This chapter analyses social and healthcare integration at regional and local level in Italy. It reviews governance arrangements for services for non-self-sufficient individuals and explores integration at the professional level. The chapter also examines interoperability of information systems and the use of tools for integrated service delivery. Evidence from surveys and focus groups provides insights into how professionals in Italy perceive integration on the ground, highlighting both progress made and persistent challenges.
Towards a Structured and Systemic Integration of Home Care for the Non-Self‑Sufficient in Italy
Abstract
This chapter draws heavily on a survey conducted by the OECD from January to April 2024. This survey covered all Italian regions and autonomous provinces to assess the current level of integration of home‑based health and social services for people who are not self-sufficient.
The chapter also presents insights based on information gathered through a questionnaire administered to professionals working in the local area.
In Italy, the governance of social and healthcare services for non-self-sufficient individuals is highly decentralised, developing across different levels of government: national, regional/autonomous province, and local (multi-level governance). As in most OECD countries, regions and local authorities have taken on an increasing role in the governance of services in Italy since the 1970s. Furthermore, due to its ability to understand and respond to the complex needs of the dependent population, civil society in general, and the third sector in particular, has taken on a crucial role in the governance of services in recent years (participatory governance).
Several initiatives have also been launched in Italy to promote an integrated multilevel governance system with integrated planning; Improve the governance of home care services. At the national level, with the enactment of Legislative Decree 29/2024, the Interministerial Committee for Policies for the Elderly (CIPA) was recently established (Article 3 of Legislative Decree 29/2024). Its task is to ensure the co‑ordination and integrated planning of national policies for the elderly, with particular attention to frail and non-self-sufficient individuals. Furthermore, at the local level, the role of ATS and health districts has been strengthened, which, with a view to socio-health integration, ensure the “integrated” provision of services to recipients. The National Plan for Non-Self-Sufficiency 2022‑2024 also includes measures to promote social and healthcare integration at the governance level. At the same time, the use of tools for the organisation and co‑ordination of health and social activities at the local level is becoming increasingly widespread, including regional Territorial Activity Programmes, Local Area Plans based on Social Territorial Areas and Programme Agreements for co‑ordination between different levels of government. Following the reform of the Third Sector Code in 2017, this is increasingly at the centre of shared administration initiatives with the public sector in the form of co-planning and co-design.
Almost all of the regions and autonomous provinces that completed the OECD questionnaire (17 out of 18) report that they have their own governance tools to improve the integration of care services. In particular, 12 regions have promoted social and healthcare integration through specific investments and projects, and seven have launched co-planning initiatives with the Third Sector.
Despite these experiments, more than half of the sample (11 out of 18) report that, even in terms of governance, the level of integration between the two types of home care currently existing in Italy – Integrated Home Care (ADI) and Home Care Services (SAD) – could be greatly improved. This assessment is supported, in particular, by the difficulties in integrating the planned intervention models, co‑ordinating the provision of mainly nursing and social inclusion support services attributable to ADI and SAD, respectively, and encouraging interprofessional collaboration.
Full social and healthcare integration cannot be achieved without greater co‑ordination between those directly involved in care activities. On the one hand, it requires greater integration between the roles and responsibilities of health, social, and social-healthcare professionals in the formal sector. On the other hand, there is an increasingly urgent need for full recognition of the role of family carers and personal and family caregivers who make up the informal sector. They play an essential role in linking the provision of existing services with the needs of dependent persons and account for a large proportion of the care provided in Italy.
In Italy, the obstacles to social and healthcare integration at the professional level are of various kinds. At the legal level, the fundamental principles of protection of the professionalism and dignity of workers do not allow for the extension of the duties provided for in contracts. In terms of training, the prevailing system in tertiary education and in continuing training takes a sectoral approach that places limited value on multi-disciplinarity. Further barriers relate to the shortage of labour in both the health and social sectors, which reduces the pool of potential users of integrated training initiatives.
The OECD survey reveals that most regions and autonomous provinces grant the right to request an assessment and to participate in the assessment itself to a variety of professionals (in some contexts, these two phases involve up to 8 and 11 actors, respectively). Furthermore, in almost all the responding regions and autonomous provinces (16), opportunities for discussion between the professionals involved in the assessment are provided.
On the other hand, professional integration is less evident in the service delivery phase, as shown not only by the high number of respondents who consider the level of integration between Integrated Home Care (ADI) and Home Care Services (SAD) to be insufficient, but also by the low number of regions (6) that use case managers to promote an integrated approach to care. International practices on territorial and multidisciplinary teams, and on their co‑ordination, have demonstrated the effectiveness and efficiency of integrated models.
Most Italian regions and autonomous provinces also have their own legislation that provides for and/or defines the role of personal or family caregivers. Given the high prevalence of irregular work (between 52% and 76% of personal/family caregivers work irregularly, according to various estimates) and the difficulties in monitoring the quality of care provided, some regions have adopted measures to promote the regular employment of caregivers, including tax incentives, financial contributions and the creation of regional registers. These initiatives could be reinforced by recently introduced national policies to promote and standardise the training of personal/family carers and their regular employment.
Despite these promising developments, the vast majority of regions and autonomous provinces responding to the survey (14) indicate that they do not have data on the number of family carers and, despite the existence of statistical reports, on personal/family caregivers active in their territory. This reveals a potential limitation to their ability to develop appropriate policies for these professionals.
Adopting policies to support family caregivers is essential to ensure the well-being of these essential roles in the care of non-self-sufficient people and to improve the quality of life of all those concerned.
The availability of data in the healthcare and social sectors is essential for the effective design and monitoring of public policies in these areas. A key tool for full integration is the interoperability of the respective information systems. Efficient management of health and social data can enable health, social, and social-healthcare professionals to plan interventions in a fully informed manner. Furthermore, the presence of interoperable information systems can increase the equity of the care system, the quality of interventions and patient participation in the planning of interventions. In Italy, this objective is initially limited by the considerable divergence between the level of digitisation of social and health information systems.
In the social sector, the Unified Social Services Information System (Sistema Informativo Unitario dei Servizi Sociali – SIUSS), introduced at national level in 2017, is an information resource with great potential for collecting data on social services, offering policymakers a tool to support the planning, monitoring and evaluation of social policies.
However, its use is hampered by the limited transmission of data by municipalities, many of which have not yet adopted digital solutions, resulting in a fragmented information landscape. At regional and local level, the OECD survey also reveals the existence of an innovative digital tool for managing and storing information on social services: the Cartella Sociale Informatizzata (CSI, Computerised Social File), which is already operational or about to be activated in 15 of the 18 regions and autonomous provinces that responded. However, the implementation of the CSI is fragmented at the territorial level, even within individual regions. Among the main obstacles to its full implementation are the lack of adequate technical and IT tools and privacy issues.
In the healthcare sector, the digitisation of information systems appears to be more advanced and less fragmented. Several tools have been introduced since the 1990s. These include the Home Care Monitoring Information System (SIAD), which allows the collection of data on health and social care provided by the National Health Service in the context of home care. The Electronic Health Record (FSE), established in 2015, also allows both professionals and patients to easily access health data. Among the regions responding to the survey, nine indicate that issues related to privacy, resistance from healthcare professionals and a lack of specific training are hindering the full implementation of the FSE at the regional level. The use of the FSE will be promoted throughout the country by the Steering Committee for the New Health Information System (NSIS), which sets the strategic objectives and new functionalities of the FSE.
The shortcomings in the digitisation of health and social information systems are accompanied by a limited level of interoperability between them, both at national and regional level. The survey indicates that only three regions are currently preparing an integrated information system for Integrated Home Care (ADI) and Home Care Services (SAD); here too, the main obstacles encountered are related to privacy and the lack of adequate technical and IT tools. Some recent national initiatives aimed at promoting data interoperability, in particular the establishment of the National Digital Data Platform (PDND), may encourage the emergence of new regional and local experiences in the social and healthcare sector.
The co‑ordination of intervention methods in the care of non-self-sufficient individuals is the last of the pillars of social and healthcare integration described in this report. As already mentioned, Italy has two different home care services based on the cultural model of reference and the nature of the services offered: Integrated Home Care (ADI), which falls under the responsibility of the National Health Service, and Home Care Services (SAD), which is a social service provided by municipalities.
Because of these differences, most regions think the level of integration between these two service delivery models could be improved significantly.
The preliminary dashboard below (Figure 4.1), based on a set of 34 indicators broken down into four policy areas, gives a fairly accurate estimate of the level of integration achieved in the 18 regions and autonomous provinces that took part in the survey. Dark red indicates a very limited degree of integration, while the gradual shift towards green indicates an increasingly advanced and comprehensive model of integrated social and health services.
Source: OECD, based on surveys of regions and autonomous provinces.
As part of the pilot phase of the project, professionals’ views on the level of integration maturity were analysed. The main sources of information were focus groups, conducted in 14 local areas, and the “Scirocco” questionnaire (see Box 4.1) on the level of integration maturity.
4.5.1. Answers to the “Scirocco” questionnaire
The “Scirocco” questionnaire, administered online between 9 December 2024 and 11 February 2025, received a total of 500 responses, allowing for the analysis of 12 aspects of integration – from governance to process co‑ordination and funding (see Box 4.1).
The questionnaire was developed through the activities of the SCIROCCO Exchange project funded by the Health Programme of the European Union (www.sciroccoexchange.com).The questionnaire assesses the maturity of integrated care and identifies areas for improvement and barriers to integration through 12 questions:
Readiness to change: Is there recognition of the need to create new roles, new work processes and practices, and new systems to support information exchange and team collaboration?
Structure and governance: Is there an adequate multi-level, multi-stakeholder governance structure in place?
Digital infrastructure: Is there an integrated and interoperable information system?
Process co‑ordination: Is there a systematic approach to defining integrated care pathways?
Funding: Is there secure, multi-year funding and/or reimbursement mechanisms accessible to all stakeholders to ensure the sustainability of interventions and services?
Removal of inhibitors: Have obstacles to change – such as legal issues, resistance to change from individuals or professional groups, cultural barriers to the use of technology, perverse financial mechanisms, lack of skills – been removed?
Population approach: Is the stratification of the population based on needs fully implemented?
Citizen empowerment: Are citizens involved in decision making processes relating to interventions to maintain and improve their health, and are they also included in decisions concerning service delivery and policy choices?
Evaluation methods: Is the approach to evaluation systematic and does it represent a complete cycle?
Breadth of ambition: Is there full integration between social services and health services?
Innovation management: Is innovation recognised, evaluated and, where possible, extended to benefit the whole system?
Capacity building: Is there a person-centred integrated care delivery system in place that involves reflection and continuous improvement of the workforce?
Source: AReSS Puglia, Regional Strategic Agency for Health and Social Services (n.d.[1]).
Figure 4.2 shows the average score and variability by pilot area for each of the 12 aspects of the assessment. Specifically, all aspects received an average score of less than 3.5, which is the average value on the assessment scale (scores vary from 1 to 6). “Process co-ordination” and “Breadth of ambition” are the two aspects that received the highest average scores (3.3). The degree of integration is considered lower for “Removal of inhibitors” (2.5) and “Digital infrastructure” (2.7). The “Breadth of ambition” score shows the highest variability between geographic areas, while the “Structure and governance” and “Innovation management” scores show the lowest variability between geographic areas.
Note: In addition to the average value, the variability of scores between geographic areas is also reported.
Source: Scirocco questionnaire, see Box 4.1.
Figure 4.3 describes the average scores for each assessment aspect by geographic area. Operators in Trento Sud consistently awarded scores above the average, while operators in Conversano and Merano awarded scores below the average for all 12 aspects of integration.
Figure 4.4 shows the average scores by professional category (500 responses). Community nurses and professionals in “other professional categories” (e.g. gerontologists, educators) who responded to the questionnaire gave a higher than average score to all 12 aspects of integration. Social healthcare workers and social workers consistently gave scores below the average.
Note: Colour scale, where dark green indicates significantly above average and red indicates significantly below average.
Casentino, Cerignola and Lecce were excluded from the analysis by pilot area because the number of responses was less than 10. Therefore, the analysis by pilot area is based on 490 responses.
Source: Scirocco questionnaire, see Box 4.1.
Note: Colour scale, where dark green indicates significantly above average and red indicates significantly below average.
The category “Altro ruolo professionale” (“Other professional categories”) includes gerontologists (N=11), educators (N=7), physiotherapists (N=7) and administrators (N=6).
Source: Scirocco questionnaire, see Box 4.1.
4.5.2. Focus groups at local level
To further analyse the information gathered and understand the specificities and complexities of social and healthcare integration in Italian regions, 14 focus groups were conducted in five regions and two autonomous provinces between February and March 2025. A total of 191 professionals from social and healthcare services participated (further details are provided in Annex 4.A).
The focus group meetings, each lasting four hours, were conducted in the pilot areas using the integration analysis model presented in a previous chapter of this report as a reference and were divided into three main thematic sessions: structural and systemic integration; the characteristics that define their innovative scope; and the role of community welfare:
Structural and systemic integration – i.e. the transition from integration understood as the simple juxtaposition of healthcare and social services in relation to individual complex cases, to integration as a permanent and pre‑organised link for a unified response to complex health needs (multiple chronic conditions, non-self-sufficiency and disability, frailty and social marginalisation): the focus group stressed a clear need to move beyond the fragmented, service‑based approach to care, which focusses on the episodic management of individual cases, and to favour organisational models capable of responding in a unified and continuous manner to the complex needs of non-self-sufficient older people. This transition requires a review of existing organisational structures, which are still characterised by a silo mentality. Participants highlighted the absence of a catalyst to promote integrated action between health, social and healthcare services, without which professionals often continue to operate in parallel chains. Some organisations, such as the ATS in Lugo di Romagna and the Empolese‑Valdelsa Health Authority, have developed “natively integrated” organisational structures, supported by shared governance tools, which are promising practices towards more advanced models of integrated care.
Characteristics that define their innovative scope – i.e. home care settings, the high complexity of health needs, and the need for continuous and long-term action: these three characteristics pose serious challenges for existing organisational structures, which are often still based on service‑oriented responses that are fragmented by sector and limited in duration – reason why home‑based activities have always been the least developed area of action. Faced with a complex demand, it is not possible to provide partial answers: it is necessary to develop Individualised Care Projects (PAIs) capable of coherently recomposing the results of multidimensional assessments, overcoming the current fragmentation and integrating health, social and protective interventions. It is therefore essential to have a solid and widespread territorial infrastructure that connects the home care chain with chronic care and proximity services, and that allows for the articulation of a continuum of care based on three key components: proactive healthcare, integrated assistance and protection of social vulnerabilities. This approach requires specific organisational tools, such as multi-professional micro-teams, joint home visits, standardised assessment forms and integrated care programmes, as well as strong interpersonal skills with individuals, families and caregivers. Relevant examples of this come from the districts of Vicenza and Lecce, where models have been developed that go beyond the mere juxtaposition of services and offer integrated responses to the entire family unit through a dual capacity: the development by public health and social services of a broad and engaging relationship with the person, the caregiver and any family assistant; and the creation of an advanced accreditation system capable of responding appropriately to the entire range of a PAIs that addresses care, assistance and protection.
Community welfare – i.e. the context of complex healthcare and social networks, public and private, formal and informal, limited or widespread, capable of contributing to the development of healthcare responses within the territory in question: these responses are based not only on meeting healthcare needs, but also on support and interaction between the various organised entities within a local community, enhancing and qualifying their different roles, skills, functions and capabilities. Building community welfare requires intentional and proactive action to build stable networks and promote a sense of belonging as a source of shared well-being among institutions, public and private organisations, individuals and families, including through shared administration tools such as co-planning and co-design. Home care, by its very nature, develops within family and community contexts, whose balance directly influences the possibility of providing adequate and continuous assistance. In addition to working with families, working with community organisations is an integral and constitutive part of the home setting and, even if some sectors receive help from volunteers, building permanent networks with third sector organisations remains a challenge. For this reason, it is necessary to invest in professionals capable of acting as a bridge between the public system and civil society organisations, supporting the transition from informal neighbourhood relationships to structured and purposeful networks. Experience gained in areas such as Chiavari, Rovereto and Val Badia demonstrates the possibility of promoting greater integration between public services and active communities, for example through the figure of the family and community nurse or the creation of “permanent solidarity tables” with a social welfare and educational focus.
Furthermore, common and cross-cutting elements emerged in all 14 focus groups, albeit with varying degrees of intensity, which deserve attention when formulating responses to needs:
The need to codify, institutionalise and transform into an operational tool what has been built up in daily practice, thanks to initiatives based mainly on the goodwill and willingness of health and social workers to collaborate and share experiences.
The lack of or difficulty of using IT tools, which hinders both the necessary exchange of information and the implementation of truly integrated and comprehensive care for the person.
A significant use of human and economic resources, despite only managing to involve a limited number of recipients, and despite the high quality and value of the interventions carried out.
Difficulties in dialogue and interaction between the various actors involved, which compromises the overall effectiveness of the interventions.
Critical issues related to the recruitment of staff and the lack of adequate training for operators: labour demand in the LTC sector is growing, but the sector struggles to respond due to unattractive working conditions, low wages, precarious contracts and limited opportunities for training and professional development, which hinder recruitment, retention and the quality of care. Added to this is the scarcity of structured opportunities for discussion, which further limits the development of shared skills and the construction of a common approach.
References
[1] AReSS Puglia, Regional Strategic Agency for Health and Social Services (n.d.), Scirocco Exchange, https://aress.regione.puglia.it/aree-tematiche/sanita-integrata-e-digitale/scirocco-exchange.
Fourteen focus groups were conducted in five regions and two autonomous provinces in February-March 2025, with a total of 191 professionals participating, including social and healthcare workers, local administrators, representatives of patient organisations and other relevant stakeholders. The date, location and number of participants in each focus group are presented in in Figure 4.5.
The guided focus group discussions focussed on aspects such as structural and organisational barriers; existing facilitators; experiences of success and failure; concrete proposals for improving care integration; the implementation of new needs-based assessment tools; the promotion of interoperability of information systems; and the development of skills and capacities for integrated care.
The population – total and over the age of 65 – and the type of municipalities involved – Centres versus Internal Areas – in the pilot areas are shown in Figure 4.6.
Note: Provincia autonoma (Autonomous Province).