and/or approval for short-term interventions.

Resources

The Support at Home programme is financed through a mixed system based on public contributions and user contributions, in accordance with principles of fairness and sustainability. The government will fully fund clinical services (e.g. nursing care and physiotherapy), while moderate contributions will be required for services related to independence (e.g. personal care, aids and home adaptations) and higher contributions for services related to daily living (e.g. cleaning and gardening). Rates will be set per unit of service and will vary according to the type of service provided. Individual contributions will also be adjusted according to income. To protect those receiving long-term care, there will be a cumulative cap of AUD 130 000 (EUR 72 152) on individual contributions. From 2026, a pilot scheme for pooled funding for collective settings (e.g. retirement villages) will also be launched, in which users will be able to access flexible services by sharing their individual resources.

Transferability

The introduction of a single assessment system, the aggregation of multiple programmes into a single modular structure, and the presence of a co‑ordinating provider for each user are key tools for ensuring integration, efficiency, and personalisation. However, challenges remain related to the shortage of qualified personnel, the ability of providers to adapt to new requirements, and the risk of regional inequalities in implementation. The success of the reform will also depend on the ability to integrate digital tools and common information systems to facilitate quality monitoring and information sharing.

The new model emphasises the importance of continuity and consistency in care. In addition, the role of local providers, including non-profit organisations and social enterprises, is enhanced. They will continue to be accredited and funded according to standardised and transparent criteria.

3.3.5. Basque Country, Spain: The 2021‑2024 strategy for social and health care

In Spain, long-term care follows a multi-level structure: the central government defines the general principles, while the autonomous communities, such as the Basque Country, have extensive powers in the planning, management and financing of social and health services. All autonomous communities, albeit to varying degrees, rely on the participation of private operators for the construction or management of health and social infrastructure (Díaz-Tendero and Ruano, 2024[37]).

In the Basque Country, social and healthcare assistance is supported by a regulatory framework consisting of three main laws: Law 27/1983, which governs institutional relations in the autonomous community; Law 8/1997 on healthcare organisation, supplemented by Decree 100/2018 on integrated healthcare organisations; and Law 12/2008 on social services, with Decree 185/2015 regulating criteria, requirements and procedures for accessing the Basque social services system.

Framework agreements have been in place since 1996 to ensure that social and healthcare needs are met. Over time, various strategies have been developed to support the integration of social and health care (2013‑2016; 2017‑2020; 2021‑2024). The 2025‑2028 strategy is currently being developed.

The governance model

Social and health care involves various actors at different levels of governance:

• The Basque Government, whose responsibilities range from social and health policy planning to the planning and provision of health, social and care services.

• The provincial governments (Álava, Bizkaia and Gipuzkoa), whose responsibilities mainly focus on social policies and the provision of care services.

• The 252 Basque local councils, which are the main gateway to social and primary care services.

The Basque Country’s 2021‑2024 social and healthcare strategy outlines the integrated governance model. It provides for an inter-institutional, multi-level and multidisciplinary framework for interaction between the main institutions and organisations involved in the management and delivery of social and healthcare services. It defines multidisciplinary and inter-institutional decision making bodies and functional co‑ordination bodies for health and social services.

One of the tools developed by the Basque Government are the social and health co‑ordination protocols – guidelines that describe and aim to simplify the collaborative relationships and activities of the institutions and organisations involved in the governance and delivery of social and healthcare services. The protocols are to be reviewed periodically and reports documenting the status of implementation of social and health co‑ordination procedures are to be drawn up regularly. Among the difficulties encountered in the management and evaluation of the protocols are the lack of defined criteria for the validity and revision of the protocols, the poor alignment between protocols in different local contexts, and the lack of involvement of social service managers in the integration process in some local contexts (OECD, 2024[38]).

Interventions and providers

In the Basque Country, social and health care is based on strategies that aim to provide co‑ordinated and holistic responses to the social and health needs of the population (not exclusively for older people). Experience from previous strategic programmes indicates that effective co‑ordination at the micro level requires flexible teams that are rooted in the community and based on relationships of mutual trust. This vision has proved particularly relevant in complex contexts such as those that have emerged after the COVID‑19 pandemic, where co‑ordination between different levels of care is essential.

Social and healthcare teams may include primary and/or secondary care professionals, depending on the care pathway required. The 2021‑2024 strategy has two main strands: strengthening primary social and health care, as the gateway to the system, through dedicated teams working in co‑ordination with other levels of care when necessary; and developing specific interventions for target groups, with an emphasis on early intervention.

The action plan provides for the creation of a map of social and healthcare contacts, including those in the local area; the drafting of a conceptual guide to consolidate the functions of primary social and healthcare assistance; the mapping and analysis of existing protocols and procedures in the various historical areas; experimentation with pilot projects for team co‑ordination; the presentation to interest groups and the development of shared proposals; and the dissemination and implementation of interventions (Basque Government, 2021[39]).

Information systems and interoperability

One of the pillars of the Basque Country’s 2021‑2024 social and healthcare strategy is the development of interoperability between social and healthcare information systems, with the dual objective of guaranteeing citizens the right to interact with the administration electronically in administrative procedures and adapting existing information systems to an integrated and co‑ordinated working model between social and healthcare professionals. To achieve this, the strategy provides for the standardisation of content and messages, the development of interoperable platforms, the design of tools for joint case management and the systematic evaluation of data exchange services (Basque Government, 2021[39]).

Resources

The 2021‑2024 strategy provides for the definition of a shared and stable public funding framework to support the social and health services listed in the regional catalogue in a co‑ordinated manner, clarifying the methods and proportions of public funding by the institutions involved (Basque Government, provinces and local authorities).

Launched with the 2017‑2020 Strategic Priorities and consolidated in the 2021‑2024 Strategy, the project provides for the development of a shared financing model, the definition and signing of inter-institutional agreements for the allocation of costs, and the establishment of a joint executive committee responsible for planning and monitoring investments in social and health services, including criteria, frequency and review mechanisms (Basque Government, 2021[39]).

Transferability

The experience of the Basque Country offers important insights for the construction of an integrated model based on a territorial approach. In particular, it is worth noting the consistency between the multi-level governance structure and the adoption of concrete operational tools, such as inter-institutional protocols, mixed social and health teams and the progressive interoperability of information systems. The holistic and flexible approach could also be useful in Italy, where the fragmentation of responsibilities between the state, regions and municipalities often hinders continuous and integrated care. Potentially transferable elements include the formalisation of co‑ordination roles at the local level; shared mapping of professionals and resources; and the definition of a stable framework for public co-financing between institutional levels.

3.3.6. Conclusions

The five case studies (Japan, England, Denmark, Australia, Basque Country) show how other systems are advancing in the integration of social and health care. A comparative analysis identifies key elements such as institutional configuration, single access and standardised assessment, financial integration, multi-level governance and integrated planning, local teams and human resources, information infrastructure and monitoring, and social capital and informal support, with insights for the Italian case.

• Institutional setup. Using the methodology proposed by Caiolfa (2022[40]) to categorise the integration models identified in the case studies, the most common model among the systems analysed is that of co‑ordination, as in Japan, England and the Basque Country. Australia is an example of full integration: with the Aged Care Act 2024, the Support at Home programme will replace three separate schemes and will be regulated, funded and monitored at federal level.

• Single access and standardised assessment. Establishing a single point of access, equipped with a nationally or regionally recognised multidimensional assessment procedure, can help ensure equity in care provision. In Japan’s Comprehensive Community Support Centres, a questionnaire with 74 indicators translates needs into an insurance level with a spending ceiling; in Australia, the Single Assessment System will link the assessment to the quarterly budget associated with each user; in the English ICS, the local hub summarises health and social criteria. The Basque Country is setting up district-based social and health service centres, while in Denmark there are still multiple entry points, reflecting the experimental nature of the initiatives.

• Financial integration. In the cases analysed, one integration objective is to convert multiple sources into a single economic endowment that can be spent on modular service packages. Japan achieves this convergence through the LTCI; Australia will adopt, with Support at Home, a federal tariff with graduated co-payments accompanied by a lifetime spending cap; in England, pooled budgets allow NHS and municipal resources to be combined within the ICS; in the Basque Country, a three‑level commission redistributes contributions from the region, provinces and municipalities into a shared fund. A clear definition of the integrated package allows users to know their economic rights and encourages managers to provide continuous and efficient care.

• Multi-level governance and integrated planning. Integration is consolidated when there is a body with planning and financial leverage powers. In the English ICS, the Board controls health funds and the Partnership approves local strategy; in Japan, the CCSCs are unique access points for different services; the Basque Strategy provides for inter-institutional round tables with a three‑year review of protocols. These mechanisms create accountability and reduce the risk of fragmentation – a major challenge for Italy (Maino, Betti and De Tommaso, 2022[41]).

• Local teams and human resources. In all five cases, operational responsibility is delegated to multidisciplinary teams with managerial autonomy. For example, Japan entrusts co‑ordination to regulated care managers who define individual plans, while in Denmark small self-managed teams plan shifts and visits; in the Basque Country, a mixed team reports to district social and healthcare co‑ordinators. However, critical issues remain regarding staff availability, indicating that integrated functions require investment in training and study programmes dedicated to LTC.

• Information infrastructure and monitoring. The case studies associate operational integration with significant investment in information systems. Japan has launched the LIFE database, which collects process and outcome indicators across the entire LTCI in a uniform manner; England has planned a single clinical and social record within the ICS for 2026; in the Basque Country, an interoperable platform has been developed between health registries and social files. These initiatives contribute to transparency on costs and outcomes and allow for comparison of the performance of different units.

• Social capital and informal support. Systems with advanced levels of integration assign a formal role to community networks. Japan includes self-help and mutual aid as complementary pillars to insurance coverage; the English ICS funds Social Prescribing Link Workers to connect social needs and civic resources; in the Basque Country, structured volunteer programmes are part of social and health protocols, while Denmark is experimenting with forms of community housing with strong local participation. These measures address two critical issues for Italy: the growing burden on family caregivers and the still patchy co‑operation with the third sector. By integrating the informal dimension into governance – with recognition of roles, training and targeted funding – the systems analysed ease the pressure on public services, strengthen territorial resilience and support continuity of care.

Various insights can be drawn for Italy. In the Italian context, co‑ordination appears to be the most compatible strategy, allowing common standards and local autonomy to be combined. Furthermore, the experience of the five systems analysed confirms that social and health integration works when a number of elements converge, such as a single point of access with standardised assessment, a financial endowment that unifies sources, governance with spending levers, integration committees with decision making powers, multidisciplinary local teams, training that strengthens the autonomy and skills of local teams, an interoperable information infrastructure and publicly accessible datasets on care outcomes, as well as tools that institutionalise informal support.

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