This chapter sets out an analytical model for assessing integration. It begins by reviewing various models of integration, from basic co‑ordination to full institutional merger. It then introduces the framework applied in this report, which combines three perspectives. First, it identifies the main policy areas relevant for integration: governance, workforce, information systems and care delivery. Second, it considers the dimensions of integration – institutional, planning, professional, managerial and community – through which these areas can be organised. Third, it anchors the analysis in home‑based interventions and services, distinguishing between medical/nursing care, personal care and assistance. Together, these perspectives provide a structured tool to assess the Italian system and compare it with international experiences.
Towards a Structured and Systemic Integration of Home Care for the Non-Self‑Sufficient in Italy
Abstract
The significant growth in the prevalence of chronic conditions among the population has increased the need for an integrated system of care for non-self-sufficient persons. In the Italian national debate, the concept of integration between the health system and social services represents the key to policies capable of reorganising existing services, reducing fragmentation and the lack of co‑ordination. A greater awareness of the influence of social factors on health has led to the identification of social and health integration as the tool for implementing a renewed approach to care capable of responding to the multidimensional and complex needs of the non-self-sufficient population.
At the international level, there are multiple definitions and models of “integrated care”. The World Health Organization defines it as ‘an approach aimed at strengthening health systems by placing the needs of the person at the centre through the provision of quality services throughout the life course, designed on the basis of the multidimensional needs of the population and delivered by multidisciplinary teams’. Several countries have developed public health and chronic care management models aimed at improving the quality of care services and the well-being of the population. The evidence on the positive impact of such integrated care models in terms of improving access to services and user satisfaction is growing in strength and number. In addition, some experiences show that integrated care makes it possible to improve the appropriateness of interventions, reduce recourse to hospitalisation and preserve the autonomy of the person, ensuring their overall well-being.
In recent years, the integration of public services – and of health and social services in particular – has become a policy priority in many OECD countries. Different models are emerging, ranging from partially integrated approaches to fully integrated solutions.
The literature indicates that linking or “networking” services to improve access and user experience can generate significant efficiency and effectiveness gains, especially for people with multiple and complex needs. The high specialisation of services can make it difficult to achieve the combination and sequencing of services best suited to the complex needs of users.
The idea of integrating services to overcome fragmentation originated mainly in the health sector, but models and definitions are now also being applied to social systems, to borderline areas between health and social care, but also to further areas such as education and employment services (OECD, 2023[1]).
Integration models within and between systems are often multidimensional and include various elements – such as case management, integrated care pathways, changes in working practices, and changes in organisational, governance and financial systems. The OECD report Integrating Social Services for Vulnerable Groups (OECD, 2015[2]) distinguishes between horizontal integration – the most common in Europe, bringing together actors from different sectors or entities to respond to the needs of users – and vertical integration, which aims to combine governance and financing across multiple service levels (from intergovernmental co‑operation to co‑ordination between residential, home and community-based services at the micro level). In the specific case of the elderly, it refers to Leutz’s model (1999[3]), which distinguishes between:
Full integration: Pooling of organisational and financial resources from different sectors, within a single structure or through contractual agreements, with shared objectives.
Co‑ordination: Explicit structures to facilitate care delivery between distinct sectors, e.g. through discharge planning, case management or information sharing.
Linkage: Minimal integration between separate health and social services, each with its own responsibilities, funding and rules.
These models are comparable to “ricongiungimento”, “ricomposizione” and “rammendo”, respectively, under Caiolfa’s interpretation (2022[4]).
Putting people at the centre of care requires offering a range of services that are aligned with individual needs, and ensuring smooth transitions between institutional, community and home‑based settings. Long-term care services which are well integrated with healthcare not only improve quality of life and health outcomes, but also enhance cost-effectiveness and help to reduce pressure on hospitals and other health facilities.
This project focusses specifically on the integration of home‑care social and health services for non-dependent elderly persons. Home care is one component of a broader continuum of integrated care, which also encompasses hospital, residential and semi-residential services, and specialised care.
The integration analysis model used in this project is based on a framework wherein three groups of elements intersect:
The available home care support and services
The policy areas
The dimensions of integration.
Together, these three groups of elements form an analytical and constructive framework capable of outlining the prospects for the creation of an innovative territorial welfare system (Figure 2.1).
2.2.1. Policy areas
Given the complexity of the topic, it was decided to structure the analysis around four policy areas: governance, workforce, data and information systems, and service delivery. Each of these areas represents an essential component in the mosaic of practices, policies and services that make up the universe known as “integrated care”.
An effective governance model for health and social integration must be based on close co‑operation between the various institutional levels, with the aim of ensuring unified planning and management of health and social services. The guiding principle in this area is the creation of integrated multi-level governance that allows for effective and synergic management of resources at local and national levels, overcoming the current fragmentation. The proposed actions include the formalisation of the collaboration between Health Districts and Social Territorial Areas, through the joint drafting of Territorial Activity Programmes (PAT) and Area Plans (PdZ). This favours the alignment of planning and the implementation of an integrated approach to home services as well.
Social and health integration cannot be realised without an adequately trained and valued workforce. The guiding principle in this area is the creation of an interdisciplinary working environment, which recognises the importance of both the formal and informal care sector. One of the most important challenges for health and social integration is continuous training for the different actors involved, including nurses, social workers and family caregivers. The key proposal is the establishment of common and compulsory training courses for multidisciplinary teams, which strengthen the transversal skills needed to work in an integrated setting. Training must also include the use of technological and digital tools, so as to facilitate the sharing of information between the various professionals. Moreover, it is crucial to enhance the contribution of informal carers (such as family caregivers) by offering them training and care support. It is precisely with this in mind that Legislative Decree 29/2024 provides for the adoption of specific guidelines to define uniform methods for implementing training programmes. Regions can use these guidelines, within their own autonomy, to achieve uniform training standards throughout the country. The implementation of this regulatory provision aims to improve, including through the grading of needs, and standardise the training offering for care professions, as well as define the procedures for obtaining the professional qualification of family assistant.
Effective social and health integration requires interoperable information systems that allow information to be shared between the various actors involved. The guiding principle in this area is the interoperability of health and social information systems, which makes it possible to monitor needs and interventions in real time, reducing duplication of effort and improving the quality of care. Currently, separate information systems exist in Italy for the management of health and social services, making data sharing complex. The central proposal is the development of an integrated platform of existing information systems, ensuring access to data by all professionals involved in the care pathway. Such a platform must be accompanied by clear regulations on data protection and access to information to guarantee the security and privacy of users. In this regard, it should be noted that the guiding criteria for the implementation of Law No. 33 of 23 March 2023, include “strengthening the integration and interoperability of the information systems of the competent bodies and administrations within the framework of existing programmes to enhance infrastructure and IT networks, also by leveraging citizen-generated data and evidence, as well as data resulting from surveys, studies, and research conducted by third sector entities.” This principle has been incorporated into Legislative Decree no. 29/2024, which provides that “the Ministry of Labor and Social Policies, the Ministry of Health, the Delegated Political Authority for Disability, INPS, the regions and autonomous provinces, municipalities, and ATSs shall promote the interoperability of their IT systems, in compliance with the guidelines on the technical interoperability of public administrations adopted by the Agency for Digital Italy (AGID) and the guidelines defined by the National Agency for Digital Health (ASD).” This aims to facilitate the simplification and integration of procedures for assessing and evaluating the condition of non-self-sufficient elderly persons, which is further implemented under Article 28, paragraph 5, of the aforementioned Legislative Decree 29/2024, which establishes the procedures for sharing databases containing information or findings that, for any reason, enter into the basic assessment and evaluation process, as well as the collection of data, communications, and information related to its conclusion.
The provision of home services for non-self-sufficient persons must follow a well-defined pathway providing integrated, continuous and personalised care. The guiding principle in this area is the creation of an integrated care pathway combining all the necessary health and social services, with a multidimensional assessment of the patient’s needs. Proposed actions include the establishment of a Single Point of Access (PUA) in each territory to facilitate the orientation and care of non-self-sufficient persons. PUAs must be able to manage the initial assessment and refer patients to the competent multidisciplinary teams, which will be responsible for drawing up and monitoring the Individualised Care Proejct (PAI). The PAI must be updated regularly according to the evolution of the patient’s condition, thus ensuring that care is always appropriate to the specific needs.
2.2.2. Dimensions of integration
The fundamental public functions of “Healthcare” and “Social Care” are characterised by deep constitutive asymmetries that condition their possibilities for integration, a structural condition with which the countless local experiences based on the meeting of spontaneous good will are confronted. The decisive point is the transformation of these voluntarist encounters into integration arrangements that are instead permanent, recognisable, consistent and widespread throughout the country. With respect to the basic elements that characterise these asymmetries, it is possible to identify dimensions on which to pivot in order to attempt to realign the interactions between health and social care, trying to make them stable and continuous:
Institutional: Structured forms of involvement and co-decision making of regional, corporate, municipal institutional levels.
Planning and management: Unitary planning tools for the social and healthcare areas; forms of sharing management functions.
Organisational and management: Shared and common organisational systems between health and social services; production of services with health and social components; forms of resource sharing.
Multi-professional: Integrated care processes with common tools and organisational methods.
Community: Participative modalities in the social and health area; activation of community networks of proximity; use of the institutions of “Shared Administration”.
The constitutional reform of 2001 requires that the exercise of fundamental functions be divided according to the vertical structure of administrative powers at the state, regional and municipal levels. This is in turn decisive for integration, considering that healthcare is a regional responsibility and social assistance is a municipal responsibility, while the state is responsible for defining minimum healthcare and social service levels. For these reasons, it is only possible to propose a systemic and structured vision of integration within a multi-level institutional logic that finds its operational basis in co‑ordinated territorial action between the Health Districts and the Social Territorial Areas.
2.2.3. Home care
The analysis of the integration of social and health care for elderly people who are not self-sufficient requires consideration of the three fundamental dimensions of medical/nursing care, personal care and assistance. These dimensions represent distinct functions, which can be traced back to different regulatory and institutional areas, but are deeply interdependent in the concrete configuration of needs and care pathways. Medical/nursing car refers mainly to home‑based health services, predominantly nursing and rehabilitation; personal care includes support (in various forms and intensities) for activities of daily living, necessary to ensure that people can remain in their own homes; assistance concerns the needs for protection, support for instrumental activities of daily living and social support, which are fundamental to ensuring equity and effectiveness in the provision of services (see the previous chapter for a description of the Italian system). The adoption of an integrated perspective makes it possible to grasp the multidimensional nature of non-self-sufficiency and to assess the capacity to activate co‑ordinated responses.
References
[4] Caiolfa, M. (2022), Il Sistema Nazionale Anziani: unagovernance multilivello per la nonautosufficienza.
[3] Leutz, W. (1999), “Five Laws for Integrating Medical and Social Services: Lessons from the United States and the United Kingdom”, The Milbank Quarterly, Vol. 77/1, pp. 77-110, https://doi.org/10.1111/1468-0009.00125.
[1] OECD (2023), “Integrating local services for individuals in vulnerable situations”, OECD Local Economic and Employment Development (LEED) Papers, No. 2023/08, OECD Publishing, Paris, https://doi.org/10.1787/1596644b-en.
[2] OECD (2015), Integrating Social Services for Vulnerable Groups: Bridging Sectors for Better Service Delivery, OECD Publishing, Paris, https://doi.org/10.1787/9789264233775-en.